October online exam
57/M
1)Reason for ascites:
As per the history and examination: ? A)cirrhosis of the liver secondary to chronic daily alcohol consumption
Hepatosplenomegaly suggestive of portal hypertension
B) hypo albuminemia-serum albumin being 1.6 , suggesting chronic pathology, ?decreased synthesis by the liver, (accompanied by decreased synthesis of vit k dependant clotting factors)
2)Reasons for lymphedema:
Secondary causes as per history and examination are 1)infection:filariasis, cellulitis
2)trauma 3) non obstructive causes of chronic venous insufficiency
https://www.ncbi.nlm.nih.gov/books/NBK537239/
Reason for ulcerations and recurrent blebs
Lymphedema-the stagnation of lymph obstructs the clearance of bacteria
Leading to constant cytokines and other inflammatory mediators release
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2804019/
3)asterexis and constructional apraxia
The cause for asterixis is the increased passage of ammonia across the blood brain barrier , absorbed more in the areas of cerebellum and basal ganglia I
Ref from sleisenger (pathophysiology of hepatic encephalopathy, pg 1578)
The treatment included, using non absorbable disachharide (lactulose ) for causing catharsis and lowering intestinal pH to decrease the abdorbtion of ammonia, and use of antibiotics rifaximin for altering intestinal Flora and stool ph
Q2)54/M
As per the guidelines suggested here, ATT should be given according to Child PUGH's criteria
<=7 - two potential hepatotoxic drugs , except pyrazinamide can be used
8 to 10 -one hepatotoxic drug
>10 -alternative drugs wid fluroquinolones, tetracycline can be used if renal parameters are normal.
Drugs should be stopped if serum ALT levels rise to 5 times normal,
Or atleast by 3 times if patient has jaundice or symptomatic for hepatitis.
Drug induced hepatitis is usually a diagnosis of exclusion
As the patient is a chronic alcoholic , the baseline levels can be above the normal limit prior to the start of ATT
2)clinical investigations were sputum positive tb
3)high saag and low ascitic protein suggestive of cirrhosis is the cause for ascites
47/M
1)further approach to this patient is doing a renal biopsy , as the cause is not evident in the history and examination, and the course of development with aggrevation of symptoms without known trigger for one month,
2)https://www.kidney-international.org/article/S0085-2538(15)56330-8/fulltext
With respect to the article stated above in relation to advantages and disadvantages of biopsy for the patient
The prognosis can be accertained and response to treatment with spacing interval renal biopsy in case of resistance to treatment .
One of the case reports for advantage of renal biopsy in nephrotic syndrome with possible corelation with other disease
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125421/
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