Active learning of the topic Paraparesis

Hello. We had been given a few cases every week to enhance our competence in the field of medicine and taught to enhance our learning by having active conversations with our peers and teachers.

You can find the case details here  https://vaish7.blogspot.com/2020/05/medicine.html?m=1 and my interpretation of the case here https://caseopinionsbyrollno156.blogspot.com/2020/05/trio-of-paraparesis-cases.html

I have borrowed this excerpt from my peer https://medcases.blogspot.com/2020/05/case-discussion-on-paraparesis-case.html 

We were given 3 cases of paraparesis with very different etiologies. But in the journey of reaching the diagnosis we came up with a lot of questions. Here's  a peak

[29/05/20, 8:38:56 PM] Student16: 1.WHAT IS THE REASON FOR 

Elevated Liver enzymes and reduced Creatinine and Lymphocytes ;

Frequent Change of Position recommended to the patient ;

Rt sided reflexes being more pronounced than left sided ? Does is have anything to do with Lt sided enhancement being more than Rt side in the MRI as pyramidal tracts cross-over at lower medulla ?

2. WHEN HE FELL, DID HE JUST FALL BECAUSE HIS LEGS WERE WEAK / HE LOST HIS BALANCE / HE BECAME UNCONSCIOUS ?

[29/05/20, 8:40:09 PM] Student16: 1. HAS ELEVATED LEVELS OF COMPONENTS IN RFT, OUT OF WHICH FEW ELEVATIONS CAN BE EXPLAINED w.r.t THE CORTICOSTEROID THERAPY AND SALICYLATE THERAPY, OTHERS ARE NOT. ALBUMIN IS SEEN IN URINE, COULD THE PT HAVE CHRONIC RENAL PATHOLOGY ?

2. CHANGE IN MUSCLE WEAKNESS w.r.t TEMPERATURE ?

3.HOW LONG HAS THE NON PITTING B/L LL EDEMA BEEN THERE ? DID IT CHANGE TO NON-PITTING TYPE OVER A PERIOD OF TIME?

4. 2 YEARS IS A LONG TIME, DID THE PATIENT NOT SEE ANY OTHER PHYSICIAN ? RELEVANT DRUG HISTORY WHICH MIGHT HELP ?

COULD HE BE PRONE TO DIABETES ?

COULD THE REASON FOR B/L NON PITTING LL EDEMA BE MUSCULAR WEAKNESS WHICH LEADS TO DECREASED VENOUS RETURN AND VENOUS STASIS, OVER A PERIOD OF TIME CAUSING FIBROSIS ?

[29/05/20, 8:49:26 PM] Post Residency PG1: 

Someone please attempt to answer these. Have you shared these with the treating team members? 

Hope all of you have their Whatsapp numbers?

[29/05/20, 8:50:59 PM] Student1: I think frequent change of position is due to the abscess he has

[29/05/20, 8:58:45 PM] Post Residency PG1: Abscess where? The treating intern blog should have shared an image

[29/05/20, 8:59:10 PM] Student1: Gluteal abscess sir

[29/05/20, 9:01:32 PM] Post Residency PG1: That patient was 23M and this one is 18M?

[29/05/20, 9:02:27 PM] Student1: 23 M sir

[29/05/20, 9:05:03 PM] Post Residency PG1: 

[29/05/20, 10:09:46 PM] Student17: http://durgamahadev118.blogspot.com/2020/05/gm-paraparesis-case-of-23yr-old-elog.html

My questions r in this log book

[29/05/20, 10:44:24 PM] Student18: 1 : Change of position may be due to pain due to abscess. So frequent change in position may give him relief

[29/05/20, 10:49:33 PM] Student19: What is the cause for non projectile vomiting .?

[29/05/20, 10:50:47 PM] Student11: Why vomitings have occured? Are there any signs of Raised ICT? If not so what can be the reason?

[29/05/20, 10:54:06 PM] Student20: May b

[29/05/20, 10:54:07 PM] Student20: Due to

[29/05/20, 10:54:11 PM] Student20: Turberculoma

[29/05/20, 10:54:39 PM] Student20: Lesions... AST is elevated which might cause vomitings

[29/05/20, 11:05:59 PM] Student6: Yes.. heart failure can cause liver failure which causes raised bilirubin... But is the patient having the heart failure of the severity that is required to cause liver failure to cause increased bilirubin levels...?

[29/05/20, 11:07:43 PM] Student17: Cause - https://www.medicalnewstoday.com/articles/325838#causes

[29/05/20, 11:07:54 PM] Student17: https://www.medicalnewstoday.com/articles/325838#causes

[29/05/20, 11:12:44 PM] Student17: No ! There is no raised ict . So no projectile vomitings

[29/05/20, 11:55:49 PM] Student21: Is there a relation between gluteal abscess and tb in this patient ?

[30/05/20, 9:53:48 AM] Post Residency PG1: What are projectile vomitings and how are they different from regular vomitings?

[30/05/20, 9:59:38 AM] Post Residency PG1: How is AST related to increased vomitings? Any scientific reference links with your quotes from the relevant portions

[30/05/20, 10:06:17 AM] Student22: Projectile vomiting is a sudden occurence of vomiting

Not preceeded by nausea

And expulsion of gastric contents with great force

[30/05/20, 10:08:01 AM] Post Residency PG1: So non nauseous is the key word? Please share the source link for the definition. Also which physiological organ is responsible for nausea that is spared here?

[30/05/20, 10:16:06 AM] Student22: https://www.healthline.com/health/projectile-vomiting

[30/05/20, 10:17:20 AM] Post Residency PG1: Nope. Always share the relevant portions in quotes. And share scientific articles with cross references

[30/05/20, 10:27:40 AM] Student22: No sir

Since it is a forceful explusion of gastric contents.. it may or may not be preceeded by nausea..

Mostly we come cross projectile vomiting as a complaint in children..(most common cause:infantile pyloric stenosis)