Question

Q1. An elderly female pt. who was a known case of T2DM (on SGLT2 inhibitor), and ischemic HF for 2 years ago, highly strict to anti-failure measure and aldosteron antagonist, with Hx of chronic AF, presented recently with nausea and vomiting, abdominal pain, visual impairment (blurred and sometime yellow vision) with frequent syncopal attack and reduced urinary output. On examination, fully conscious, oriented, jaundiced, elevated JVP with significant character, afebril, pulse rate is 40 BPM, regular, BP 130/60 mmHg, bilateral creps, soft heart sound, pansystolic murmur at apical region radiated to left axillary region and with maximum intensity at expiratory phase.
A. What is the cause of his GIT symptom?
B. What is the medical term of this visual impairment?
C. What is the causation of jaundice?
D. What is your auscaltatory interpretations? And why happen?
E. What does JVP character mean? And what is the normal JVP?
F. What is your expected ECG findings? And what are the name of this ECG changes?
G. What is the benefit and superiority of SGLT2 inhibitor, and give examples? and named aldosteron antagonists?
H. What is the investigations you should order?
I. What is your lines of management?

Answer 1

A. What is the cause of his GIT symptom?

Ans:-  GIT gastrointestinal (GI) symptoms generally are accepted as more common in people with diabetes than in the general population, the reported prevalence has varied substantially, being much higher (≥70%) in most but not all outpatient samples (1–5) compared with community studies. More than 60% of the risk factors for hypertension are associated with metabolic disorders. Furthermore, many metabolic risk factors can directly cause the vascular dysfunction and the elevated blood pressure. It suggests that the GI tract could be an initial organ of metabolic hypertension.

B. What is the medical term of this visual impairment?

Ans:- Amblyopia is a vision development disorder in which an eye fails to achieve normal visual acuity, even with prescription eyeglasses or contact lenses. Also called lazy eye, amblyopia begins during infancy and early childhood. In most cases, only one eye is affected. Symptoms: Blurred vision

C. What is the causation of jaundice?

Ans:-  Jaundice is caused by a buildup of bilirubin, a waste material, in the blood. An inflamed liver or obstructed bile duct can lead to jaundice, as well as other underlying conditions. Symptoms include a yellow tinge to the skin and whites of the eyes, dark urine, and itchiness

D. What is your auscaltatory interpretations? And why happen?

Ans:-  Asculatatory interpretation An auscultatory gap is a period of diminished or absent Korotkoff sounds during the manual measurement of blood pressure. The improper interpretation of this gap may lead to blood pressure monitoring errors: namely, an underestimation of systolic blood pressure and/or an overestimation of diastolic blood pressure. 130/80 to 139/89 is now considered Stage 1 hypertension and anything 140/90 or above will be considered stage 2 hypertension. Previously, people were not considered to have high blood pressure until the top reading hit 140. so patient is in stage 1 of hypertension Abnormally slow heart rates are usually those below 60 beats a minute and can be either harmless or life threatening

E. What does JVP character mean? And what is the normal JVP?

Ans:-  The absence of 'a' waves may be seen in atrial fibrillation. An elevated JVP is the classic sign of venous hypertension (e.g. right-sided heart failure). JVP elevation can be visualized as jugular venous distension, whereby the JVP is visualized at a level of the neck that is higher than normal JVP

Normal: JVP is 6 to 8 cm above the right atrium.

The jugular venous pressure (JVP, sometimes referred to as jugular venous pulse) is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different forms of heart and lung disease

F. What is your expected ECG findings? And what are the name of this ECG changes?

Ans:-

The commonest abnormalities were T wave changes. Other significant abnormalities were sinus bradycardia, ST segment changes, ventricular premature beats and U waves.

Name of ECG myocardial ischemia and myocardial infarction.

G. What is the benefit and superiority of SGLT2 inhibitor, and give examples? and named aldosteron antagonists?

Ans:-

The SGLT2 inhibitors offer many advantages. These medications provide effective treatment for patients in all stages of type 2 diabetes regardless of blood glucose level, insulin sensitivity, and insulin secretion. SGLT2 inhibitors work independently of insulin secretion, therefore lowering the risk of hypoglycemia. exmple of inhibitors canagliflozin (Invokana) canagliflozin/metformin (Invokamet) canagliflozin/metformin extended release (Invokamet XR) dapagliflozin (Farxiga) dapagliflozin/metformin extended release (Xigduo XR) aldosterone antagonists = There are currently two aldosterone antagonists commercially available in the United States, spironolactone and eplerenone. Spironolactone is a nonselective aldosterone antagonist, and eplerenone is selective to the aldosterone receptor.

H. What is the investigations you should order?

Ans:-

Random blood sugar test

Oral glucose tolerance test.

CBC

Liver function tests

Cholesterol test

ECG

Chest x-ray

USG

Urine test

sputum tests

Myocardial perfusion imaging (single-photon emission computed tomography) [spect]

Positron emission tomography [pet]

I. What is your lines of management?

Ans:-  In a service line model, the service line manager is responsible for coordinating patient care and information flow in a comprehensive manner along the patient's journey of care. During a course of care, patients are cared for by providers in many departments or facilities of the healthcare system

focusing on the patient improving the quality of care and patient safety Continuity of care   improving coordination in providing care creating a common vision and goa

There are many medication avilable accounding to patient conditions.

T2DM (on SGLT2 inhibitor):-

· Metformin (Glucophage, Glumetza, others). Generally, metformin is the first medication prescribed for type 2 diabetes. ...

· Sulfonylureas. Meglitinides. Thiazolidinediones. DPP-4 inhibitors. GLP-1 receptor agonists. SGLT2 inhibitors. Insulin.

Common medications used to control nausea and vomiting include:-

· promethazine (Phenergan), prochlorperazine (Compazine), droperidol (Inapsine), metoclopramide (Reglan), and ondansetron (Zofran).

Treatment of Syncope:-

1. Simple reassurance, proper hydration, anticipatory guidance, safety precautions, and increased salt intake are helpful for common type fainting (vasovagal syncope) especially in children and young adults.

2. Insertion of a pacemaker is the standard treatment for syncope caused by a slow heartbeat (bradycardia).

Active seizure flowchart:-

Midazolam, Diazepam, Phenytoin

Treating the cause of bibasilar crackles:-

- inhaled steroids to reduce airway inflammation. - bronchodilators to relax and open your airways. - oxygen therapy to help you breathe better. - pulmonary rehabilitation to help you stay active.

There are currently two aldosterone antagonists commercially available spironolactone and eplerenone. Spironolactone is a nonselective aldosterone antagonist, and eplerenone is selective to the aldosterone receptor.

Angiotensin receptor blockers (ARBs) inhibit the renin–angiotensin–aldosterone system (RAAS) by blocking the binding of angiotensin II to its receptor, which in turn leads to vasoconstriction and prevents the release of aldosterone.

General referance:-

{Eye Disease could be caused by Gut Bacteria. Even though your eyes are not located anywhere near your digestive system, it seems that there may be a connection between your vision and your gut. Autoimmune uveitis occurs when the immune system behaves erratically and attacks certain eye proteins

Abdominal pain can be caused by many conditions. However, the main causes are infection, abnormal growths, inflammation, obstruction (blockage), and intestinal disorders. Cramps associated with menstruation are also a potential source of lower abdominal pain, but more commonly these are known to cause pelvic pain.}

{Possible causes of a soft first heart sound include: early atrioventricular closure (in this situation the leaflets are semi-closed at the end of diastole)
Hence, causes include:- mitral regurgitation. - low blood pressure, for example with M.I. rheumatic carditis. severe heart failure. left bundle branch block.

Causes include mitral valve prolapse, tricuspid valve prolapse and papillary muscle dysfunction. Holosystolic (pansystolic) murmurs start at S1 and extend up to S2. They are usually due to regurgitation in cases such as mitral regurgitation, tricuspid regurgitation, or ventricular septal defect (VSD).