Bimonthly assessment for February 2021

 This is my submission of the assessment of February 2021 

Link to the current assignment is below: 

https://medicinedepartment.blogspot.com/2021/02/medicine-paper-for-february-2021.html?m=1

1Q.  50 year old man, he presented with the complaints of

Frequently walking into objects along with frequent falls since 1.5 years

Drooping of eyelids since 1.5 years 

Involuntary movements of hands since 1.5 years 

Talking to self since 1.5 years 

Link to the case presentation: 

https://archanareddy07.blogspot.com/2021/02/50m-with-parkinsonism.html?m=1

And link to the case discussion: 

https://youtu.be/kMrD662wRIQ

a. What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

PROBLEM PRESENTATION:

Regular alcoholic and tobacco chewer 

An episode of GTCS seizures 10 years back 

Diagnosed as diabetic 2 years back when he had fall from bike and got his leg fractured and was operated 

Difficult to keep his eyes open and the difficulty is progressing since 1.5 years 

Changes in behaviour as described by his wife like self talking and being reserved unlikely to his normal behaviour as of being aggressive since 1.5 years 

Started walking in to things and only looks straight ahead and involuntary movements of bilateral hands which is on and off only while doing work since 1.5 years 

Diagnosed with hypokalemia and is on supplementation since June 2020

Thin stream of urine and bed wetting since one year 

ANATOMICAL LOCALISATION:

Bilateral ptosis: weakness of Levator palpebrae superioris 

Self talk : frontal lobe 

Vertical gaze palsy : 

Mostly it is supranuclear palsy

 b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of his problems and current outcomes. 

Bilateral ptosis :

Size of pupils is normal which rule out 3rd nerve palsy and horners syndrome 

And another possibility is myasthenia gravis but patient didnot complain of fatiguable drooping of eye lids and an ice pack test was done in which drooping caused by myasthenia will show improvement after 2-3 min which is not seen in this patient. 

H/o frequent falls indicate balance disorders 

 Which can be due to neurodegeneration in basal ganglia which can be either Parkinson’s disease or progressive supranuclear palsy 

As clinical examination of 3rd nerve indicates that there is vertical gaze palsy 

It is most probably a progressive supranuclear palsy .

Timeline of events : 

Chronic smoker and alcoholic since 30 years 

 1-2 episodes of seizures 20 years back 

RTA with fracture of right leg 2 years back 

Self talk and behavioural changes along with falls and drooping of eyelids 1.5 years back 

Polyuria and bed wetting since 1 year 

Hypokalemia since 1 year 

  

c) What is the efficacy of each of the drugs listed in his current treatment plan ?

Currently the patient is put on syndopa ( carbidopa+ Levodopa) for progressive supranuclear palsy 

And tab. Metformin for type2 DM 

 Efficacy of syndopa 

syndopa was initiated to differentiate psp from Parkinson's disease 

https://www.nejm.org/doi/full/10.1056/nejmoa033447

In this randomized, double-blind, placebo-controlled trial, we evaluated 361 patients with early Parkinson's disease who were assigned to receive carbidopa–levodopa at a daily dose of 37.5 and 150 mg, 75 and 300 mg, or 150 and 600 mg, respectively, or a matching placebo for a period of 40 weeks, and then to undergo withdrawal of treatment for 2 weeks. The primary outcome was a change in scores on the Unified Parkinson's Disease Rating Scale (UPDRS) between baseline and 42 weeks

The severity of parkinsonism increased more in the placebo group than in all the groups receiving levodopa: the mean difference between the total score on the UPDRS at baseline and at 42 weeks was 7.8 units in the placebo group, 1.9 units in the group receiving levodopa at a dose of 150 mg daily, 1.9 in those receiving 300 mg daily, and –1.4 in those receiving 600 mg daily (P<0.001)

Efficacy of metformin : 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5647555/

2Q. Patient was apparently asymptomatic 2 years back then he developed weakness in the right upper and lower limb, loss of speech.

Link to case presentation: 

https://ashfaqtaj098.blogspot.com/2021/02/60-year-old-male-patient-with-hrref.html?m=1

Case discussion links: 

https://youtu.be/7rnTdy9ktQw

a) What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

Problem representation: 

H/O CVA 2 years back on medication weakness of limbs improved but loss of speech persisted

Shortness of breath grade 4 according to NYHA with Orthopnea and PND since 2 months 

Bilateral Pedal edema up to ankle along with abdominal tightness and discomfort since 2 months 

Oliguria along with burning micturition since 2 months 

C/o generalised weakness along with pain in bilateral lower limbs since 2 months 

Anatomical localisation: 

Based on history : 

Sob orthopnea and PND indicates left heart failure due to atherosclerosis 

Risk factors for atherosclerosis include 

Elderly age ( 60 years) 

Alcohol intake

Hypertension 

Based  on examination:

shift of apex to 6th ics,presence of thrill palpable at apex(?s1), nature of the apex not mentioned

presence of loud p2 ,dilated veins ,pedal edema,s3 in both apical and left parasternal areas.

(?biventricular failure)

b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of his problems and current outcomes. 

etiology:

CAD

Ecg showing 

1)normal axis

2)pathological Q waves from v1 to v6

3)poor R wave progression

suggest a CAD probably involving LAD and LCX territory 

confirmed with finding on the echo showing LAD akinetic RCA with LCX hpokinetic  

Time line of events : 

Episode of CVA with persistent loss of speech since 2 years 

Shortness of breath, PND, orthopnea bilateral pedal edema , oliguria since 2 months 

b. What is the efficacy of each of the drugs listed in his current treatment plan?

1. Salt and fluid restriction: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282615/

Ninety-seven stable patients in NYHA class II-IV, on optimal medication, with previous signs of fluid retention, treated with either >40 mg (NYHA III-IV) or >80 mg (NYHA II-IV) of furosemide daily were randomized to either individualized salt and fluid restriction or information given by the nurse-led heart failure clinics, e.g. be aware not to drink too much and use salt with caution, and followed for 12 weeks. Fluid was restricted to 1.5 L and salt to 5 g daily, and individualized dietary advice and support was given.

Results After 12 weeks, significantly more patients in the intervention than in the control group improved on the composite endpoint (51% vs. 16%; P < 0.001), mostly owing to improved NYHA class and leg oedema. No negative effects were seen on thirst, appetite, or QoL

2. SPIRONOLACTONE: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5675712/

A total of 360 patients were randomized, of whom the median age was 65 years, 129 (36%) were women, 200 (55.5%) were white, 151 (42%) were black, 8 (2%) were Hispanic or Latino, 9 (2.5%) were of other race/ethnicity, and the median left ventricular ejection fraction was 34%. Baseline median (interquartile range) NT-proBNP levels were 4601 (2697-9596) pg/mL among the group treated with high-dose spironolactone and 3753 (1968-7633) pg/mL among the group who received usual care. There was no significant difference in the log NT-proBNP reduction between the 2 groups (−0.55 [95% CI, −0.92 to −0.18] with high-dose spironolactone and −0.49 [95% CI, −0.98 to −0.14] with usual care, P = .57). None of the secondary end point or day-30 all-cause mortality or heart failure hospitalization rate differed between the 2 groups. The changes in serum potassium and estimated glomerular filtration rate at 24, 48, 72, and 96 hours. were similar between the 2 groups.

3. THIAMINE : 

Used in patients with addiction to alcohol 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4550087/

Eighty-five adult men (mean age = 48 ± 8 yrs) meeting DSM-IV-TR criteria for current alcohol dependence participated in a randomized, double-blind, placebo-controlled trial of 600 mg BF vs placebo (PL) for 6 months. Psychometric testing included a derived Lifetime Alcoholism Severity Score (AS), Symptom Checklist 90R (SCL-90R), and the Barratt Impulsivity Scale (BIS) at baseline and at 6 months with data analyzed using ANOVA and MANOVA modeling.

3Q. 52 year old male , shopkeeper by profession  complains of  SOB, cough  ,decrease sleep and appetite since 10 days and developed severe hyponatremia soon after admission. 

Case presentation link :

https://soumya9814.blogspot.com/2021/01/this-is-online-e-log-book-to-discuss.html?m=1

Case presentation video:

https://youtu.be/40OoVEQBgS4

a) What is the problem representation of this patient and what is the anatomical localization for his current problem based on the clinical findings?

Problem representation: 

  52 year old who is a known hypertensive and diabetic 

 with c/o sob 

Productive cough 

Decreased sleep and appetite since 10 days 

Anatomical localisation; 

 Lesion is in lungs and is a lower respiratory tract infection 

b) What is the etiology of the current problem and how would you as a member of the treating team arrive at a diagnosis? Please chart out the sequence of events timeline between the manifestations of each of his problems and current outcomes. 

)?Sub acute combined degeneration of spinal cord secondary to vit B12 deficiency.

?Diabetic neuropathy

?Hypervolemic hyponatremia secondary to heart failure

?Pseudohyponatremia secondary to uncontrolled sugars

c) What is the efficacy of each of the drugs listed in his current treatment plan especially for his hyponatremia? What is the efficacy of Vaptans over placebo? Can one give both 3% sodium as well as vaptan to the same patient?  

tolvaptan vs placebo

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3573862/

Hyponatremic patients in the SALT-1 and SALT-2 studies with a diagnosis of SIADH were identified based on clinical diagnosis by individual study investigators. Subjects were randomized to receive oral placebo (n=52) or tolvaptan 15 mg daily, with further titration to 30 and 60 mg daily, if necessary, based on the response of serum [Na+] (n=58).

In patients with SIADH, improvement in serum [Na+] was significantly greater (P<0.0001) with tolvaptan than placebo over the first 4 days of therapy as well as the entire 30-day study, with minimal side effects of increased thirst, dry mouth, and urination. Only 5.9% of tolvaptan-treated patients had overly rapid correction of hyponatremia as defined by current guidelines. After discontinuation of tolvaptan, serum [Na+] declined to values similar to placebo. A significant positive treatment effect favoring tolvaptan on the physical component, and a near-significant trend on the mental component, was found using the SF-12 Health Survey. Tolvaptan was associated with a significantly reduced incidence of fluid restriction.

https://www.sciencedirect.com/science/article/pii/S0085253815557803

This review focuses on why hyponatremia should be treated and the role of these antagonists in the treatment. Upon analysis of the available literature, we conclude that there is presently no role for vaptans in acute symptomatic hyponatremia. Although numerous therapeutic approaches are available for chronic symptomatic hyponatremia, vasopressin antagonists provide a simpler treatment option. Vaptans are efficacious in raising serum sodium in long-standing ‘asymptomatic’

3%NACL and tolvaptan

https://link.springer.com/article/10.1007/s00228-020-02848-6

From a total of 77 patients included in the analysis, 24 (31.2%) showed sodium overcorrection (> 10 mmol/L/24 h); 2 (2.6%) in heart failure cohort, 17 (22.1%) in SIADH cohort, and 5 (6.5%) in unknown cause cohort. More than half of patients (51.9%) were administered hypertonic saline prior to tolvaptan. Hypertension, cancer, diuretics, baseline serum sodium, and SIADH were associated with the risk of overcorrection in the univariable analysis.

from the above data,vaptans shouldnt be used in acute hyponatremia and prior administration of 3%NACL leads to over correction with the use of vaptan.

4) Please mention your individual learning experiences from this month?

-Learnt about management of DKA occurring in type 1 diabetes mellitus 

-Attended opd and seen patients 

-Done ascitic tap under guidance of seniors 

-Assisted in intubation and cpr to seniors 

-Seen a case of pontine infarct with characteristic pinpoint pupils. 

-Seen a case of 27 year old with chronic pancreatitis and congenital heart disease palpated him to feel precordial heave and pan systolic murmur.