Interdepartment case corrected quiz.pptx

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Quiz
Case

1. Refractory Shock – a case report MEDi-P2 ORCHESTRA

2. A 44-year-old female, presented to the casualty with complaints of Ge neralized weakness and fatigue since 15 days Loss of appetite since 1 days Fev er since 3 days. Clinical Formulation

3. Past History K/c/o hypothyroidism on tablet Thyroxine 25 mcg/day since past 3 years. No h/o any other comorbidities No h/o of previous hospitalisation except for the deliveries (FTND)

4. Family history: Not significant Menstrual history: Menarche : 15 years Irregular menses : since 3 years Amenorrhea : since 1 year. Obstetric History P4L4A0 All FTND Blood loss and blood transfusion in last delivery 8 years back.

5. On Examination Temperature 100 ◦ F. Pulse Rate 44/min, regular with peripheral pulses well felt RR 14/min BP 70/40 mmHg on right arm in supine position SpO2 98 % on room air JVP Not raised Patient conscious, oriented and obeying commands E/O Mild lower limb edema, facial swelling, pallor and dryness of skin.

6. Systemic Examination CVS S1 S2 heard. No murmur. RS Chest clear & B/L Air Entry Equal. CNS Conscious, oriented, obeying commands. P/A Soft, Non-tender

7. Bedside Investigations in Casualty… RBS: 127mg/dl ECG: Suggestive of sinus bradycardia without any ST-T abnormalities. Chest X ray: Within normal limits. ABG: Normal

8. What are the possibilities ? Can it be cardiogenic shock ? Can it be septic shock ?

9. Considering the history of fever and hypotension, patient was presumed to be in the septic shock. Normal saline (500ml) wasgiven as 300ml NS bolus f/b @60ml/hour but still the hypotension was persistent. Patient was taken on nor-adrenaline support and was shifted to ICU for further management. In the Casualty …

10. In the ICU… Central line was inserted in right internal jugular vein . Ce ntral venous pressure was negative. Patient was started on inotropic support, antibiotics, IV fluids as per CVP along with temperature, I/O charting and vitals monitoring. All routine labs along with blood culture and urine culture were sent.

11. Investigations on Day 1 Parameter Value HEMOGRAM Hemoglobin 10.4 gm /dl WBC 12.1 × 10 3 / uL Platelets 191.3 × 10 3 / uL E.S.R 40 at the end of 1 hour CRP 67.8 FEVER PROFILE Dengue Negative Widal Negative Malaria Negative Leptospira Negative RFT Blood Urea 35 mg/dl Creatinine 0.7 mg/dl Parameter Value LFT Total Bilirubin 0.7 mg/dl Direct Bilirubin 0.3 mg/dl SGPT 16 U/L SGOT 38 IU/L Total Protein 6.6 gm /dl Serum Albumin 3.4 gm /dl SEROLOGY HIV Negative HbsAg Negative HCV Negative SERUM ELECTROLYTE Sodium 137 mmol /L Potassium 3.8 mmol /L PT/INR 13/1.07 UPT Negative

12. Parameter Value CARDIAC MARKERS Troponin I 701 pg /ml CKMB 42 THYROID FUNCTION TEST TSH 2.04 T3 <40 T4 <0.91 Further Investigations

13. Patient’s fever subsided on day 2 of admission ; but the hypotension was persistent. Patient was maintaining BP of 100/70mm of HG on IV fluids (NS/RL @150cc/hr and Inj. Noradrenaline (8mg in 50 cc NS @ 10cc/ hr ). CVP was still negative despite of IV fluids and Inotropic support. Any attempt to taper down the Inotropic support resulted in fall in blood pressure. Course in the hospital … Refractory Shock under evaluati on

14. Further Investigations Urine Routine Normal Blood culture No growth Urine culture No growth USG (A + P) NAD 2D Echo Within normal limit Free T3 0.8 Free T4 0.5 Troponin I 122

15. Further investigation s Considering the menopausal age, FSH and LH values were on the lower side. TSH, T3, T4 were on the lower side pointing towards central cause of hypothyroidism. Serum 8AM cortisol was sent which turned out to be low i.e. 4mcg/dl . (Normal range: 5-25 mcg/dl) Test Value Reference range for menopausal women FSH 5.9 25.8 to 134.8 IU/L LH 6.49 14.2 to 52.3 IU/L

16. Differential Diagnosis Septic Shock Cardiogenic Shock Hypovolemic Shock Adrenal Insufficiency

17. Differential Diagnosis Parameter Septic Shock Cardiogenic Shock Hypovolemic Shock Adrenal Insufficiency Fever     Extremeties Warm Cool Cool Variable Pulse Rate  Variable   Ejection Fraction Normal Decreased Normal Normal CVP Normal /    Normal/  SVR     Cardiac Enzymes Normal  Normal Normal/ 

18. Based on the labs and clinical presentation, patient was preliminary diagnosed with adrenal insufficiency. Patient was started on Tablet Hydrocortisone 10mg – 5mg – 2.5mg in morning, early afternoon and late afternoon. Patient eventually responded with tapering of Inotropes and fluids. Eventually, blood pressure was 110/60mm HG without inotropic/fluid support. Day 5 of hospitalization….

19. The cause of adrenal insufficiency was most likely secondary (Central) due to following reason: TSH, FSH, LH was on lower side. 8AM cortisol was low. Electrolytes were normal i.e. mineralocorticoid was normal.

20. Types of Adrenal Insuffiency

21. History of heavy blood loss after 4th delivery with history of blood transfusion but records not available. Patient had lactational failure after the delivery. History of irregular menses afterwards. Not able to conceive thereafter. If you remember what happened 8 years ago….

22. Based on this history and presentation, we arrived at the provisional diagnosis of: “ Adrenal insufficiency secondary to Pituitary Necrosis”

23. MRI Brain with Pituitary cuts was ordered for confirmation. Films showed following findings: Coronal Section of MRI Brain showing Empty Sella

24. “ Piuitary gland is thinned out at the floor of pituitary fossa. Rest of the fossa is filled with CSF. Findings suggestive of partial empty sella .” MRI Report

25. Partial Empty Sella <50% gland filled with CSF. Complete Empty Sella >50% gland filled with CSF.

26. Finally, The Mystery Ends! This was a case of Sheehan’s syndrome. Think Masters, Think Pituitary

27. Sheehan Syndrome Definition: Necrosis of cells of the anterior pituitary gland following significant post-partum bleeding, hypovolemia, and shock. First & most common symptom : Absence of lactation. Other signs and symptoms may not present until years after the insult. Pathophysiology : Increase in pituitary volume and cell count occur in pregnant women but the blood supply to anterior pituitary does not increase. Hence it is more prone to ischemia after PPH.

28. Sheehan Syndrome Acute Presentation Lactational failure Difficulty in menses after childbirth Chronic Presentation Occurs months to years after initial insult Symptoms of hypothyroidism and hypocortisolism develop over the years Physicians may note hypotension and bradycardia during examination.

29. Hormone failure associated with hypopituitarism occurs sequentially: During childhood, growth retardation is presenting feature. In adults, hypogonadism is the earliest symptom.

30. Treatment Not much role of growth hormone replacement in adults.

31. Treatment Table from Harrison

32. TAKE HOME MESSAGE “ Always listen to the patient, they might be telling you the diagnosis.” – William Osler.

33. Medical Fun/Quiz

34. Q1. Which is the drug derived from this plant? Galega officinalis (Goat’s rue) Answer:- Metformin Prescribed to almost every 6 th patient. This is a traditional herbal medicine found in Europe. Which lowers blood glucose .

35. Q2. Nobel Prize in 2005 in Physiology or Medicine was awarded to Barry Marshall and Robin Warren for? Answer :- “For their discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease".

36. Trivia:- After failed attempts to infect piglets in 1984, Marshall, after having a baseline endoscopy done, drank a broth containing cultured H. pylori, expecting to develop, perhaps years later, an ulcer. On day eight, he had a repeat endoscopy, which showed massive inflammation (gastritis), and a biopsy from which H. pylori was cultured, showing it had colonized his stomach.

37. Q3. A 38 years old female presented with complaints of headache since 8 days. She was recently diagnosed with HIV. Her CSF showed following microscopic picture. Identify the image. Answer:- This is I ndia ink preparation of CSF showing a yeast cell along with non staining capsule. This is s/o Cryptococcal meningitis with image showing Cryptococcus neoformans

38. Q4. Which Indian physician discovered a novel treatment for Scorpion bite and what is it? Answer:- Dr. Himmatrao Bawaskar first used Prazosin for scorpion bite to reduce fatality rate from 40% to about 1%

39. Q5. Which one is better for emergency fluid resuscitation? Answer:- 18 G Peripheral IV cannula Central Venous Catheter 18 G Peripheral IV Cannula

40. Q6. What should be the ratio of blood products in massive transfusion protocol? : : Packed Cell Volume Platelets Fresh Frozen Plasma Answer:- PCV : Platelet : FFP should be transfused in ratio of 1:1:1 or 2:1:1

41. Q7. Which is the first medical college established in India (Mention the year)? Answer : Calcutta Medical College was the first college established in India on 25 th January 1835.

42. Q8. What are the charges for CBC and Serum Creatinine investigations in our Hospital? Answer:- 40 Rupees each are charged for CBC and Serum Creatinine respectively

43. Q9. Hanging garden

44. Q10.biometric names

45. Thank You!