Bimonthly internal assessment October

 CASE 1

https://swathibogari158.blogspot.com/2020/09/chronic-decompensated-liver-disease.html

1) Reason for this patients ascites 

The most common cause of Ascites is

      Cirrhosis of liver 

      risk factors in this patient : 

     1. Chronic alcoholism since 40 years 

     2. Truncal obesity leading to metabolic syndrome causing NAFLD leading to cirrhosis

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 which is of pitting type is due to decrease in the albumin level trends due to course of the disease and long standing cirrhosis causing decrease in the production of proteins causing decrease in the oncotic pressure leading to accumulation of fluid.

ulcerations are due his limited self practising manoeuvres done in inappropriate conditions such as 

improper dressing of the wound, not maintaining aseptic conditions , indescriminate use of steroids (self medication) to quote from history (Patient attenders were giving history of multiple self medications whenever patient developed fever or shortness of breath they used to take decadron injections, larigo tablets,monocef and pantop over 4 months intermittently )  causing ? immune suppression leading to secondary infections hence cellulitis and non healing of wound. 

3) What was the reason for his asterixis and constructional apraxia and what was done by the treating team to address that?  

ANS:- HEPATIC ENCEPHALOPATHY

In hepatic encephalopathy (due to cirrhosis of liver ) damage occurs to brain cells due to the impaired metabolism of ammonia is predominantly related to the development of asterixis in hepatic encephalopathy.

SYRUP. HEPAMERZ - It is used for protecting the liver from harmful chemicals or free radicals. L-ornithine- L-aspartate (LOLA), the salt of the natural amino acids ornithine and aspartate acts through the mechanism of substrate activation to detoxify ammonia.

SYRUP. LACTULOSE - Helps to reduce the amount of ammonia in the blood of patients with liver disease. It works by drawing ammonia from the blood into the colon where it is removed from the body. It also reduces enteric production of ammonia.

TAB.RIFAXIMIN - It is a poorly absorbed antibiotic that is thought to reduce ammonia production by eliminating ammonia-producing colonic bacteria. Many small studies have suggested that rifaximin is effective in treating acute HE and is extremely well tolerated.

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. 

1. Air or water bed to prevent pressure bed sores in the dependent areas

2. Fluid restriction <1.5litres/day so as to decrease of fluid dissemination into the extra vascular space

Salt restriction <2.4gms/day to prevent retention of water due to osmotic gradient as sodium causes retention

3. Inj augmentin 1.2gm IV/BD to prevent secondary bacterial infections 

4. Inj pan 40 mg IV/OD

5. Inj zofer 4mg IV/BD

6. Tab lasilactone (20/50)mg BD ( combination of furosemide and aldactone to decrease pedal oedema
If SBP <90mmhg - to avoid excessive loss of fluid

7. Inj vit k 10mg IM/ STAT ( as vitamin K causes coagulation to further prevent bleeding manifestions

 
8. Syp lactulose 15ml/PO/BD for hepatic encephalopathy 

9. Tab udiliv 300mg/PO/BD contain ursodeoxycholic acid used to dissolve gallstones

10.syp hepameiz 15 ml/PO/OD - It is used for protecting the liver from harmful chemicals or free radicals. L-ornithine- L-aspartate (LOLA), the salt of the natural amino acids ornithine and aspartate acts through the mechanism of substrate activation to detoxify ammonia.

11.IVF 1 NS slowly at 30ml/hr to maintain hydration

12. Inj thiamine 100mg in 100mlNS /IV/TID as thiamine deficiency's occur in chronic alcoholics

13.strict BP/PR/TEMP/Spo2 CHARTING HOURLY 

14.strict I/O charting 

15.GRBS 6th hourly

16.protein x powder in glass of milk TID for protein supplementation and muscle wasting which commonly occurs in cirrhosis patients 

17. 2FFP and 1PRBC transfusion to support coagulation pathways 

18 .ASD DONE for wound infections and ulcer

19. High protein diet (2eggs / day) for decreased albumin synthesis

CASE 2

https://sainiharika469.blogspot.com/2020/09/hello-everyone.html?m=1

Q1 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:- His ATT was stopped because of ELEVATED LIVER ENZYMES AND LIVER FAILURE (? ATT INDUCED LIVER DAMAGE)

2) What were the investigational findings confirming the diagnosis of pulmonary TB in this man? 

ANS:- Infiltrates in CHEST X-RAY

Plueral thickening and fibrocavitory changes noted in HRCT.

Sputum positive TB with RIFAMPICIN sensitivity.

3) What was the cause of his ascites?

Ans: High saag and low ascitic protein Suggestive of cirrhosis is casue for ascites

• LATE BUDD-CHIARI SYNDROME
• HYPOALBUMINEMIA

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. 

High protein diet 4eggs daily for protein supplementation 

ORS sachets in 1 litre of water to compensate electrolytes lost due to diarrhoea 

Inj PIPTAZ 4.5gm for antibiotic cover

Vit k 10 mg Iv OD for 5 days to prevent forthcoming bleeding manifestations as his PT INR APTT are elevated 

IVF - 1 DNS @50ml/hr for hydration

Nebulisation with salbutamol and mucomist 12th hourly for cough and crepts

Inj thiamine 100 mg in 100 ml NS IV TID. for chronic alcoholism.

CASE 3

https://sushma29.blogspot.com/2020/09/ascites-secondary-to-nephrotic-syndrome.html?m=1

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-The treatment for nephrotic syndrome is steroids 

If this is steroid sensitive nephrotic syndrome the patient responds to the drugs

The steroids are started and they are slowly tapered as per the requirement

The cause for nephrotic syndrome maybe primary which is idiopathic or secondary such as

Glomerular pathology,diabetes ,cancer ,drugs ,infections and some congenital diseases

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-Renal biopsy would be really helpful if the nephrotic syndrome is due to any glomerular pathology 

There are disadvantages to the renal biopsy such as affordability of the patient,time taking,and the post biopsy complications.