Clinical Problem Solving- January 2022
E LOG MEDICINE
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I have reviewed one of the following E logged cases, made by Dr. P. Rashmitha, for a ‘Clinical problem solving’ conference
Briefing up the case and the discussion,
A 55 year old male, shepherd by occupation, presented to the OPD with the chief complaints of fever (on and off), loss of appetite, headache, body pains, generalised weakness since 2 months, cough since 2 weeks and vomitings and pain in abdomen since 2 days, had got to be diagnosed as Multiple Myeloma.
Q1) Critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyze the diagnostic and therapeutic uncertainties.
— Quantitative assessment : 7/10
— Qualitative assessment :
- Title must have been more elaborative
- Must have used bullet points to make it less clumpsier.
Positives
- Case sheet is novel and ethically sound.
- Detailed and consistent history taking.
- Periodic input of investigations ordered.
- Detailed input of lab investigations and results.
Negatives
- Title of the blog can be improved
- Pictures showing pallor are absent.
- Could have made it in a more organised manner making it easier to understand and free flowing.
- Treatment history not mentioned, if any.
Q2) Problem list in order of perceived priority.
1. Patient is severely anaemic with initial Hb value of 3.8 which quite improved to a value of 7.3 on administration of 1 unit PRBC.
2. Patient’s deranged renal function tests diagnosed him with acute renal failure, hence administered inj. Lasix 20
3. Sputum showed positive gram positive cocci and gram positive bacilli, hence administration of antibiotics has been emphasised.
4. These antibiotics can cause Acid reflex, commonly known as heartburn, hence administration of Pantop was emphasised.
Q3) Include the review of literature around sensitivity and specificity of the diagnostic interventions mentioned and same around efficacy of the therapeutic interventions mentioned for each patient and suggest innovative solutions
OVERVIEW: Multiple myeloma is a cancer that forms in a type of white blood cell called a plasma cell. Healthy plasma cells help you fight infections by making antibodies that recognize and attack germs.
In multiple myeloma, cancerous plasma cells accumulate in the bone marrow and crowd out healthy blood cells. Rather than produce helpful antibodies, the cancer cells produce abnormal proteins that can cause complications.
DIAGNOSTIC INTERVENTION : Tests and procedures used to diagnose multiple myeloma include:
Blood tests. Laboratory analysis of the blood may reveal the M proteins produced by myeloma cells. Another abnormal protein produced by myeloma cells — called beta-2-microglobulin — may be detected in the blood, giving clues about the aggressiveness of the myeloma.
Additionally, blood tests to examine your kidney function, blood cell counts, calcium levels and uric acid levels also helping in diagnosis.
- Urine tests. To check how well the kidneys are working and analysis of the urine may show M proteins, which are referred to as Bence Jones proteins when they're detected in urine.
Examination of your bone marrow. Examined for myeloma cells. Specialized tests, such as fluorescence in situ hybridization (FISH) can analyze myeloma cells to identify gene mutations.
- Imaging tests. To detect bone problems associated with multiple myeloma. Tests may include an X-ray, MRI, CT or positron emission tomography (PET).
Information taken from: https://www.mayoclinic.org/diseases-conditions/multiple-myeloma/diagnosis-treatment/drc-20353383
Diagnosis can also be made if you have a blood test for something else and it shows:
- Too much calcium in your blood (hypercalcemia)
- Too few red blood cells (anemia)
- Kidney problems
- High total protein levels in your blood, but low levels of one called albumin (also called as a "globulin gap").
COMPLICATIONS: Multiple myeloma can cause problems like:
- Bone problems. Your bones can become weaker, leading to fractures.
- Blood problems. You might get anemia, which means your body doesn't have enough red blood cells. This can make you tired and pale and cause heart problems. You might also have too few platelets, which makes it harder for your blood to clot.
- Infections. When you have myeloma, your body produces a lot of weak antibodies that crowd out healthy ones, making it harder for you to fight infection. A lack of white blood cells can also weaken your immune system.
- Kidney damage. Myeloma can clog your kidneys so they don't filter the way they should. This might lead to kidney failure.
THERAPEUTIC INTERVENTION:
Based on what was emphasised in the blog, the patient was given symptomatic treatment.
On research, the following are useful in treatment of multiple myeloma. There is no cure but the disease progression can be slowed down.
1. Chemotherapy. Chemo drugs are generally given in mixtures. The ones that treat multiple myeloma are:
- Bendamustine (Treanda)
- Cyclophosphamide (Cytoxan)
- Doxorubicin (Adriamycin)
- Etoposide (VP-16)
- Liposomal doxorubicin (Doxil)
- Melphalan (Alkeran, Evomela)
- Vincristine (Oncovin)
Corticosteroids. These drugs can help other treatments work better. When you're getting chemo, dexamethasone or prednisone are prescribed to help with side effects.
**click the corresponding blue colour words for more details.
2. Targeted Therapies. Target proteins, genes, or tissues and prevent cancer from growing.
— Immunomodulatory drugs make your immune cells stronger so they can attack cancer cells. They also help starve the myeloma cells in your bone marrow by keeping new blood vessels from forming.
— Monoclonal Antibodies help your immune system find and destroy myeloma cells.
— Proteasome inhibitors stop the process that eats up extra proteins in cells. Myeloma cells make lots of proteins. When they build up, the cancer cells die.
— Histone deacetylase (HDAC) inhibitors, affect which genes are active in your cells.
— A nuclear export inhibitor, selinexor, kills tumor cells by holding back a protein called XPO1.
— Antibody drug conjugates: Belantamab mafodotin-blmf (Blenrep), is currently the only drug classified as a BCMA (B-cell maturation antigen) inhibitor. It's a combination of a monoclonal antibody and a toxin.
3. Immunotherapy. This uses your immune system to fight cancer cells. Chimeric antigen receptor (CAR) T-cell therapy involves versions of your immune T cells that have had their genes changed to attach to cancer cells.
4. Interferon. When it's used as a drug, it can slow the growth of myeloma cells. You might take interferon if you've had treatment and are in remission.
INNOVATIVE SOLUTION: STEM CELL TRANSPLANT.
- A machine is used to remove some of your stem cells, then freeze and store them. Or they may use stem cells from a donor.
- Next, a high-dose chemotherapy is given, sometimes with radiation.
- This will destroy almost all the cells in your bone marrow, the plasma cells that cause the disease as well as healthy ones.
- Your doctor will put the saved or donated stem cells into your bloodstream through a tube called a catheter.
- These can replace the destroyed bone marrow and start making healthy blood. It may take several weeks to refresh all of your blood cells.
- Stem cell transplantation often helps you live longer, but it doesn't cure multiple myeloma, and it can cause serious complications. For example, it can make you more likely to get infections.
Ethical trials for the above solution have no intervention and comparator, to put into a P.I.C.O format.
But for further details, the following links can be checked out:
Q4) Link to your own case report.
I have collaborated with a final year UG mam, to learn and discuss about a case of A 70 year old daily wage labourer by occupation, was brought to the casualty with chief complaints of altered sensorium since one day and fever, shortness of breath and productive cough since 20 days, diagnosed with ALTERED SENSORIUM SECONDARY TO UREMIC ENCEPHALOPATHY.
Following is the link for the so,
Q5) Patient centered experiences.
Last month was quite an experience where i came across different kinds of patients with different kinds of problems.
It all starts in comforting the patient first and then extracting the details. And over a period of time, i became well versed. I still remember how nervous i was when it was my first history taking case, but now i am even more confident and enthusiastic.
I improvised as to how to put up the jumbled pieces of a puzzle together and learn to make a diagnosis. Its really interesting about how much new stuff you learn daily, and that is what keeps you motivated further.
It such a sublime experience wherein you’ll come across how some habits have affected some people’s lives and how some are struggling to make it the next day. How some people are so strong to battle through such situations and how some people become oblivious about their condition.
For an instance, i was in ward the other day and there was a patient diagnosed with chronic kidney disease with underlying conditions like diabetes and HTN and current high creatinine value. She was supposed to be on MHD, but the patient’s attendant refused the treatment and took the patient home even after a PG explained the after consequences and the urgent need to go for MHD. But the patient and attendant had no cool to hear us out but for behaving oblivious.
Another incidence where a patient’s history tells us about his smoking and drinking habits which landed him into severe health complications.
Apart from subjective wisdom, i learned a lot of other moral values which would have a real impact on my personality.
On a whole, i would like to thank Dr. Rakesh Biswas Sir and GM department for teaching us and providing us opportunities like these.
Thank you.
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