Case wise Active learning and discussion-7
Case 7--Hypogonadism and Right heart failure due to primary pulmonary artery hypertension
A 30 YEAR OLD WITH BILATERAL PEDAL EDEMA AND DYSPNEA ON EXERTION
We the MBBS final year students have been given these cases on weekly basis to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
- Link to my analysis:
ACTIVE LEARNING AND CONVERSATIONAL DECISION SUPPORT TO TREATING TEAM OF THIS CASE :
- My active learning discussion:
[5/30, 13:51] MBBS 2016 UG 3: Sir...in the 30 yr old patient...he has a high stepping gait which indicates peripheral neuropathy
[5/30, 13:52] MBBS 2016 UG 3: But the diagnosis in his case report says that he has proximal lower limb myopathy
[5/30, 13:52] MBBS 2016 UG 3: Sir...in that case...he should be have waddling gait??
[5/30, 13:54] MBBS 2016 UG 3: This indicates that he should be having distal weakness
[5/30, 16:49] Post Residency PG1: Yes very good point.
Please enter that query onto your log and also share with the treating team 👍👏👏
[5/30, 16:58] MBBS 2016 UG 3: Ok sir👍
[5/30, 16:59] Post Residency PG1: Can you share the patient's intern log link?
[5/30, 17:00] MBBS 2016 UG 3: Yes sir
[5/30, 17:01] MBBS 2016 UG 3: https://saikiranpatnam.blogspot.com/2020/05/medicine-case.html?m=1
[5/30, 17:16] Post Residency PG1: Absolutely chuffed to inform that Sai Kiran, our intern from previous batch has shared a link suggesting low testosterone levels could increase risk of PAH.
Because of his profound thinking, I went ahead and searched if the link really is true. This is what I found.
Patients with PAH also had lower testosterone (8.63 vs 14.13 ng/mL; P =.02) and progesterone (0.32 vs 0.68 ng/mL; P <.001) levels compared with controls.
Having higher estradiol and estradiol/testosterone levels was significantly associated with an increased risk for PAH (odds ratio per ln estradiol, 3.55; P <.001; odds ratio per ln estradiol/ testosterone, 4.30; P <.001). Conversely, having higher testosterone and progesterone were both associated with a reduced risk for PAH (odds ratio per ln testosterone, 0.48; P =.003; odds ratio per ln progesterone, 0.09; P <.001).
[5/30, 17:16] Post Residency PG1: 👏👏👍 Can we explain all his problems with hypogonadism? How do we explain his neurological findings? Also by guaging his current Tanner's status what would be the severity of his hypogonadism?
[5/30, 17:16] Post Residency PG1: Testosterone deficiency (<9.9 mmol/l) was found in 54% patients with a mean value of 8.63 in patients with idiopathic PAH. In age, sex and BMI matched controls, a mean TT value of 14.9 was observed. Seems significant to me.
[5/30, 17:20] MBBS 2016 UG 3: Yes sir
[5/30, 17:20] MBBS 2016 UG 3: Hypogonadism can have neurological features
[5/30, 17:20] MBBS 2016 UG 3: https://pubmed.ncbi.nlm.nih.gov/23292617/
[5/30, 17:20] MBBS 2016 UG 3: This link says it all sir
[5/30, 17:21] Post Residency PG1: 👍👏👏
[5/30, 17:22] Post Residency PG1: Please quote the portions relevant to our current patient
[5/30, 17:22] MBBS 2016 UG 3: Ok sir
[5/30, 17:34] Post Residency PG1: Anything more specific to our patient's neurological findings?
[5/30, 17:45] MBBS 2016 UG 3: Sir...this source https://eje.bioscientifica.com/view/journals/eje/156/6/1560673.xml says that there in change in calf muscles elasticity in hypogonadism
[5/30, 17:49] MBBS 2016 UG 3: And Sir...i also found a case of testosterone induced myopathy
[5/30, 17:54] MBBS 2016 UG 3:
I've highlighted that point
[5/30, 17:57] Post Residency PG1: 👏👏👍
[5/30, 17:58] MBBS 2016 UG 3: Thank you sir
- OTHER DISCUSSIONS:
[5/31, 08:50] MBBS 2016 UG Student 10: http://shravanireddy15.blogspot.com/2020/05/general-medicine-e-log-book-6.html
A question for the reader:
How does Right Ventricle fails in pulmonary artery hypertension?
[5/31, 08:54] MBBS 2016 UG Student 22: In pulmonary artery hypertension there is increased afterload to the right ventricle
[5/31, 09:04] Post Residency PG1: 👍What is afterload vs pre-load and what is their significance in the management of heart failure?
[5/31, 09:04] MBBS 2016 UG Student 5: *The heart needs to work harder to force the blood through the vessels against this pressure. Over time, this causes the right side of the heart to become larger. This condition is called right-sided heart failure, or cor pulmonale.
[5/31, 09:06] MBBS 2016 UG Student 22: Afterload is resistance against which ventricle has to pump and preload is amount of ventricular stretch
[5/31, 09:06] MBBS 2016 UG Student 10: 👍Why right ventricle only affected ?
[5/31, 09:09] Post Residency PG1: 👏👏👍Cor pulmonale may not have failure. What is the exact definition of cor pulmonale?
[5/31, 09:09] Post Residency PG1: 👍👏👏
[5/31, 09:10] Post Residency PG1: Answer this someone
[5/31, 09:10] Post Residency PG1: To put it in another way when will the left ventricle similarly get affected?
[5/31, 09:11] MBBS 2016 UG Student 22: When there is systemic hypertension
[5/31, 09:12] MBBS 2016 UG Student 5: Structural integrity of right ventricle
[5/31, 09:13] MBBS 2016 UG Student 21: Aortic stenosis
[5/31, 09:13] MBBS 2016 UG Student 10: Yes...Right Ventricle is thinwalled
[5/31, 09:13] MBBS 2016 UG Student 22: Cor pulmonale occurs when the blood pressure in the pulmonary artery—which carries blood from the heart to the lungs—increases and leads to the enlargement and subsequent failure of the right side of the heart.
[5/31, 09:13] MBBS 2016 UG Student 22: When there is rt ventricular failure ,preload to the left ventricle decreases this can lead to left ventricular failure also
[5/31, 09:17] Post Residency PG1: 👍👏👏
Dr Vara now can you answer Dr Shravani's question again by looking at Dr Sai Bhavana's answer?
[5/31, 09:18] MBBS 2016 UG Student 20: Cor pulmonale is the right heart failure when there is primary lung disorder?
[5/31, 09:18] Post Residency PG1: 👍Why is it called cor pulmonale?
[5/31, 09:19] Post Residency PG1: Does it always have to have failure? What is the exact definition?
[5/31, 09:19] Post Residency PG1: 👍
[5/31, 09:20] Post Residency PG1: Does reduced pre-load cause failure or it's a strategy to treat failure?
[5/31, 09:22] MBBS 2016 UG Student 22: Reduced preload can lead to decrease in cardiac output
[5/31, 09:22] MBBS 2016 UG Student 5: COR PULMONALE÷
●DEFINITION÷
Cor pulmonale, often referred to as pulmonary heart disease. is defined as dilation and hypertrophy of the right ventricle in response to diseases of the pulmonary vasculature and/or lung parenchyma. Historically, this definition has excluded congenital heart disease and those diseases in which the right heart fails secondary to dysfunction of the left side of the heart.
[5/31, 09:26] Post Residency PG1: Why is pre-load reduction an often used strategy in heart failure other than afterload reduction?
[5/31, 09:27] Post Residency PG1: 👍👏👏Good Dr Vara. Please always share the reference link to anything that you share that are not your original thoughts.
See the important thing here is dilatation and not failure?
[5/31, 09:30] MBBS 2016 UG Student 5: Harrison's tb
18th edition pg no 1913
[5/31, 09:30] MBBS 2016 UG Student 22: Preload reduction results in decreased pulmonary capillary hydrostatic pressure and reduction of fluid transudation into the pulmonary interstitium and alveoli.
[5/31, 09:33] MBBS 2016 UG Student 3: In heart failure, preload is already elevated due to ventricular dilation and/or increased blood volume. Hence preload reduction will not exacerbate pulmonary or systemic congestion and edema.
[5/31, 09:36] Post Residency PG1: 👍How? Please elaborate
[5/31, 10:12] MBBS 2016 UG Student 22: decreasing preload leads to a reduction in ventricular wall stress by decreasing the size of the heart. Reducing venous pressure decreases proximal capillary hydrostatic pressure, which reduces capillary fluid filtration and edema formation
[5/31, 10:14] MBBS 2016 UG Student 22: Thank you sir ...for this discussion I got to know many things.
[5/31, 10:28] MBBS 2016 UG Student 13: Yes sure sir. Please send me his number.
[5/31, 10:37] MBBS 2016 UG Student 17: Cor pulmonale is primarily due to a respiratory disorder
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