Name: A. M. A.

Ragibul Munna
MC: 1447
Group: C
AFMC 18
Answer to question 1.
a) My diagnosis is myocardial infarction.
b) Diagnosis of a case of MI:
1. ECG - ST elevation - T wave inversion - Pathological Q wave
2. Cardiac enzymes –
Troponin I and T: Rises at 2 - 4 hours; Persists for 7 days
- CPK: Rises at 4 - 6 hours; Persists for 2 - 3 days
- AST: Rises at 12 hours; Persists for 3 - 4 days
- LDH: Rises at 12 hours; Persists for 7 to 10 days
c) Treatment of MI:
1. Admission in CCU
2. Complete bed rest
3. High flow O2 inhalation (60%) - 2 to 4 L/min by nasal canula
4. To relieve pain - inj morphine (5 to 10 mg) plus antiemetic (cyclizine
or metoclopromide) IV.
5. Aspirin - 300 mg (4 tablets)
6. Thrombolytic therapy - streptokinase, provided there is no
contraindication
7. Percutaneous coronary intervention
8. Others: - B blocker: IV bolus atenolol 5 to 10 mg or metoprolol 5 to
15 mg slowly over 5 minutes - Sublingual nitroglycerin - ACE inhibitor
- Statin – Heparin
Ans. to the question no: 2
a) Diagnosis: Subacute Bacterial Endocarditis (SBE)
b) Investigations:
• Hematological examinations
- CBC, ESR: Anaemia, Neutrophilic leukocytosis, High ESR
- CRP: High
- Serum urea & creatinine
- Urine R/M/E: Haematuria, proteinuria may present
- Blood culture (both aerobic & anaerobic): 3 samples from different
sites at 1hour apart.
• Imaging tests & others:
- Chest Xray P/A view shows cardiomegaly
- Echocardiography: To see vegetations, valvular lesions etc.
Transoesophageal echo is more sensitive.
- ECG
c) Treatment plan:
Ideally antibiotic should be given according to culture and sensitivity.
However, treatment should be started as soon as the blood sample is sent
for culture and sensitivity.
• For viridans streptococci-Benzyl penicillin 1.2 g IV 4 hourly and
gentamycin 1 mg/kg IV 8hourly for 4 weeks or ceftriaxone 2 gm once
daily IV for 4 weeks or vancomycin 15 mg/kg IV 12 hourly for 4 weeks.
• In acute case-flucloxacillin 2gm IV 6 hourly is added to cover
staphylococci.
• In penicillin allergy or meticillin resistant Staph. aureus (MRSA)
infection--triple therapy with vancomycin with gentamycin. Or another
regimen-vancomycin 1 gm 12 hourly IV with ceftriaxone 2 g every 24
hours.
• In penicillin resistant case-Flucloxacillin plus gentamicin IV.
• In prosthetic valve endocarditis-IV penicillin 6 weeks and IV
gentamicin 2 weeks should be given.
• For HACEK organisms-ceftriaxone 2 gm IV once daily for 4 weeks. If
prosthetic valve is involved, then treatment should be given for 6 weeks.
• Q fever endocarditis-prolong treatment with doxycycline and
rifampicin or ciprofloxacin.
Answer to the question no 3.
a) Most likely diagnosis: Hypothyroidism.
b) Investigations suggested for the patient:
Specific Investigation:
1. Serum free T3, T4, TSH level:
Low T3 T4 and elevated TSH: Primary hypothyroidism
Low T3 T4 and low/normal TSH: Secondary hypothyroidism
2. Thyroid peroxidase antibody
Nonspecific investigation:
1. ECG: Sinus bradycardia, Low voltage ECG
2. Serum enzymes: creatinine kinase(CK), Aspertate
aminotransferase(AST), Lactate dehydrogenase(LDH) maybe elevated
3. Plasma Lipid Profile: hypercholesterolaemia
4. Hb% and PBF: normochromic normocytic or macrocytic anaemia
5. Serum Electrolytes: hyponatraemia
6. Ultrasonography of thyroid gland
c) Medical emergency that may arise in case of this patient:
Myxoedema coma
Treatment:
- It is a medical emergency and treatment must begin before biochemical
confirmation of the diagnosis.
- Tri-iodothyronine is given as an intravenous bolus of 20 microgram
followed by 20 microgram 8 hourly untill there is sustained clinical
improvement.
- In survivors there is a rise in body temperature within 24 hours and
after 48-72 hours it is usually possible to substitute oral Thyroxine in a
dose of 50 microgram per day.
- Unless it is apparent that the patient has primary hypothyroidism e.g.
thyroidectomy scar or goitre, the thyroid failure should be assumed to be
secondary to hypothalamic or pituitary disease and treatment given with
hydrocortisone 100 mg IM 8 hourly.
- Supportive treatment:
1. Slow rewarming
2. Cautious use of intravenous fluids
3. Broad spectrum antibiotics
4. High-flow oxygen
5. Occasionally, assisted ventilation may be necessary.
Answer to the question no. 4
a) Classification of Oral hypoglycemic drugs:
1. Biguanides – Metformin
2. Sulphonylureas – Gliclazide, glibenclamide, glimepiride, glipizide.
3. Meglitinide – Repaglinides and nateglinides
4. Alpha-glucosidase inhibitors – Acarbose and miglitol
5. Thiazolidinediones – Pioglitazone, rosiglitazone
6. Incretin based drugs – Dipeptidyl Peptidase-4-inhibitors ( DPP-4) –
Sitagliptin, vildagliptin, linagliptin
Glucose like peptide – 1 ( GLP-1) inhibitors – liraglutide, exenatide

Indication of insulin therapy

- Diabetic ketoacidosis, Hyperosmolar hyperosmotic coma, Lactic
acidosis
- Surgery
- Pregnancy
- Severe infection
- Hepatic failure
- Severe renal failure
b) Difference between hypoglycemic coma and DKA

Points Hypoglycemic Coma DKA

History Excess insulin but no Too little or no

or insufficient food insulin but maybe
intake, heavy concurrent infection
exercise or digestive
disturbance
Onset Rapid onset; usually Slow onset
after taking insulin

Symptoms Weakness, tremor, Excessive thirst,

sweating, palpitation, polyuria,
hunger, occasional dehydration,
vomiting from depot vomiting, air hunger,
insulin abdominal pain

Signs –
1. Skin and tongue Moist Dry
2. Eyes Normal Sunken
3. Pulse High volume, Weak
4. BP tachycardia Low
5. Breathing Normal or raised Kussmaul’s
6. Acetone Smell Shallow or normal breathing
7. Reflexes Absent Present
8. Planter Response Brisk Diminished
Often extensor Usually flexor

Urine -
1. Ketone Body Absent Present
2. Glycosuria Absent Present

Blood –
1. Glucose Hypoglycemia Hyperglycemia
2. Bicarbonate Normal Reduced
3. pH Normal Low – metabolic
4. Acetone Normal acidosis
High

Treatment Oral or IV glucose Insulin or others

Prognosis Good Bad

Ans to the question no. 5

a)Possible cause: Tubercular plural effusion
b)Investigations:
i) USG guided plural fluid aspiration-straw color in appearance
ii)CBC- lymphocytosis ; high ESR
iii)Chest Xray- patchy opacity
iv)Serum protein to see Transudative/Exudative
v)Serum ADA
vi)Sputum for AFB stain & culture
vii)GeneXpert
c)Management:
i)Therapeutic aspiration-if breathlessness occurs. The performance of
the therapeutic thoracocentesis is highly recommended as soon as the
diagnosis is confirmed.
ii)Treatment of underlying cause- Standard Anti-TB chemotherapy:
Adequate therapy for tuberculous pleuritis is a 9 month course of
isoniazid and rifampicin daily.
iii)The administration of corticosteroids will rapidly relieve the patient's
symptoms of pleuritic chest pain, malaise, and fever.Markedly
symptomatic patients should be started on prednisolone 40 mg/day and
then gradually tapered over several weeks.
Ans to the question no-6
a) My clinical diagnosis is bronchiectasis.
b) Causes of bronchiectasis:
A) Congenital:
1) Cystic fibrosis.
2) Ciliary dysfunction syndromes: Primary ciliary dyskinesia (immotile
cilia syndrome). Kartagener's syndrome (sinusitis and transposition of
viscera
3) Primary hypogammaglobulinaemia.
B) Acquired – children:
1)Pneumonia (complicating whooping cough or measles).
2) Primary TB
3) Inhaled foreign body.
C) Acquired - adults:
1) Suppurative pneumonia.
2) Pulmonary TB
3) Allergic bronchopulmonary aspergillosis complicating asthma.
4) Bronchial tumours.
Complications of bronchiectasis:
1) Pneumonia.
2) Pneumothorax.
3) Empyema.
4) Metastatic cerebral abscess.
5) Severe life-threatening haemoptysis.
6) Recurrent infection.
7) Pulmonary hypertension.
8) Cor- pulmonale.
9) Type -2 respiratory failure.
10) Amyloidosis.
c) Investigations :
1) Chest X-ray: Bronchiectasis, unless very gross, is not usually
apparent on a chest X-ray. In advanced disease, thickened airway walls,
cystic bronchiectatic spaces, and associated areas of pneumonic
consolidation or collapse may be visible.
2) High-resolution CT scan of chest: Much more sensitive & and shows
thickened dilated airways
3) Sputum examination: Microscopic examination & culture.
4) X-ray of paranasal sinuses: 30% have concomitant rhino-sinusitis.
5) Serum Immunoglobulins: 10% of adults with bronchiectasis have
antibody deficiency (mainly IgA).
6) Sweat electrolytes: If cystic fibrosis is suspected.
7) Assessment of ciliary function: Nasal clearance of saccharine.
Treatment:
Principles of treatment are –
1) Physiotherapy : Postural drainage of sputum. At least 3 times daily for
10- 20 minutes.
2) Antibiotic: The appropriate antibioties are the same as those used in
COPD -
Aminopenicillin or a macrolide
Co-amoxiclav (where beta-lactamase producing organism are common)
Anthetic therapy should be guided by the microbiological results
• For pseudomonas - Oral ciprofloxacin (500-750 mg 12-hourly or
Ceftazidime by intravenous injection or infusion (1-2 g 8-hourly).
3) Bronchodilators.
4) Anti- inflammatory agents : Inhaled or oral steroids.
5) Surgical treatment : Excision of bronchiectasis areas is only indicated
in a small proportion of cases usually young patients in whom the
bronchiectasis is unilateral & confined to a single lobe or segment on
CT.