Name - Chenna Bhavana
Posted from 12/08/2022 to 11/10/2022
Case No - 1 :
32 year old female with swelling of Multiple Joints and Fever
QUESTIONS AROUND THIS PATIENT :
1. Deflazacort vs prednisolone in autoimmune arthritis?
A : Clinical studies have indicated that the average potency ratio of deflazacort to prednisolone is 0.69–0.89 and 6 mg of deflazacort is equivalent to 5 mg of prednisolone. However, the therapeutic dosage ratio has been reported to range from 1:1.2 to 1:1.5.
Due to the short pharmacokinetic half-life of its active metabolite, pharmacodynamic effects of deflazacort are of shorter duration than those of methylprednisolone and prednisolone.
Based on the results of seven trials of various design, including double blind cross-over studies, paired patient studies, and between-patient studies involving 160 patients, the potency ratio of deflazacort vs. prednisolone was estimated to be 1.28 by Avioli.5 In fact, the equivalence ratio of deflazacort/prednisolone may depend on the disease [i.e., 1.2:1 in rheumatoid arthritis,6 juvenile chronic arthritis7 and nephrotic syndrome,8 and 1.4:1 in asthma9 and polymyalgia rheumatica.
DISCUSSION AROUND THIS PATIENT -
Can this be distal RTA sir ??
ABG showing bicarb of 8
Left renal calculus
RA??
Also urine ph 6
But abg is showing HAGMA
139-(104+8.7)=26
Na 139
K 3.2
Cl 104
The study of intermediates and end-products of metabolism in the context of immune cell functions is an emerging field that has been termed immunometabolism (Pearce et al., 2013). It is now clear that molecules such as succinate, lactate, acetyl-CoA, fumarate are more than intermediate by-products in metabolic pathways as they function as signaling molecules capable of linking metabolic reprograming with immune and inflammatory responses in immunity, inflammation and cancer (Figure 1; Haas et al., 2016). Whether metabolic perturbations are causal or the effect of the disease and how they can impact on the prognosis of RA is an area of significant current research.
Nuclear magnetic resonance (NMR) spectroscopy–based metabolomics on serum and urine samples from people with RA has identified a metabolic signature of patients with active established RA which differs from that of healthy controls (Young et al., 2013). Among the metabolites investigated 3-hydroxybutyrate and lactate were much higher in RA than in the control group. In addition choline, lactate and low-density lipoprotein (LDL) lipids strongly correlated with CRP a marker of disease activity (Young et al., 2013). This evidence suggests that NMR could be used as a tool to predict the development of atherosclerosis and other metabolic complications often associated with inflammatory disease.
Points in favour of distal RTA
Abg showing acidosis
Autoimmune condition
Hypokalemia
Urine ph >5.5
Renal caliculi
And most importantly a similar case report that I have found
Renal tubular acidosis (RTA) is a disorder of renal acidification characterized by inability to acidify urine to pH <5.5 despite the presence of severe systemic metabolic acidosis and hypokalemia. Hypokalemia leads to acute-onset paralysis and may be a presenting manifestation of RTA. Its association with various autoimmune disease has been reported previously in published reports, but has not been much emphasized. We, hereby, report a case of RTA that presented during the flare of rheumatoid arthritis (RA). A 42-year-old female, a known case of RA for 5 years, presented with persistent joint pain for 1 week and acute-onset quadriparesis for 3 days. Primary investigations revealed hypokalemia with metabolic acidosis. She was managed conservatively with potassium supplements and bicarbonate supplements along with steroids and disease-modifying anti-rheumatic drugs. Such a presentation of renal tubular acidosis in a patient during the flare of rheumatoid arthritis is distinctly rare and previously unreported in published studies.
Definition of bone erosion :
Bone erosion is a radiological term and reflects the fact that imaging is used for detection.10 Erosions are visible on plain radiographs as breaks in the cortical bone surface, and are often accompanied by loss of the adjacent trabecular bone."
Alkali therapy may be used to correct acidosis in patients with distal or proximal RTA .In patients with distal RTA, alkali therapy also corrects for hypokalemia. Alkali therapy with 1–2 mmol/kg/day NaHCO3 or KHCO3 is normally sufficient to equal daily acid production . however, in patients with nephrolithiasis or nephrocalcinosis, the elevated Na+ load with NaHCO3 therapy may cause increased urine calcium excretion, which can precipitate kidney stone formation. In these patients, K-citrate administration is preferable; this will also increase urine citrate excretion and prevent recurrence of kidney stones . Patients with severe hypokalemia should also receive K+ replacement (i.e., with KCl or K-citrate) to prevent further lowering of serum K+ concentrations and symptomatic hypokalemia . Long-term treatment of distal RTA generally requires a combination of NaHCO3 and KHCO3 . Children with distal RTA require sufficient NaHCO3 or KHCO3 (usually 4–8 mmol/kg/day) to maintain normal serum HCO3– concentrations and prevent growth retardation
Anion gap
143-(12.4+103)=27
Delta anion gap=(pt anion gap-normal anion gap)=27-10=17
Delta bicarb =difference between normal and pt bicarb=25-12.4=12.6
If delta anion gap Is more than delta bicarb It means the patient is having both normal and high anion gap
If delta anion gap = delta bicarb patient is only having high anion gap
The pathophysiological mechanism of dRTA in relation to autoimmunity remains unclear. Several reports suggest that autoantibodies against the CAII enzyme [36, 57] or the acid–base transporters are involved in the pathogenesis of dRTA in autoimmune disease
Urine anion gap in our patient is positive(228+15.6-221=26) indicating RTA in our patient
Gastrointestinal bicarbonate losses can be differentiated from RTA by estimating the urine anion gap. Negative urine anion gap indicates increased renal NH4 + production (extrarenal cause for metabolic acidosis), while positive gap suggests RTA
For adults, normal urine potassium values are generally 20 mEq/L in a random urine sample and 25 to 125 mEq per day in a 24 hour collection.
This is because the urine K+ should have been much lower for that hypokalemia and this is classically "pseudonormal". Same like with normal PTH in hypercalcemia is abnormal
Case No - 2 :
45 year old male with Shortness of Breath and Abdominal pain
QUESTIONS AROUND THIS PATIENT:
1. What is the Cause of his Septic Shock?
A : If you look at his AKI you can better explain it with a biliary sepsis than with adrenocortical insufficiency
2. How does the Septic shock leads to Adrenocortical Insufficiency?
A : In patients with severe sepsis, numerous factors predispose to glucocorticoid insufficiency, including drugs, coagulation disorders and inflammatory mediators. These factors may compromise the hypothalamic–pituitary axis (i.e. secondary adrenal insufficiency) or the adrenal glands (i.e. primary adrenal failure), or may impair glucocorticoid access to target cells (i.e. peripheral tissue resistance).
3. We see septic shock everyday. How many develop adrenal insufficiency?
A : On the other hand, the prevalence and diagnosis of adrenal insufficiency (AI) in critically ill patients remain controversial. AI is estimated to occur at the rate of 25%-40% in the patient with septic shock (5), depending on the diagnostic test and the threshold applied for the diagnosis of AI.
Case No - 3 :
40 year old male with Flank pain, Decreased urine output and Burning Micturition
Questions to be explored :
1. Didn't his first operating surgeons notice a PUJ when they operated on his ten years back?
2. Are his Renal calculi due to his Metabolic syndrome?
OT outcome:
As Patient shifted to OT he was catheterised sir. Immediately 300ml of PUS drained into urobag. Then started with incision. Intra op they found few adhesions and pus in the kidney. So did nephrectomy and now patient is stable sir. 2 units of blood given intraoperatively.
Case No - 4 :
26 year old Female with Fever and Heavy Menstrual Bleeding
1. Can a Dengue patient present with Heavy Menstrual Bleeding?
A : In sexually active women, dengue can co-present with menstruation and this can lead to severe dysmenorrhea and excessive menstrual bleeding.
Case No - 5 :
50 year old Male with Fever, Loose stools and Vomiting
Case No - 6 :
41 year old Female with Fever and Burning Micturition
My Learning Experience:
During Units Duty :
* Learned to Insert Foley's Catheter for a patient under the Guidance Dr.Sai Charan (PGY3) on my Duty day in the Casualty.
* Inserted Foley's Catheter for Patients in AMC and ICU.
* Learned to Insert Ryle's tube under the guidance of Dr.Sai Charan (PGY3) on my duty day in the Casualty.
* Inserted Ryle's tube for patients in AMC and ICU.
* Learned to take ABG sample under the Guidance of Dr. Sai Charan (PGY3) on my duty day in the Casualty.
* Took ABG samples for patients in Ward,ICU,Casualty and AMC
* Took Venous samples for the routine investigations in Casualty,AMC,Ward and ICU.
* Learned to do CPR.
* Learned to Perform Lumbar Puncture.
* Learned the Blood Transfusion Procedure.
During ICU Duty :
* Inserted Foley's Catheter for a patient in ICU Bed NO.6 and ICU bed NO.2.
* Inserted Ryle's tube for a patient in ICU Bed NO.1.
* Took Many ABG samples.
* Did CPR.
* Assisted in the Intubation of a Patient in ICU Bed NO.6.
During Nephrology Duty :
* Assited Dr.Nishitha (PGY1) and Dr.Shashikala (PGY3) in the insertion of Central Line and also Applied Sutures Twice.
During Ward Duty :
* Took ABG samples for patients in the ward.
* Placed a IV cannula for a patient in the ward.
* Took Venous samples for Routine Investigations of the Patients.
Case Presentations :
* Presented a case of 45 year old Male with Shortness of Breath and Abdominal Pain under Dr.Sai Charan (PGY3) and Dr.Pavan kumar (PGY1) on 16/08/2022.
* Presented a case of 40 year old Male with Flank pain, Decreased urine output and Burning Micturition on 26/09/2022.
