Bi Monthly Exam NOV 16

 First case

This is a case of a 55 year old man with severe acute pancreatitis who landed up with SIRS and Acute kidney injury, ARDS and paralytic ileus 

The anatomical location is the inflammation to pancreas secondary to gallstones, alcoholism and hyperlipidemia. 

Acute pancreatitis rarely lands up to end organ failure by release of proteolytic enzymes and cytokines causing peri pancreatitic inflammation, fat necrosis, coagulative necrosis, hemorrhage.

The patient is complaining of pain abdomen because of pancreatitis and abdominal distension because of ascites due to third space fluid loss.

Chest X-ray shows bilateral pleural effusion because of third space fluid loss. 

A. CECT Abdomen to look for complications of pancreatitis and any pancreatic necrosis 

ERCP for any obstructing gallstones 

B. the patient was put on NPO as food intake when the pancreas is already inflamed is not advised as it leads to release of pancreatic enzymes 

2. Antibiotics in acute pancreatitis is not advisable as it’s an inflammatory process. Antibiotics have only been advised in few cases of pancreatic necrosis. 

The main stay of treatment is fluid therapy, analgesia for the pain.

Second case 

This is a case of 55 year old man with Anemia, renal failure, bone pains, recurrent infections and lytic punched out lesions in the skull 

The anatomical location is the bone marrow where there is a malignant proliferation from a single clone of cells 

Anemia in these patients occurs because of the growing tumor in the bone marrow, further suppression myeloid production, reduced erythropoietin production.

Renal failure occurs because of light chain deposition in the tubules causing tubular damage, hypercalcemia, hyperuricemia, 

Amyloid deposition in glomerulus 

and hence these light chains remain undetectable in the urine on complete urine examination for which we do urine for bence jones proteins which detects the free light chains in the urine. 

Bone pain occurs because of suppression of osteoblasts mediated bone formation and osteoclasts cells activation via the cytokines released by the myeloma cells leading to hypercalcemia. These patients also tend have vertebral collapse because of this reason. 

These patients are severely immunocompromised also because of the immunosuppressants they are put on so they tend to catch up recurrent infections.

B. Thalidomide or lenolidomide which is a thalidomide derivative is used with a dexamethasone

3rd case is 

51 year old man with heart failure with reduced ejection fraction 

History of right frontal lobe infarct and Atrial Fibrillation 

The anatomical location is the heart.  Diabetes mellitus, hyperlipidemia and hypertension are risk factors for heart failure

This occurs because of cardiomyocyte loss and fibrosis

B. The mainstay in the treatment of heart failure is to reduce the preload and the afterload.

Diuretics is used to reduce the preload. After load can be reduced by drugs such as ACE inhibitors, ARBs. Beta blockers reduces the rate of contractility and myocardial oxygen demand and it also prevents cardiac remodelling.

Fluid restriction and salt restriction is to keep a check on the preload

4th question

 31 year old man with heart failure and peripheral neuropathy due to thiamine deficiency in an alcoholic patient 

It is a high output cardiac failure. 

Wet beri beri is associated with peripheral vasodilation, arteriovenous shunting,cardiac failure. 

Decreased metabolic energy to the tissue causes weakening of cardiac muscle and cardiac failure.

B. Supplementation of thiamine everyday and replacing the lost thiamine

Diuretics to reduced preload