A 52 year old lady , with known asthma comes to the ED department with complaints of weakness, fatigue, difficulty in breathing .

 A 52 year old lady , with known asthma comes to the ED department with complaints of weakness, fatigue, difficulty in breathing .

She says she had a high grade fever almost 4 days ago. On examination , at the moment she is afebrile. Her Blood pressure is 100/60 mmHg and Oxygen saturation is 89 Percent on Air.

There are bilateral wheeze on auscultation on inspiration and motivation expiration.

You decide to organise an HRCT / High resolution computed tomography, the images of which are shown below :

Copyrights reserved with author.

Anonymized Data provided after taking consent of patient for teaching purpose only.

1. What are the findings on HRCT?

2. Name some causes of these findings and most likely Diagnosis in this patient?

3. Which inflammatory markers are used to monitor response to treatment in such cases?

4. What are treatment options ?

Answers given in comments section.

1. What are the findings on HRCT? 

HRCT shows ground glass appearance / opacities in both lung fields. 

Ground glass is glass whose surface has been ground to produce a flat but rough (matte) finish, in which the glass is in small sharp fragments.

Ground-glass opacification/opacity (GGO) is a descriptive term referring to an area of increased attenuation in the lung on computed tomography (CT) with preserved bronchial and vascular markings.

 It is a non-specific sign with a wide etiology including infection, chronic interstitial disease and acute alveolar disease.

Ground glass opacification is also used in chest radiography to refer to a region of hazy lung radiopacity, often fairly diffuse, in which the edges of the pulmonary vessels may be difficult to appreciate .

The use of the term ground glass derives from the industrial technique in glassmaking whereby the surface of normal glass is roughened by grinding it.

2. Name some causes of these findings and most likely Diagnosis in this patient? 

The patient in question has diffuse ground glass opacification of both lung fields. Broadly speaking, the differential for ground-glass opacification can be split into :

A .Infectious processes (opportunistic vs non-opportunistic)

B .Chronic interstitial diseases

C . Acute alveolar diseases

D. Other causes 

In this lady given the current scenario and having a recent history of sore throat and fever , we need to consider Covid 19 pneumonitis associated SARS as one of top diagnosis and should under take Covid 19 PCR . Covid 19 antibodies should be performed and any exposed family members be advised to undertake Covid 19 testing and exercise extreme caution.

3. Which inflammatory markers are used to monitor response to treatment in such cases? 

The comminly used inflammatory markers used to monitor course of Covid 19 pneumonitis and SARS include : 

FBC / Full Blood count inclusing White cell count. 

CRP , 

Myoblobin , 

D- dimer levels , 

Ferritin , 

Interleukin 6 Levels and 

Procalcitonin apart from Covid 19 PCR and Antibodies , throat swabs for Flu detection.

 Also patient should be attached to cardiac monitor and any arrythmias be detected and treated earlier. 

Renal profile is also very important to monitior.

If possible an Echocardigram and Arterial Blood gases should also be done as well to decide course of disease.

4. What are treatment options ? 

Treatment is manly supportive and consists of high flow oxygen to maintain O2 levels more than 95 in healthy patoents and more than 89 in COPD patients. 

Intravenous cortiscosteroids such as Dexamethasone or hydrocortosone are also useful. 

For old patients with high risk if DVT or thrombsois , daily Loprin is also useful . 

Heparin may also be given at discretion of consultant. 

Broad spectrum antibiotics are useful such as Tazocin 4.5 Gram tds. ABC/ Airway breathing Circulation should be maintained at all times. 

Intravenous fluids to avoid severe AKI . intake output record is a must. Remdesivir and tocilizumab have beneficial effects in Covid pneumonitis . 

Indomethacin that has anti interleukin storm effect is also of value.

https://media.go2speed.org/brand/files/dcm/164/20180503162756-relax-160x85.jpg

A 48 year old lady / woman presents to your clinic with complaints of generalized body swelling over the last 6 months and abdominal distension and swelling of feet.

 A 48 year old lady / woman presents to your clinic with complaints of generalized body swelling over the last 6 months and abdominal distension and swelling of feet.

She gets easily short of breath on walking short distances.

Onexamination,

Her Blood pressure is 140/80 mmHg

She has high BMI of 32

Her JVP is raised.

There is bilateral pitting oedema of her feet.

Abdominal examination shows

Liver is palpable 2 finger breadths under right hypichondrium.

There is also presence of ascites.

Examination of lungs :

Dullness of lung bases on both sides.

Reduced air entry in basal regions.

You order an abdominal ultrasound which is given below :

1 . What are the findings In Ultrasound.

2 . What is the most likely diagnosis in this patient ?

3 . Which further investigations should be done?

4.. Which other cardiac conditions can lead to these findings.

What characteristic physical sign would be present in this patient?

Copyrights reserved with Author

Answers given in the comments section.

1. What are the findings In Ultrasound.

Passive hepatic congestion / hepatomegaly

Dilated hepatic veins and inferior vena cava

2. What is the most likely diagnosis in this patient ?

Congestive cardiac failure leading to passive hepatic congestion and hepatomegaly .

3. Which further investigations should be done?

Echocardiogram

Chest X ray

ECG

BNP levels

4.. Which other cardiac conditions can lead to these findings

Passive hepatic congestion usually secondary to

Congestive heart failure

Constrictive pericarditis

Right heart failure

Characteristic sign on physical exam

– Hepatojugular reflux

An 11 year old boy is brought to your OPD by his father with history of recurrent seizures

 An 11 year old boy is brought to your OPD by his father.

According to him , his son gets episodes of seizures when he becomes unresponsive and is characterized by jerking movements of his right hand and legs and they may last up to 3 – 4 minutes and he becomes confused after the seizures resolve.

He gets urinary incontinence with these fits as well and tends to bite his tongue and he has to put his wallet between his teeth to prevent this.

1 . What investigations will you like to perform?

2 . What is the investigation shown in the Figure and what are its findings ?

3. What is the most likely diagnosis ?

4. What are the causes of this disease ?

5 . How will you manage this patient ?

Copyrights reserved with Author.

Answers given in comments section.

1 . What investigations will you like to perform? 

Investigations

Full blood count

Check fever

Neurological examination including cranial nerves , visual fields eye movements and power in upper and lower limbs

Temperature Record

Exclude meningitis, check neck stiffness , Any history of photophobia

Monitoring of Sugar levels

Analysis of Serum Electrolytes : Sodium , Potassium , Calcium and Magnesium levels

Septic screen , exclude chest infection , urinary tract infections

Any history of head injury.

CT Brain and MRI brain if needed to exclude inracranial space occupying lesions.

EEG / Electroencephalogram

2 . What is the investigation shown in the Figure and what are its findings ? 

his is a picture of MRI brain which is normal.

3. What is the most likely diagnosis ? 

Grand Mal Epilepsy / Tonic clonic seizures. 

A grand mal seizure ,also known as a generalized tonic-clonic seizure — is caused by abnormal electrical activity throughout the brain. Usually, a grand mal seizure is caused by epilepsy. But sometimes, this type of seizure can be triggered by other health problems, such as extremely low blood sugar, a high fever or a stroke.

Many people who have a grand mal seizure never have another one and don't need treatment. But someone who has recurrent seizures may need treatment with daily anti-seizure medications to control and prevent future grand mal seizures. Grand mal seizures have two stages:

Tonic phase. Loss of consciousness occurs, and the muscles suddenly contract and cause the person to fall down. This phase tends to last about 10 to 20 seconds.

Clonic phase. The muscles go into rhythmic contractions, alternately flexing and relaxing. Convulsions usually last one to two minutes or less.

4. What are the causes of this disease ? 

Causes

Grand mal seizures occur when the electrical activity over the whole surface of the brain becomes abnormally synchronized. The brain's nerve cells normally communicate with each other by sending electrical and chemical signals across the synapses that connect the cells.

In people who have seizures, the brain's usual electrical activity is altered and many nerve cells fire at the same time. Exactly what causes the changes to occur often remains unknown.

However, grand mal seizures are sometimes caused by underlying health problems, such as:

Injury or infection

Traumatic head injuries

Infections, such as encephalitis or meningitis, or a history of such infections

Injury due to a previous lack of oxygen

Stroke

Congenital or developmental abnormalities

Blood vessel malformations in the brain

Genetic syndromes

Brain tumors

Metabolic disturbances

Very low blood levels of glucose, sodium, calcium or magnesium

Withdrawal syndromes

Using or withdrawing from drugs, including alcohol.

5 . How will you manage this patient ?

Medications

Many medications are used in the treatment of epilepsy and seizures, including:

Carbamazepine .

Phenytoin .

Valproic acid.

Oxcarbazepine.

Lamotrigine .

Gabapentin .

Topiramate (.

Phenobarbital

Zonisamide .

Finding the right medication and dosage can be challenging. Usually , first, a single drug at a relatively low dosage is sytarted, and then increase the dosage gradually until patients seizures are well-controlled.

https://media.go2speed.org/brand/files/dcm/164/20180503162941-stinnos-160x85.jpg

 A 45 year old man presents to your OPD with 1 month history of difficulty in breathing and cough.

On history taking you find out he had a pneumonia 2 months ago in his left lung which required intravenous antibiotics and hospital admission for 1 week.

There is no history of smoking and no blood in sputum.

On examination , he appears weak and distressed.

His Temperature is 37 C and respiratory rate is 22 / minute.

BP is 130 / 80 mmHg.

There is reduced chest expansion on left side.

On auscultation , air entry on left side of lung is reduced and a wheeze in expiration is audible.

Percussion reveals dull percussion notes.

Oxygen saturation is 90 percent.

You decide to organize a chest X ray which is given below :

1. What is the most likely Diagnosis ?

2. How will you mange this patient ?

Copyright reserved with Author.

Answers given in comments section.

1. What is the most likely Diagnosis ?

The chest x ray shows collapse of left lung . And there is a history of recent pneumonia as well.

This is highly suggestive of left sided atelectasis secondary to pneumonia or even a para pneumonic lung effusion.

An ultrasound of chest will better help determine the cause of lung collapse / atelectasis.

Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung.

It occurs when the tiny air sacs (alveoli) within the lung become deflated or possibly filled with alveolar fluid.

Atelectasis may be caused by many things, including: mucus plug,foreign body,tumor inside the airway, injury,chest trauma, pleural effusion, pneumonia ,pneumothorax, and scarring of lung tissue.

2. How will you mange this patient ?

Treatment of atelectasis depends on the cause.

Mild atelectasis may go away without treatment.

Sometimes, medications are used to loosen and thin mucus.

If the condition is due to a blockage, surgery or other treatments may be needed.

Chest physiotherapy:

Techniques that help the patient breathe deeply to re-expand collapsed lung tissue are very important.

They include:

Performing deep-breathing exercises (incentive spirometry) and using a device to assist with deep coughing may help remove secretions and increase lung volume.

Positioning the body so that your head is lower than the chest (postural drainage). This allows mucus to drain better from the bottom of the lungs.

Tapping on your chest over the collapsed area to loosen mucus. This technique is called percussion. Also, mechanical mucus-clearance devices, such as an air-pulse vibrator vest or a hand-held instrument may be used.

Surgery

Removal of airway obstructions may be done by suctioning mucus or by bronchoscopy.

If a tumor is causing the atelectasis, treatment may involve removal or shrinkage of the tumor with surgery, with or without other cancer therapies (chemotherapy or radiation).

Continuous positive airway pressure (CPAP) may be helpful in some people who are too weak to cough and have low oxygen levels (hypoxemia).

A 52 year old woman comes to your OPD with complaints of dizziness on getting up.

 A 52 year old woman comes to your OPD with complaints of dizziness on getting up.

She has a past history of Myocardial infarction 7 years ago.

You decide to organize an ECG  which is given below :

1 . Comment on R wave from leads V1 - V 6.

There is poor progression of R wave from V1 - V6 .

Poor R wave progression refers to the absence of the normal increase in size of the R wave in the precordial leads when advancing from lead V1 to V6.

In lead V1, the R wave should be small. The R wave becomes larger throughout the precordial leads, to the point where the R wave is larger than the S wave in lead V4. The S wave then becomes quite small in lead V6.

2 . What are the causes of this phenomenon ?

The causes of Poor R Wave Progression are as follows:

Old anterior myocardial infarction

Lead misplacement (frequently in obese women)

Left bundle branch block or left anterior fascicular block

Left ventricular hypertrophy

Wolff-Parkinson-White syndrome

Dextrocardia

Tension pneumothorax with mediastinal shift

Congenital heart disease

A 45 year ol man presents to your ED clinic with complaints of left sided chest pain since 45 minutes.

 A 45 year ol man presents to your ED clinic with complaints of left sided chest pain since 45 minutes.

He is a known smoker and Diabetic as well.

He says it seems like a heavy stone on his chest.

You immediately order an ECG and send Tropinin T  levels as well. 

1. Comment on the ST segment in Leads V 1 , V2 and V3 :

There is ST segment elevation in Leads V1 , 2  and V 3.

2. What are the causes of ST segment Elevation :

Causes of ST Segment Elevation

Acute myocardial infarction.

Coronary vasospasm (Printzmetal's angina)

Pericarditis.

Benign early repolarization.

Left bundle branch block.

Left ventricular hypertrophy.

Ventricular aneurysm.

Brugada syndrome.

3. What is the most likely diagnosis in thes patients case ?

Acute Anterior STEMI / ST segment Elevation Myocardial Infarction.

https://www.medstudentnotes.com/?ref=SAADSHAH

https://www.medstudentnotes.com/?ref=SAADSHAH