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A Game of Diagnostics

May 24 | 1:30 PM

This is definitely an sumptuous for all physicians by this amazing Medflix select faculty - Dr. Tushar Shah. The first step in healing is to diagnose the problem, but the key is to do so with only the most basic and necessary resources. Clinical diagnosis is the key for all Indian physicians but it comes with experience. Let's understand from Dr. Tushar Shah how to effectively do the diagnosis and what are the essential diagnostic tests required for any particular condition.

[Music] so good evening everyone i'm dr nivedita and i welcome you all this evening on behalf of team netflix uh it's a slightly different session and for this session we have dr prashasha he's a consultant physician with advanced multi-sociality hospital in mumbai so i'll just introduce the game we call this a game of diagnostics it is played in a format called password which is a childhood game that i used to play in colleges in school there are 13 sets of clues each set has three clues and uh we'll give all all clues are towards one diagnosis there are 13 such diagnosis we will be giving one clue you have to for uh dr jacob block mr oklahoma will try to guess the condition if they can't guess in the first clue they'll get the second clue and third clue they'll get 30 20 and 10 points uh depending on which clue they guess the condition in then we'll discuss the condition a bit discuss all the clues so uh let's start so this is the first clue all three of you can any three any one of you three can answer that we are not playing it any in any particular order so there are two conditions of the 13 which have a slight overlap with the quiz we played last time i'm sorry for that but i think we can always have a revision you want etiquette dopamine deficiency in iron deficiency are the two most common causes any guesses what condition are we talking about we'll go to the second clue and i can request the audience also to put their answers in the comments section uh so that we know that they are also following the clues second group pre garland is now preferred over dopaminergic drugs because of impulse control disorders with the latter so restless like syndrome restless leg syndrome is the correct answer jacob you get 20 points and the third clue is symptoms safely occur in the lower limbs during periods of inactivity and supine position a little bit about restless leg syndrome which we also discussed last time uh restless leg syndrome we all know how to diagnose patients have a discomfort especially in the lower limbs when they lie down to sleep and they cannot sleep because of that discomfort it is very important to understand that the discomfort is a restlessness and not a cramping pain pain is not considered a symptom of restless leg syndrome though the patient may sometimes tell you that there is this is a painful condition it is more like an uncomfortable situation and a very important feature is that as soon as the patient stands up and starts walking the discomfort disappears this is an important symptom to elicit in restless leg syndrome the commonest secondary cause of restless tech syndrome which you cannot miss is iron deficiency so you every patient of restless lexicon you must look for serum iron studies or serum ferritin and if there is iron deficiency you must replenish the ion that itself is enough to cure the restless leg syndrome if uh and if it is not present and if there are no other secondary causes like for example pregnancy or ckd then you have to treat with drugs to correct the dopamine deficiency the typical drugs that have been used so far are dopamine allergic drugs lycrinol and pramipexole however both these drugs are now known to cause two kinds of problems one is something called impulse control disorder impulse control disorder is where the patients start gambling uh trading more in the stock market having uh sexual compulsions shopping uh like a maniac these are all impulse control disorders which are side effects of dopaminergic drugs and the second problem is something called augmentation augmentation is worth swimming of restless leg syndrome due to dopamine energy drugs and this these two reasons are why pregabalin and gabapentin are now considered first choice drugs for restless leg syndrome uh yeah so that is about restless leg syndrome any uh any questions from jacob nasman nissar and of course i'll take questions from the audience later okay let's go to the second clue second set the first one of the following three options constitute the first line of treatment of this condition drug x 100 mg bdd for five days drug y 160 by 800 mgpd for three days and drug z three gram single dose what condition are we trying to treat enteric fever can you make can you find tell me what is this drug said three grams single dose do you know of any drug which comes in a three gram single dose okay why huh imagine what disease are we talking about let's go to the second clue the condition is defined by its occurrence in an immunocompetent non-pregnant female in the child bearing age group who has no morphologic neurologic abnormalities that is how the condition is defined what condition are we talking about where you can use cotrimoxazole or these other two drugs let me tell you drug z is phosphor myosin and drug x is nitrofuran joint 100 mm now we are talking about a condition where the typical symptoms are dysuria increased frequency without vaginal discharge which may resolve with without antibiotics in a significant proportion of patients now can you tell me the condition many audiences have participated in written uti right but that is like the exact diagnosis anything else within uti that you would like to say right it is uti it is lower uti and it is uncomplicated systems now this is a very important definition it is not just it cystitis it is uncomplicated status why do we call it uncomplicated because it has to occur in a non-pregnant female if a pregnant female gets a status it is complicated it has to happen in a child bearing age group if a child gets cystitis it is complicated systems senior woman consisted in complications and no morphologic neurologic abnormalities that is the definition of uncomplicated cystitis for example prostate hypertrophy in men is a morphologic abnormality stones in a female as a morphological normality the reason why we define this as uncomplicated cystitis is that these patients do not require ultrasound you need not do sonography of these patients secondly these patients do not require urine culture in acute and currency studies you don't need urine culture so there are two important uh reasons why you should know this condition the drug treatment is either nitrofuran hundred milligram bdd fibres or cotrimoxazole any one of these three empirically depending on the patient's kind of predilection to side effects you have to give it empirically without a urinary culture can you get away without giving antibiotics very important a large percent 40 percent of patients can have resolution of uci say in honeymoon cystitis without any antibiotics so you could just treat symptomatically maybe for the pain with nsaids and the patient will become better uh on her own okay any questions here dr nisha jacob dr nasman sir how to differentiate it with other uti so cystitis you know how to diagnose right cystitis so probably big pain significant burning maturation increased frequency usually without fever upper unit right infection pyelonephritis is with high grade fever rigers vomiting flank pain without much dysuria in upper abdominal [Music] and frequency are less common so that's how you make out upper and lower uti and then if you diagnose cystitis then you have to these conditions have to be fulfilled child bearing age group non-pregnant female even incompetent so this then you know you have that your label is acute and complicated cystitis yeah we go on to the next this is uh i'll give you a hint this is a neurological condition where complete recovery is less likely if there is lateral reduction in salivary flow a neurological condition where if there is reduction in survival flow on the same side as the lesion complete recovery will be less likely whatever responsibility autonomic synthesis that is gustatory tearing all of you know it as crocodile tears may occur as a late manifestation and a recognized treatment is prednisolone 60 milligram per day for six days followed by a rapid paper over four days i will talk to you about a little bit about the bill uh policy and very sponsored as you know it is the uh seventh cradle now affection it's a lower motor neuron facial no affection typically caused by the virus is usually hsv herpes simplex virus and some patients have actually a program of viral infection meaning a upper issue attack infection but usually that is absent it it comes on suddenly bell's palsy and as you know it affects the whole face including forehead following eye closure angle of the mouth etc the important thing in belt policy is the treatment because if you die the diagnosis is very easy but if you start treatment late then the recovery becomes less likely full recovery as you know per se even if you don't treat it a large number of patients fully but the recovery is improved by giving steroids so you and the steroids should be started within ideally within 48 hours maximum 72 hours they should you should start used to your treatment steroids are all steroids 1 mg per kg per day so 60 mg in an adult male or 60 kg male 1 6 days followed by a rapid paper or 4 monday so 10 days of steroids or you can give even 60 milligram per day for a total of 10 days and stop abruptly because steroid can be stopped abruptly if even less than two weeks and uh so this is the and many people also give acyclovir cycle that is herpes antiviral therapy i believe that absolutely zero good evidence for giving antiviral therapy so you can avoid antibiotic therapy completely and just give steroids many people send patients for physiotherapy again something that i don't think has any scientific evidence and you may not waste the patient's time or money going to the physiotherapist for treatment so uh that is about baseball any question here we will ask the audience questions once we are done with uh uh is my sound okay because i'm getting some echoes of my sound focus sorry okay great let's go to the next condition [Music] okay this is a slightly tricky clue mosquito bone disease manifesting is cough fever destiny and wheezing googly but not not difficult dango fever cough disney and wheezing you think lucker in dengue unless unless there's a rds then the patient will have hypoxia etc no not dengue i'll go to the second clue it's its recurrence can be prevented by one's yearly administration of albin dissolved plus diethyl karamazi kalazar is incorrect and peripheral eosinophilia with absolute visual account more than 2000 is a hallmark of these uh hallmark and dc that is diethyl carbohydrate is given for 21 days now there are some people have written filariasis but that is not the correct answer that i would like yeah somebody just said tropical eosinophilia a tropical pulmonary eosinophilia which is a component of phyllariasis so filariasis has these components the first component of phalaenosis is the acute event the first occurrence of filarial disease which is a proximal disease in the groin in males for example hydrocele in females for example para uterine collection of fluid this and with of course fever and rigors with what is called as centrifugal lymphangitis meaning proximal image that is spreading downwards is your acute final areas then the second manifestation is when the adult worm residing in the lymphatic releases microfile area these microfilaria go into the bloodstream hoping that some mosquito will catch them but not all microfilaria will be caught by the mosquitoes and the microfilaria will end up in the pulmonary circulation where they will they will die there they will get entrapped and will die in the small vessels when they go into the pulmonary vessels they cause an inflammation which is called tropical pulmonary eosinophilia the hallmark of this probably polygonophilia is an illness which has fever of dyspnea and vz and the peripheral eosinophilia is usually more than two thousand absolute counts the commonest problem with us physicians when when we uh encounter such patients is differentiating between low flow syndrome and tropical pulmonary using villa i'll tell you what a low floor syndrome is low flow syndrome is when the larvae of say or round travel through the bloodstream from the lungs they travel upwards into the trachea bronchial tree and go down the gi tract i hope you know this life cycle of worms now why do worms travel like this from the gi tract uh the larvae go into the circulatory system go into the lungs and go into the airways and then back to the chair is to mature and then the larva when they come back into the gi tract they become adult worms in in tropical publication philia the microfileria will not mature in the bloodstream they are just there to be taken up by the mosquitoes so that they can infect other people they will mature within the mosquitoes so we have to understand that tropical pulmonary uranophilia symptoms will be persistent whereas low flow syndrome symptoms are self-limiting as soon as the larvae go out of the lungs into the gi tract the symptoms will go away so short lasting symptoms which may not require any treatment would happen in low flare syndrome whereas in tropical pelvisionophilia what looks like an asthmatic episode with fever like your bronchitis it will stay unless you treat it this is very important understand how do you treat it how do you diagnose it one some people look for microfilaria on the peripheral smear rarely found there is a serology test for my phyllariasis which you can do and if you have classic symptoms and an absolute account which is high 2000 plus you just give the patient diethyl carbohydrate 6 mp per kg per day for 21 days not 14 days 21 days and as the adult worm is going to stay in its place in the lymphatics you have to give such a person every year a combination of alpha dissolve and the pec single dose each six some people kgd every year so that they don't get recurrent tropical pulmonary ears yeah uh somebody's written i will make things another option for prevention it is a correct uh it's the body we said which is the right thing we can give periodic iowa medium also 200 to 400 micrograms per kg body weight per dose so that is tpe next to this cardiac condition is diagnosed only if the symptoms are more than two months old and i'm not worsening over that period what am i talking about [Music] heart failure no heart failure is not diagnosed not diagnosed if symptoms are more than two months old immediately no it is considered stable because most patients will do well with conservative therapy and will not need intervention now it becomes easier means metal brainsmith is incorrect and drugs like trimeth are sometimes used to alleviate symptoms now what is the diagnosis angina stable agile wonderful chronic stable angina is the correct answer now let us define angina properly china as you know is chest pain due to coronary ischemia on walking which is relieved usually on resting stable angina is angina which is not worsening meaning there is no crescendo neither is the duration of anjan increasing nor is the distance at which angina occurs reducing that's called stable angina chronic stabilization any angina that is more than two months old is now called chronic stable angina now this angina does not have a significant escalation to acute coronary syndrome that is why it's called chronic stable angina and most such patients can be managed conservatively why is less than two months called not stable angina it is statistically known that if an angina period angina starts today the chances of getting an acute current syndrome are high for the first two months which is why the first two months are considered a period of instability and of course you know that unstable angina is therefore defined as shorter than two months angina that is worsening in duration or in a shortening of the disease angina occurring at rest anjana occurring post meal all these are now called unstable angina treatment of chronic stable enzyme of course the number one treatment the most important drug to be given of course besides aspirin and statin which are given all atherosclerotic diseases is beta blockers beta blockers are the mainstay of conservative therapy in angina the reason why peter blocks are used is because they reduce the heart rate and hence reduce the demand of blood supply then there is amplified as an enzyme there are nitrates there is uh there is diameter sitting evaporating the evaporation is typically used when beta blockers are not uh contraindicated or if beta blockers are reducing the blood pressure too much then you can add evaporating then there is the potassium channel or drug called granulosa these are all uh and yeah nicole and life of what we currently remember that all these drugs trimmed acetylene evaporating granular zinc nitrates and nicola do not improve endpoints like mortality they are symptomatic drugs they improve the quality of life they allow the person to walk more and do their normal day-to-day activities yeah so there is chronic stable angina let's go to the next one clue number one in the tanzanian language in one of the tanzanian dialects it means to become contorted what disease are we talking about to become conducted controlled of course means to become you know bent and crooked in your limbs etc yeah the mortality in this mosquito born illness in ammonia is more due to excessive use of nsaids and steroids than the disease itself and arthritis resolves within three weeks in seventy percent of patients in a small procedure the arthritis can last more than two years and we require disease modifying anti-romantic drugs like methodology a few points about chicken mania which are which are very important and i think chicken has one of the like dengue is mismanaged uh in the majority of cases that we have to improve our uh our management of ammonia first thing is easy to diagnose clinically sometimes you can diagnose in those in these monsoon months when chicken is more because if you do the same mosquito as dengue a patient will come into your clinic with you know bent knees limping supported by a relative land with fever fever in chile does not last more than three days that is very important to know sometimes even just one day rash of chicken which is usually a macular rash will not last more than one or two days extremely important to know no long term rash and third important thing is chikungunya causes more actual years than oil years so arthralgia arthritis is the whole mark like in dengue myalgia is the hallmark but arthralgia is the hallmark so if you get myalgias also with arthralgias you should start thinking whether it is more like dengue and not cheating what is the what is the arthritis like uh jacob is the arthritis more axial skeleton or appendicular strike more limbs or more spendicular appendicular skeleton appendicular is is the arthritis asymmetric or symmetric uh asymmetry very very good is it more distal or more proximal within the lifter asymmetric distill more than proximal perpendicular more than axial skeleton so it is not difficult to digest but there are tests in the first five days what tests can you do chicken ghonia pcr pcr is a test that you can do in the first five days and after 15 days the chicken igm may come positive and that also only about 50 of patients so mostly it is a clinical diagnosis less an investigation diagnosis now the most important thing we the pain the pain is severe as you know the pain is debilitating pain patient can't go to the loo you cannot get up from bed so you are always tempted to give strong drugs arsenal does not work very well and nsaids are typically used my suggestion is use nsaids but use them in uh spurts when you use nsaids for three four five days stop ask the patients you paracetamol in between then maybe use headsets again be careful again about not using inserts for long time in the elderly others and says cause cardiac side effects gi saturdays kidneys everything you know that some people have started using steroids now please don't use steroids that is very important don't use steroids for children causes mortar and since then it's both increased mortality in chicken money so to give relief use insects in spurts trap paracetamol in the elderly don't give opioids like dependent or triamidol in the young you may try opioids but of course remember that they can get addictive so it is a difficult situation i often refer my patients of chikungunya to homeopaths so that you know the patients can get some uh palliative treatment from the baths till the disease cures itself important to know 70 percent of patients will get better in three weeks but 12 percent of patients will have symptoms more than 2 years 12 percent of patients so it becomes a chronic arthritis and in these people many rheumatologists after three months of persistent pain many rheumatologists believe that methotrexate or hcqs works and they have been giving these two drugs uh in some people i uh i usually refer my patients who go beyond three weeks three months to a rheumatologist for further management so that is about uh chikungunya let's go to the next condition first clue it is a benign often familial condition that can affect peripheral extremities the head and the essential tremor neurological condition i'll go through the clues and then explain the symptoms classically resolve temporarily on drinking alcohol and the principal drug is useful for symptomatic treatment clonazepam and criminal okay so essential tremor it has three names familial tremor essential trimmer benign tremor the cause is not known it is genetically predisposed and it is said that it is autosomal dominant with uh no with the phenotype not being always shown in the progeny so uh males more common than females onset can be at a young age in your 20s or 30s and it can gradually worsen three four things how to diagnose benign essential tremor or essential trouble first always ask a patient who has from who has come to be tremor whether there is any family history of flavor and you will often get that the tremor is an action dreamer action drummer like this the trimmer is not a resting drummer like in parkinson's parkinson's resting tremor like this is an action driver and the tremor is symmetrical usually both hands arkansan usually starts at one side and the trimmer classically gets better on drinking alcohol it's a test not a treatment you can get better on bringing alcohol the other area of tremor is the head you can get your patient the head can be moving like this tremor or like this so you can get a head trimmer and the third tremor which disturbs some professions is the voice trimmer a voice drama of course will be bad for teachers speakers singers etc so there are three areas of tremors you may get just hand trimmer you may get a combination of flavors uh there is no diagnostic test and you you have to treat it symptomatically the cost commonly used drug as you know is the beta blocker propranolol if the bp allows you can go up to up to 116 milligrams of problem lol but usually we start with 10 milligram bdd and then escalate if the bp allows the most important thing is first ask the patient do you think you require treat your thing you require right most patients will tell you okay i am comfortable with the tremor i can't hold my glass my cup of tea i can do my signature i don't require my treat your treatment don't give the dream but do tell them that there is symptomatic treatment available and this has to be taken life long if you need to relieve the tremor the the second record is commonly used is stropira meat which is an anti-epileptic anti-migraine drug also and then we have clonazepam uh an anxiety drug and perimeter a barbiturate these are the choices of treatment we go on to the next this chronic weight loss causing autoimmune disorder is sometimes associated with dermatitis herpetic formulas any answers weight loss causing autoimmune disorder we go to second glue when suspected one sends blood for iga anti-tissue transparent disease celiac disease celiac disease celiac yeah company already also are avoided for life a little bit about celiac proof celiac sprue is not a rare condition the most important thing that you must understand it is not a rare condition it is it should not be missed the onset can be in childhood but it can be in a later age also the presentation will be chiefly with malabsorption features diarrhea weight loss deficiencies of iron of b12 etcetera and the patient sometimes can get a rash called dermatitis her body forms the once you suspect this malabsorption syndrome there are two things that you do to diagnose it you do this antibody it's an autoimmune disease so you do this antibody test called iga and tttg antibody and 95 percent of patients will have an abnormality of this test and eight percent okay deficiency they don't have any ig at all then you will have to test for igg antibodies to ttg so now uh so when we send blood for testing we do two tests simultaneously ige anti-tttg antibody and total iga because if total iga is low or absent then we know that this igg will have to be done so that is one test the serology the second test to confirm the gold standard test is a biopsy you do an upper gi endoscopy and do a deodorant or jejunal biopsy the biopsy will show villus atrophy and that is the confirmation of the diagnosis celiac disease uh jacob is due to what sensitivity to what to entertain in wheat what is the protein and take glycogen antiglide in antibody yeah so the sensitivity of the gut is due to clear to gliadin gladin is a component of gluten and gluten is a component of wheat barley alright so gladin causes stimulation of antibodies and these antibodies then cause a trophy of the lining of the intestine or villus atrophy and the treatment therefore is to avoid foods that contain gluten and these neutral containing principle foods are of course vitra and barley uh there is no other specific therapy and this avoidance of food is life loss okay so that takes us to the next [Music] the examiner to diagnose this condition uses the thumb of her dominant hand thumb to press with a force enough to blanch the examiner's fingernail at several points on the patient's body the principal symptoms are pain both above and below the waist and fatigue that sets in on waking up in the morning fibromyalgia fibromyalgia is the correct answer some modalities that give relief include tricyclic antidepressants the loch city cyclobenzaprine which is a muscle relaxant cpt which means cognitive behavioral therapy tai chi which is a chinese form of exercise and aqua aerobics now let us let me do a little brief of fibromyalgia one important thing about fibromyalgia and is that you should not use this condition if the symptoms start after the age of 45 fibromyalgia symptoms start below the age of 45 and can continue beyond 45 the condition is more common in women the conditions of etiology is not well known pathophysical is not well known they have labeled it as psychosomatic but we don't really know what the cause of condition is and two two principal symptoms that you should keep in mind when the patient tells you this you should start thinking the first symptom is [Music] these are two very important symptoms that the patient will tell you and then you know that there are nine pairs of points just go to uh go to go on google and search for uh tender points in fibromyalgia there are nine pairs of points which you have to press on the limbs front and back nine pairs and if the definition is that if 11 out of the 18 points nine pairs meaning 18 points if 11 out of 18 points are tender when you press hard enough so that your thumb fingernail blood blanches then when you are kind of diagnosing fibromyalgia of course not a very specific diagnosis or diagonal diagnostic test but there are no blood tests for fibromyalgia so fibromyalgia will remain a clinical diagnosis and these patients again i uh very frequently either i will send the patient the patient themselves will go to for alternative therapy and because allopathy does not have great medications for fibromyalgia so we give cognitive video therapy exercises yoga tai chi aqua aerobics are supposed to be very useful and sometimes drugs which are typically used in psychiatry like tricyclic antidepressant deluxe and nighttime dose of cyclobenzaprint a muscle relaxant is very good because when then they wake up with significant relief in pain so these are the other fibromyalgia let's go to the next one maximum inappropriate prescriptions of beta http or beta word brand names maximum inappropriate prescriptions happen in this condition which condition am i talking about baby where is beta esteem wrongly given they pay baby bpp is the correct answer pppv you should not give quality yeah i'll explain this diagnosis made by something called the dick's hall pike maneuver and trade treatment is by the way maneuver and bpp is due to autolifts in the auditory economy benign paralysis okay me discuss this a little bit with you bppv one thing is bppv is a diagnosis which is unmissable you cannot miss this diagnosis the symptom is sudden onset of vertigo either subjective that is head inside is rotating or objective that is the surroundings are rotating sudden onset of vertigo which is brought on by a change in posture and if the posture is steady there is no vertigo as soon as the posture is changed there is severe vertigo within a few seconds or a minute or two [Music] on we may request them to stop go on mute if noise is within them bppv is a recurrent condition meaning the patient has bppv right now in the morning today they wake up with bppv and then it will get better then it will occur again if it gets better better with the treatment like the pre maneuver it can reoccur again after a few weeks or a few months some patient will have recurrent ppp requiring treatment recurrently there are three common three causes of peripheral vertigo the commonest is bppv what is the second commonest dr nissar dr jacob peripheral vertigo sorry first is bppv second a meniere disease and the third is vestibular neuritis also called vestibular neuronitis remember they are the three most important causes of peripheral vertigo all peripheral particles are associated with nystagmus and some are associated with uh cochlear symptoms also now what i did not tell you about the dick's hall pack this all bike manual is a maneuver where you make the patient sit turn the head 45 degree and then make them lie down with the head back head over the level of the bed and this causes a rotatory nystagmus and severe vertigo and the treatment of bppv is by something called the early maneuver excellent videos on employment who are available on the on youtube just search for apple maneuver animation and you will get the the video if done by experts or experienced people fp maneuver is extremely beneficial or curative of bppv so that is the treatment of choice actually manure is a treatment of choice don't give beta st no structure or drug like that just send the person to a toward ent specialist or a physiotherapist who knows the eblino or you love the eblin maneuver and do it in your clinic it is simple and uh that's how you basically every manual is repositioning of the auto lifts or the small crystals within the semester repositioning them so that they don't freely float within the auditory canals okay so that is uh before i forget so we said there are three causes of peripheral vertigo bppv few seconds postural only and uh disappear on epleyman mode second manier disease many years or menial disease is a disease which affects both the vestibular system and the cochlear system so banana disease will have vertigo the vertigo of many years lasts for 20 minutes to 12 hours of often a long lasting continuous vertigo and it is not brought on by postural change postural change may aggravate the body but not brought on by and it is assumed is has four symptoms vertigo deafness decreased hearing tinnitus and fullness in the ear oral fullness so these four symptoms make up many a disease it all all usually starts on one side and can become bilateral the third disease is vestibular neurology service to neuritis it's a very so vestibular united 90s is different from many years student united is like bell's policy a very interesting comparison wells policy christian neurologists are similar best policy which now seventh western united style infection is the etiology of bell's policy viral infection is the etiology of westeros hsv is the commonest implicated virus in it in a western united also hsv is the commonest implicated virus acute onset unilateral imbalance policy acute onset vestibular in neuronics symptoms stay for days or weeks sometimes months in bell's policy symptoms stay for days weeks or months with vestibularities what are the symptoms of espionage vertigo which is continuous vomiting hallmark symptom of physiologists and ataxia these are the typical symptoms of westeros occasionally you get cochlear involvement and then you get deafness and tinnitus then it is called labyrinthitis the whole labyrinth vestibular and cochlear system are involved so they call it labyrinthitis so we're studying humanities our treatment is controversial in bell's policy we definitely use steroids in western neurolitis also steroids are used the evidence is less but they are used for several days or sometimes weeks so very similar to conditions and therefore because you know west uh bill's policy very well you should be able to know western unites very well too okay so that is about bppv what condition manifests as red eye that need not be referred to an apostologist a red eye conjunctivitis may have to be referred to in uh of yours because there are more than one form infective allergy conjunctivitis and allergic keratoconus divides can actually harm the cornea sometimes you may have to reference it resolves spontaneously in days without any oral medications or eye drops and it occurs due to occasionally only it due to accelerated weapons now you know this yeah so let me show you the condition can you see this what do we call this subconjunctival image now this is a condition that scares the patients and should not scare you at all subcontinental hemorrhage as you as the name suggests is humanity below the conjunctiva the sclera becomes red [Music] they sometimes just wake up with this this is a self-limiting benign usually benign condition meaning the hemorrhage will resolve over days do any eye drops help no do any tablets help no you don't need to give just reassurance is important occasionally suburban continental hemorrhage occurs due to accelerated hypertension occasionally and therefore of course every such patient should have to be checked and uh they should therefore control their blood pressure so that is hemorrhage let's go to the last second last piece this condition is diagnosed using the ct scan of the brain the lesion appears hyper dense or white for the first two weeks i so dance between two weeks week two and six and hypodense or black after six weeks what condition am i talking about hemorrhage second clue very good if small and minimally symptomatic it can be treated with steroids we are talking about we are talking about if small and mind minimally symptomatic it can be treated with steroids now this is a little known uh fact but i come to it and per hole using local anesthesia is the commonly used therapeutic answer is chronic subdural hematoma chronic is a diagnosis that is very rewarding you miss it and the patient becomes bad and can go become comatose you diagnose it it is such a beautifully treatable condition chronic cellulite as you know occurs due to head injury occurs in the elderly sometimes the head injury is not noticed by either the relatives or the patient themselves and this head injury will manifest maybe sometimes weeks or months later and this patient will come to you with altered sensorium drowsiness disorientation speech disturbance slurring sometimes a hemi mild hemiparesis mild ataxia so neurological subtle symptoms which are not like an acute stroke and you will have to think of chronic hematoma and you do a ct scan usually and you find something like this i don't know if i'm visible very well but if you see the ventricles are seen well on one side therefore there is this is one of the causes of what we call treatable dementia we go on to the next first clue about eight percent of these catastrophic events occur after sexual intercourse second clue some patients will experience sentinel headaches a few days or weeks prior to major event yes is typically a catastrophic event the patient has headache like uh lying never experienced before this is something called a thunder clap thunder clap headache is a headache which is a unprecedented headache uh very very severe some patients will have sentient headaches that is the perineum is is ruptured but is leaking not fully ruptured it leaks when it leaks there is headache stays for some time and then goes away and then the aneurysm leaks again and then there is headache now when there is a current headache before the patient comes to you with a massive headache you will think there is a migraine and you will miss the diagnosis so sentinel headaches should not be mistaken as migraine because of the recurrence pattern and you must be very careful if the patient comes with severe headache vomiting neck stiffness older sensorium you must consider uh some background image that you can do an mri or you can do a cd scan both will usually pick up occasionally when they don't pick up you have to do a lumbar puncture and look for a hemorrhagic uh csf the it you have you have something to do urgently in treating these patients you have to do an invasive procedure you have to do a digital subtraction angiography locate the aneurysm and put a coil in it there are multiple methods clipping and coiling are two methods you would put a coil in the bariano zoom to prevent further leakage of the yeah so this is about subarachnoid image and i think that ends our session uh we can take questions from from the audience yes uh if you'll have any questions regarding any of the questions uh you can uh raise your hand so you'll have a raise and people on the right hand side uh you can do that and come up on stage dr shivani i'm accepting your request uh please turn on your audio video when prompted thank you sir hi hi sir uh sir we had a wonderful lecture and so thank you so much we had gained so much knowledge from you sir uh so i just wanted to ask uh two three questions from you sir uh so one thing that can we give beta blockers in right under branch block or left under branch block or not so they're contraindicated or we can give if patient is having tachycardia with rbb absolutely you can give no contraindication giving you the only contribution it will be if the patient has complete heart block or severe bradycardia before starting then you will have a problem but lb brb are not contraindications right sir and so patients come with us with ankle edema so many patients come to us with bilateral pdl edema and then i do work up of all the patients like we do a liver function test we do renal function test we do echoes until everything so but albumin also but so everything is normal cbc some water i meant could say then what to do say i give dieter 5 mg 10 mg patients are not relieved at all so what drugs should we give and what should we think very quickly what i am understanding is that you are evaluating for edema of the legs and no etiology has been found two most important causes in this situation one is chronic passive venous congestion that means the veins the veins the deep veins do their valves are not functioning and therefore there is a chronic passive condition this is the commonest cause of bilateral symmetric edema which is not literally just not being found and the treatment for this is not diuretics diuretics worsen the problem the second condition is something called cyclical ediba of the female is an unusual condition typically in women where the patients have cyclical meaning waxing and meaning edema of the legs and that is probably due to some abnormality in the renin angiotensin system in this condition we give an empiric trial of arvs or that tone never give loop diabetics never give thiazides in this condition which is not diagnosed by any test we give addict tone and sometimes the patient has a resolution but of course this is a cyclicality my cyclical so that it can come and go and in chronic passive condition now we usually either give something like half long or we have compression uh stockings that will improve the lower limb circulation if do not strive to treat with diabetics do not be desperate to treat if you don't find a bad cause then consider it as a benign edema you can only aggravate the problem with diuretics yeah okay so uh can we give compression stockings without doing doppler uh or we can say like patients come to us like their edema is increasing in the evening but they don't that doesn't disappear in the morning can we give compressions talking so actually the patients can't afford their poor patients come to us so can we give them graduated compression stopping there is no contraindication okay thank you they have asked for more such sessions uh so we will definitely plan um similar sessions in the future uh there's a question in the comments section by dr justine hannah was asked if you could differentiate between peripheral and central vertigo yeah so uh peripheral vertigo as you know is uh these three varieties and there are very peculiar features of bppv many hairs or western neuritis that i already explained to you central vertigo which is due to vertebral basilar insufficiency usually central vertigo will come with neurological features and the most important part of central vertigo will be that the patient have ataxia so ataxia with vertigo without any of the features of many years or so any patient comes with vertigo look for atx here you will have ataxia and vestibular neuronitis but that western neonates will be a very severe vertigo with severe nystagmus with vomiting in this you won't see a significant nystagmus but you will see a significant ataxia it actually may be in fact more than the vertigo so so you must look for ataxia and of course the other the cranial nerve science which can happen in brain stem disease thank you sir um if anybody have any other questions but he has said that we should have sessions in hindi do you get such demands of sessions in hindi no okay because i think that might be a useful thing to do sometimes where we mix languages or give sessions in hindi it's a little difficult to have it in hindi because it's a pan india audience so may not be that everybody is comfortable with the hindi uh yes after you can go ahead with your question oh very good evening sir thanks for this sir can you please elaborate uh something more on use of method in arthritis due to chikungunya okay so uh personally i don't you are used emrds and as i said before also i refer the patient to rheumatologist you there are two things about methadracia or dmards inch ammonia one thing is many people believe that chikungunya unmasks underlying rheumatoid arthritis meaning if chikungunya stays for a long time then a patient who is already predisposed to rubbing arteries becomes actually a rheumatoid arthritis patient and ah which means that there are immunomodulatory factors now not just the virus but immunology modulatory factors which precipitate arthritis and therefore they believe that we should give a trial of dmards in patients with gigamonia with prolonged chikungunya arthritis the second thing is some people believe that if it's a chronic arthritis we should treat it as a chronic rheumatoid arthritis rather than just chikungunya virus-related arthritis so so far empiric therapy is the the use of methotrexate is empiric the evidence is not great but what we have the rheumatologists have been giving methotrexate is the preferred first drug not xcqs not sulfasalazine a preferred first drug and it is used like in any other rheumatoid arthritis for your patient is used uh as you know in once a week closing with monitoring of enzymes etc so the usage is the same as in ra and the duration of treatment is unknown usually we believe that chikungunya even if it goes beyond two or three years the arthritis if it is purely due to chikungunya it will last for five years not more than that so that is what is the belief but we we we don't have hard evidence for that thank you thank you for that uh we had another question uh by dr haresh jamani who was asked how to rule out cardiac cause in patients with past history of vertigo presented with cinco so first of all we have to decide whether the symptom is vertigo or syncope cardiac disease does not cause true vertigo vertigo when we say vertigo it is a rotational sensation cardiac disease can cause of course dizziness or frank's incog the principal cardiac disease that causes syncope is either aortic stenosis or atrial fibrillation which can cause a simcoe so i don't think the differentiation will be very difficult where greediness of cardiac disease will not be mistaken as vertigo another thing that i am reminded of here is that many people there is a myth a myth that has been passed on from generation to generation of doctors that cervical spondylosis causes vertigo please remember cervical spondylitis does not cause vertigo there is no such thing as spondylosis causing you to go you can get vertical artery compression sometimes with with the severe neck problems but vertigo is not a symptom of cervical spondylosis so never let anybody label that as what you yeah thank you sir for that um i'll answer this one so what antibiotics can we give in fever with thrombocytopenia now uh um first of all i mean this this uh kind of upsets me because if uh pure thrombocytoma is most commonly due to viral infections or malaria malaria causes thermostatic fever both do not require antibiotics so please please please do not use antibiotics very few fevers especially in the monsoon months will require antibiotics flu like syndromes no antibiotics malaria not even dengue no antibiotics chikungunya no antibiotics covet no antibiotics please remember that very very few fevers as a percentage of all fevers require antibiotics yeah thank you sir for that um so we have dr shaker who's asked what is vestibular basilar insufficiency it is not vestibular basically it is a vertebral basilar i might have mispronounced vertebral basilar as you know the posterior circulation of the brain the anticirculation is accurately the posterior circulation is made up of two word triple arteries which join to become the basilar artery if there is thrombosis or embolism within the vertebral base basilar system then the affected area is typically the posterior fossa areas that is the cerebellum and the brain stem this is called vertebral basilar insufficiency yeah thank you sir um we have dr vapor who's raised hand so we'll take one final request and i'll just go over the questions to them uh dr weber i accepted your request so you can turn on your audio video when prompted and go ahead and ask your question hello hi are you audible yes yes i can speak into your english language you tell me whichever language you like [Music] questions foreign [Music] foreign [Music] oh foreign foreign [Music] foreign a i think we'll uh stop the covet questions now because uh this session was not related to covert but if you have any other questions related to covert you can write them to us and we'll send them to sir and answer can answer them uh so we'll not give you a search contact number but you can drop in your questions in the comment section here and we'll get back to you but it's not possible to ask them directly or um not dr webber that will not be possible but you can leave your uh leave your questions in the comment section and we'll make sure that they reach us thank you thank you um thank you so much sir uh for this amazing session and uh like the feedback that we've got uh we will uh we will make sure that we come up with a similar sessions with sir and uh to the participants dr nasma dr jacob and dr nassar uh thank you so much for being a part of the session as well we did not announce this course but you could i said uh we could announce the scores if uh you won so we have dr nasma with 150 points and we have dr jacob with 50 points and dr nassar with 30 points congratulations to all of you thank you for tolerating the quiz and uh thank you so much sir and we will see you again bye good night everyone

BEING ATTENDED BY

Dr. Ragini gautam Rahangdale & 1854 others

SPEAKERS

dr. Tushar Shah

Dr. Tushar Shah

Consulting Physician at Advanced Multispecialty Hospital, Mumbai

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dr. Tushar Shah

Dr. Tushar Shah

Consulting Physician at Advanced Multispecial...

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