January 2022- Clinical problem solving assessment - Rishika Koloti

This is my attempt at solving the questionairre linked -here

The topic Chosen by me is "Metabolic Acidosis " by Dr. Nikitha (Final year post graduate )

Link to the case report can be found -here

Q1. Provide your critical appraisal of the captured data in terms of completeness, correctness and ability to provide useful leads to analyse the diagnostic and theraputic uncertainities around the case . 

A1. 

Completeness -

The case report is complete. The timeline of events have been presented very clearly . Each slide is correctly explained , which makes the case report comprehensive. 

ABG values at different times have been presented and the way the diagnosis is made has been expressed clearly  in a stepwise manner .

Ability to provide useful leads around the diagnostic and theraputic uncertainities - 

these have been provided. An abstract of what can be done for the patient has been explainied . 

Q2.Please analyse the linked case report by first preparing a problem list for each patient in order of percieved priority and then discuss the diagnostic and theraputic uncertainities around solving these problems 

A2.

Discussion -
The patient presented with urinary incontinence and on biopsy a diagnosis of genitourinary tuberculosis was made. On examination, there was a non functioning right kidney and a thimble bladder .

 
In order to increase the quality of life of the patient Ureterosigmoidostomy was performed - which is a urological intervention where in the ureters from the kidney are diverted to the sigmoid colon.

However there were metabolic complications including - metabolic acidosis and hypokalemia that eventually lead to supraventricular tachycardia . 

Q3. Include a review of literature around senstivity and specificity of the dagnostic interventions mentioned and same around efficacy of the theraputic interventions mentioned for each patient .

A3. 

 Hypokalemia associate paralysis and metabolic acidosis in a patient with bilateral ureterosigmoidostomy - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411658/#:~:text=Ureterosigmoidostomy%20is%20a%20surgical%20procedure,quadriparesis%20%5B2%E2%80%936%5D

 

The above linked article aims to explain the treatment of a patient that had undergone ureterosigmoidostomyfor bladder cancer 16 years ago . 

The patient developed hypokalemia and hyperchloremic metabolic acidosis that eventually lead to quadriparesis and intestinal paralysis . 

As explined in the article - 

• Patients treated with ureterosigmoidostomy should be instructed to empty the rectum as frequently as possible  
• Potassium and bicarbonate supplementation should be done 
• Rectal tube insertion at night is effective to prevent metabolic acidosis complications 
• If possible - Ureteroileostomy should be performed as there is rapid drainage of urine into the bag that reduces contact time with the intestine. 
• Muscle strength should be evaluated quantitatively before and after treatment. 

In addition

• ABG should be monitored carefully to prevent cardiac complications. 
• Patient compliance to the given medication should be monitored with the help of regular followups .