Bimonthly internal assessment October
"57 year old man with jaundice, pedal edema and abdominal distension since three years and bleeding gums since three days"
1) What is the reason for this patient's ascites?
Ans. The cause for ascitis might be cirrhosis of liver because the patient is a chronic alcoholic since 40 years.
2) Why did the patient develop bipedal lymphedema? What was the reason for the recurrent blebs and ulcerations and cellulitis in his lower limbs?
Ans. Bilateral pedal oedema may be due to the decrease in the levels of albumin (long standing cirrhosis).
The ulcerations are due to limited movements (improper dressings).
3) What was the reason for his asterixis and constructional apraxia and what was done by the treating team to address that?
Ans. Asterixis is a clinical sign that describes the inability to maintain sustained posture with subsequent brief, shock like, involuntary movements. This sign is not pathognomonic for any condition.
He was given Lactulose and Rifamixin.
4) What was the efficacy of each treatment intervention used for this patient? Identify the over and under diagnosis and over and under treatment issues in the management of this patient.
Ans.
A. high protein diet (2eggs / day) for decreased albumin synthesis
B. Air or water bed to prevent pressure bed sores in the dependent areas
C. Fluid restriction <1.5litres/day so as to decrease of fluid dissemination into the extra vascular space
D. Salt restriction <2.4gms/day to prevent retention of water.
E. Inj augmentin 1.2gm IV/BD to prevent secondary bacterial infections
F. Inj pan 40 mg IV/OD
G. Inj zofer 4mg IV/BD
H. Tab. Lasilactone (20/50)mg BD ( combination of furosemide and aldactone to decrease pedal oedema
If SBP <90mmhg - to avoid excessive loss of fluid
I. Inj vit k 10mg IM/ STAT ( as vitamin K causes coagulation to further prevent bleeding manifestions
J. Syp lactulose 15ml/PO/BD for hepatic encephalopathy
K. Tab udiliv 300mg/PO/BD contain Ursodeoxycholic acid as an active ingredient. It is used to dissolve gall stones in various liver-related disorders such as cirrhosis
L. Syp. Hepameiz 15 ml/PO/OD
M. IVF 1 NS slowly at 30ml/hr to maintain hydration
N. Inj thiamine 100mg in 100mlNS /IV/TID as thiamine deficiency's occur in chronic alcoholics
O. Strict BP/PR/TEMP/Spo2 CHARTING HOURLY
P. Strict I/O charting
Q. GRBS 6th hourly
R. Protein powder in glass of milk TID for protein supplementation and muscle wasting which commonly occurs in cirrhosis patients
S. 2FFP and 1PRBC transfusion to support coagulation pathways
T. ASD DONE for wound infections and ulcer
A 54 year old male with cough,abdominal tightness,pedal edema and diarrhea.
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1) Why were his antitubercular therapy stopped soon after his current admission? Was he symptomatic for ATT induced hepatitis? Was the method planned for restarting antitubercular therapy after a gap of few days appropriate? What evidence is this approach supported by?
Ans. ATT was stopped because his LFT was deranged, Total Bilirubin raised and ALP was also raised. His Serum Albumin was low.
2) What were the investigational findings confirming the diagnosis of pulmonary TB in this man?
Ans. Bilateral infiltration of lung fields noted in chest X-Ray (PA view)
3) What was the cause of his ascites?
Ans. (?) Portal Hypertension.
4) What are the efficacy of each intervention mentioned in his treatment plan and identify the over and under diagnosis as well as over and under treatment issues in it.
Ans.
A. Inj Human Actrapid Insulin s/c 8am - 2pm - 8pm for diabetic management
B. Inj PAN 40 mg IV/OD
C. Inj optineuron 1 amp in 100 ml NS Iv/bd for nutritional supplementation such as Vit B12
D. ATT to be with held for hepatoxicity although should be used based on CTP score mentioned above
E. Syp lactulose 15ml HS to prevent hepatic encephalopathy
F. Protein powder 3 to 4 scoops in 1 glass of milk or water QID for protein supplementation
G. Stop all OHA s
H. Grbs charting 6th hrly
I. Strict I/0 charting
J. High protein diet 4eggs daily for protein supplementation
K. ORS sachets in 1 litre of water to compensate electrolytes lost due to diarrhoea
L. Bp charting hourly
M. Inj PIPTAZ 4.5gm/IV/bd stat - - --> TID
N. Vit k 10 mg Iv OD for 5 days to prevent forthcoming ?bleeding manifestations
O. Temp BP PR monitoring 4th hourly
P. IVF - 1 DNS @50ml/hr for hydration
Q. Nebulisation with salbutamol and mucomist 12th hourly. for ?cough
R. Inj thiamine 100 mg in 100 ml NS IV TID. for chronic alcoholism.
47 year old man with bipedal edema since one year and abdominal distension since one month
1) What will be your further approach toward managing this patient of nephrotic syndrome? How will you establish the cause for his nephrotic syndrome?
Ans.
A. The causes may be - FSGS, Membranous Glomerulonephropathy, Minimal change disease, DM, SLE, Amyloidosis, Cancer, Drugs like
NSAIDS etc.
B. Identifying complications like thromboembolism, infections and renal failure.
C. Managing symptoms like protein loss, pedal oedema and hypercoagulable state.
2) What are the pros and cons of getting a renal biopsy for him? Will it really meet his actual requirements that can put him on the road to recovery?
Ans.
Pros-
A. Renal biopsy would be helpful in establishing cause for glomerular pathology.
Cons-
A. Time and expenditure.
B. Post biopsy complications
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