Peer learning June 2023

This is an attempt to learn and share the information through peer learning and integrating clinical knowledge with available evidence to improve the patient related outcomes and improve in self learning skills .

Conversational peer to peer learning through online platforms ( whatsaap / zoom / google meet )

23/6/23  - 43F with fever, loin pain

https://vibha-hegde.blogspot.com/2023/06/43-year-old-female-with-pedal-edema_21.html

https://chat.whatsapp.com/Bpgi7D2SQAw66Cj8OGTpXP

EBM : 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3755527/

The dosage of long-acting human insulin did not show any relation to eGFR. In contrast, a strong positive relation between dosage and renal function was found for insulin glargine and insulin detemir. After classification according to renal function, the insulin dosage at eGFR less than 60 ml/min was 29.7% lower in glargine-treated and 27.3% lower in detemir-treated patients compared with eGFR greater than 90 ml/min. Considering the whole range of eGFR, short-acting human insulin did not show a relation with renal function. Only after classification according to renal function was a dose reduction found for human insulin at eGFR less than 60 ml/min. In contrast, requirements of insulin lispro were significantly related to eGFR over the whole range of eGFR. At eGFR less than 60 ml/min the insulin dosage was 32.6% lower than at eGFR greater than 90 ml/min. The requirements of insulin aspart did not show any association with the eGFR.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4470208/

Among people with T2DM the frequency of hypoglycemia will vary by treatment modality. In general the frequency of hypoglycemia is greatest with insulin and insulin secretagogues that are excreted primarily by the kidney and/or have active metabolites that may accumulate in patients with impaired renal function such as glibenclamide (glyburide) [2,34,38]. Prandial insulin (short-acting insulin administered before meals to limit postprandial hyperglycemia) is associated with a greater frequency of hypoglycemia than long-acting basal insulin [39]. Metformin, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, glucagon-like peptide 1 (GLP-1) mimetics and sodium glucose cotransporter-2 (SGLT2) inhibitors do not increase the risk of hypoglycemia when used without sulfonylureas or insulin [30,34,40].

Emperor HF trail - 

https://www.nejm.org/doi/full/10.1056/NEJMoa2107038

24/6/23 - 38M dyspnoea, oliguria and pedal Edema 

https://133trajesh.blogspot.com/2023/06/38-yr-old-with-shortness-of-breath-and.html?m=1

https://chat.whatsapp.com/J4c1YTOkejm1wZLiUxp6xi

Bronchiectasis 

https://www.ncbi.nlm.nih.gov/books/NBK430810/

25/6/23 ( Sunday ) 

Hypercalcemia

Trousseau sign?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091937/

Trousseau sign is elicited in hypocalcemia when the ionized calcium level is 1.75–2.25 mmol/L.1 The hand adopts a characteristic posture when the sphygmomanometer cuff is inflated above the systolic blood pressure within 3 minutes. The metacarpophalangeal joints are flexed, the interphalangeal joints of the fingers and thumb are extended and the thumb adopts a posture of opposition (main d’accoucheur).2 Trousseau sign is more specific than Chvostek sign for latent tetany, which can be caused by hypocalcemia, hypomagnesemia and metabolic alkalosis.3,4 A positive Trousseau sign is seen in 1%–4% of healthy people.1 The sensitivity of the sign is not known, but the sign can be absent in patients with definite hypocalcemia.

@⁨Dr Himaja Jnr Gm Kam⁩  look up how metabolic alkalosis will cause carpopedal spams

Dr Navya jnr Kam : In alkalosis calcium gets bound to albumin and there is decreased ionised calcium

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4952344/

Total serum calcium consists of free or ionised calcium (50%), calcium bound to protein (40%), principally albumin, and calcium coupled with anions (10%), eg lactate, bicarbonate. Unlike total serum calcium, ionised calcium is unaffected by albumin concentration but varies according to disturbances in acid-base balance. H+ ions compete with calcium to bind albumin. Thus acidotic states result in increased free/ionised calcium and alkalotic states conversely, a decreased ionised calcium. Acute hypocalcaemia may manifest with neuromuscular symptoms of circumoral and digital paraesthesiae, tetany, bronchospasm and cardiovascular instability and is a medical emergency.

Yes sir 4 fever spikes are there 

With max temp -102.3f

Pgy4 : Can you summaries the trends of your investigations in terms of improving or deteriorating..??

Harika : Actually MODS 

With acute liver injury increasing

Acute kindney injury (resolving )

Tlc counts decreasing 

But decrease in platelet counts (1.2. ---1.0--- 80,000)

Pgy4 : Landing up in DIC. What about BAL..??

Harika : Okay sir 

Planning to do now sir

Mini BAL done sent samples 

Fo c/s cbnaat and cytology

And escalated to piptaz

Pgy2 : Just by increasing RR it made wonders

Pgy4 : Along with RR we are looking pressures and volumes also with its rough interpretation through graphs 📊 

Good quality lavage sample.. hope we followed all aspetic precautions and completed entire procedure with in 5 min..?

28/06/23

[6/28, 7:51 PM] DrvLohith Varma Gm Jnr Kam: https://vibha-hegde.blogspot.com/2023/06/22-old-female-with-intermittent-fevers.html?m=1

[6/28, 7:51 PM] DrvLohith Varma Gm Jnr Kam: https://vasishta175.blogspot.com/2022/02/admission-3-and-6-amc-bed-1-patient.html?m=1

Previous admission blog sir

[6/28, 8:31 PM] saicharankulkarni: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3287034/figure/fig1/

[6/28, 8:32 PM] saicharankulkarni: In this classification, neurogenic bladder arises from

lesions above the pontine micturition center (e.g., stroke or brain tumor) producing an uninhibited bladder,

lesions between the pontine micturition center and sacral spinal cord (e.g., traumatic spinal cord injury or multiple sclerosis involving cervicothoracic spinal cord) producing an upper motor neuron bladder,

sacral cord lesions that damage the detrusor nucleus but spare the pudendal nucleus producing a mixed type A bladder,

sacral cord lesions that spare the detrusor nucleus but damage the pudendal nucleus producing a mixed type B bladder,

lower motor neuron bladder from sacral cord or sacral nerve root injuries.

[6/28, 8:36 PM] saicharankulkarni: In the mixed type A neurogenic bladder (the more common of the mixed type bladders), detrusor nucleus damage renders the detrusor flaccid (also referred to as detrusor areflexia), while the intact pudendal nucleus is spastic producing a hypertonic external urinary sphincter. The bladder is large and has low pressure, so the spastic external sphincter produces urinary retention. The detrusor pressure is low so upper urinary tract damage from vesicoureteral reflux does not occur, and incontinence is uncommon.

Possibly in our patient by history @⁨DrvLohith Varma Gm Jnr Kam⁩ ..??

[6/28, 8:38 PM] DrvLohith Varma Gm Jnr Kam: Yes sir

[6/28, 8:38 PM] DrvLohith Varma Gm Jnr Kam: It looks more like type A neurogenic bladder

[6/28, 8:41 PM] saicharankulkarni: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3062359/

[6/28, 8:48 PM] DrvLohith Varma Gm Jnr Kam: Sir, so this LMN type bladder involving lesion from s2 to s4?

[6/28, 10:07 PM] Dr. Navya Gm Jnr Kam: https://sowjanyareddypalakurthy150.blogspot.com/2023/06/45m-with-diabetic-ketosis-secondary-to.html

[6/28, 11:24 PM] saicharankulkarni: The maintenance of human balance mainly depends on the coordination of vestibular system, visual system and proprioceptive system (Maurer et al., 2001). In an upright position, a normal person can stand steadily when the eyes open and close; but when two or more systems are damaged, the human body will not be able to maintain balance. For example, when a patient is suffering from Sensory Ataxia, the visual system can provide compensation information when the eyes are open, so the patient can remain upright and stable; Visual compensation would disappear when the eyes are closed, patients will not be able to maintain upright stability. This is the theoretical basis of Romberg’s sign has become an important part of modern neurological clinical examination (Lanska, 2002).

In Romberg’s test, the patient’s feet are closed and arms are placed on both sides of the body. Standing is divided into two stages: opening eyes and closing eyes. Firstly, the patients are allowed to open their eyes and stand for a certain time, then the patients close the eyes and stand for a while, and the patients are observed: whether their body have obvious shaking in two stages. As long as there is a stage in which the patient shows standing instability, the Romberg’s sign is positive (Pearce, 2005). Before carrying out Romberg’s test, lower limb diseases or other factors should be excluded. In order to prevent the patient from falling down, protective pads should be laid around the patient’s standing and medical staff should also take care of the patients. During the experiment, normal people can keep their body stable whether they open or close their eyes. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046926/