65 M with chronic vomiting
65/m farmer
Dupalli Yadadri district farmer since 45 years
was brought to the casualty with complaints of vomiting since 2 months, weakness of lower limb since 1week and difficulty in walking since 1 week
2012--> pain , deformity of right knee(? Chickungunya)
2019 --> episode of giddiness while working in the farm
Went to pvt practioner and diagnosed to have HTN and started the patient on Amlodipine 5mg
( no loc,fall, syncope, chestpain, weakness of limbs, Involuntary movements)
Similar episode an year later while working in the farm
( Which attenders attributed to patient not having enough food while working during the sunny days in the farm - no loc , syncope)
2 months back--> right lower limb pain, went to pvt practioner and was prescribed symptomatic medications for the same
10days after the visit to previous hospital -- patient complained of discomfort and giddiness , vomiting
Went to various private hospitals for the same reason and was investigated to GI causes
Endoscopy done - showing antral gastritis
Ct abdomen - normal
From past 3-4 days patient developed weakness of lower limbs and fatigue , Inability to walk
Patient continued to have these episodes of vomiting everyday almost 1 -2 each day for which he decreased food consumption
Vomiting-- Non bilious,? Projectile, nausea+ ,water or food as content, non foul smelling, not blood tinged, 2- 3 episodes a day
No headaches, blurring of vision, neck pain, syncope attacks
K/c/o htn since 2 years - tab amlong 5mg po od
No similar complaints in the past
N/k/c/o DM ,Asthma,CAD, Tb ,Epilepsy
Personal history-
Diet - mixed
Appetite- decreased
Sleep- increased
Bowel and bladder - normal
Addictions- nil
Family history -
No relevant family history
General examination:
https://sannithreddykasala.blogspot.com/2022/12/a-case-of-65year-old-male-with-vomitings.html
Discussion around the case--
[20/12, 20:06] Dr Rakesh Biswas Sir HOD: Do the relatives want to get him operated?
Also unable to still reconcile or integrate the two different sequence of events that led to his right knee OA and his cerebellar tumor.
Can someone share the detailed sequence of events here? What about the case report link?
[20/12, 21:13] Dr.Deepika Ch: 2012--> pain , deformity of right knee(? Chickungunya)
2019 --> episode of giddiness while working in the farm
Went to pvt practioner and diagnosed to have HTN and started the patient on Amlodipine 5mg
( no loc,fall, syncope, chestpain, weakness of limbs, Involuntary movements)
Similar episode an year later while working in the farm
( Which attenders attributed to patient not having enough food while working during the sunny days in the farm - no loc , syncope)
2 months back--> right lower limb pain, went to pvt practioner and was prescribed symptomatic medications for the same
10days after the visit to previous hospital -- patient complained of discomfort and giddiness , vomiting
Went to various private hospitals for the same reason and was investigated to GI causes
Endoscopy done - showing antral gastritis
Ct abdomen - normal
From past 3-4 days patient developed weakness of lower limbs and fatigue , Inability to walk
Patient continued to have these episodes of vomiting everyday almost 1 -2 each day for which he decreased food consumption
Vomiting-- Non bilious,? Projectile, nausea+ ,water or food as content, non foul smelling, not blood tinged
No headaches, blurring of vision, neck pain, syncope attacks
[20/12, 22:04] Dr Rakesh Biswas Sir HOD: Much clearer now
[20/12, 22:06] Dr Rakesh Biswas Sir HOD: But 2012 Monoarthritis is not due to Chikungunya perhaps. It needs more details but at least it has now been completely relegated to the past and his cerebellar symptoms dominate the present
[20/12, 22:07] Dr Himaja Jr Gmed: It is just the family assumption sir. They don’t have any evidence on that and didn’t use any medications too
[22/12, 09:54] Dr Rakesh Biswas Sir HOD: Where?
[22/12, 10:17] Dr.Deepika Ch: NIMS , punjagutta sir
[22/12, 11:09] Dr Rakesh Biswas Sir HOD: Why not NKP? What did we lack?
[22/12, 13:28] Dr Vinay Pg Gmed 2: Equipment in ot sir
[22/12, 13:29] Dr Rakesh Biswas Sir HOD: Which equipment?
[22/12, 20:38] Dr Vinay Pg Gmed 2: Some micro instruments too sir was saying
[22/12, 20:38] Dr Vinay Pg Gmed 2: Craniotome or cranial drill.primarily we are unable to do coz of this being missing
The rest are
Rongeurs,pneumatic bone etc
[22/12, 20:38] Dr Vinay Pg Gmed 2: Cranial drill
[22/12, 20:38] Dr Vinay Pg Gmed 2: That’s the main thing
[22/12, 20:38] Dr Rakesh Biswas Sir HOD: 👍
[24/12, 15:15] Dr.Deepika Ch: Update -
Patient was operated 2days back, post procedure patient had fall in saturations was found to have bleed from tumour bed(excision site)
Was taken for 2nd surgery and bleed was stopped
Patient was put on ventilator for a day
Toady was weaned off from ventilator
Patient able to talk ,identify and spontaneous eye opening +
75% of tumour excision was done
25% was left behind(? Invasion)
Biopsy was sent post sx - will take a week for the report
[24/12, 15:18] Dr Rakesh Biswas Sir HOD: Do you think that the surgery may have served it's purpose if 25% was left behind especially if this turns out to be malignant? Could a frozen section helped or either way it would have been impossible to remove that remaining 25% and this entire operation was at best an excision biopsy?
[24/12, 15:22] Dr.Deepika Ch: If it turns out to be malignant , may be the other modalities of treatment like chemo and radio could be of use to regress the remnant
And might be risk ratio benefit made them leave the 25% tumour inside sir
[24/12, 15:23] Dr Rakesh Biswas Sir HOD: Share the literature around the efficacy of chemo radio in cerebellar cancer
[24/12, 20:39] Dr.Deepika Ch: RT is frequently used in older patients with GBM. Its superiority over supportive care alone has been demonstrated in a French multi-institutional randomized trial of 85 elderly patients aged 70 years and older [44]. *The median survival and progression-free survival times were 29.1 and 14.9 weeks in patients treated with RT (50 Gy given in daily fractions of 1.8 Gy) plus supportive care, and 16.9 and 5.4 weeks for those treated with supportive care alone (p = 0.002), respectively. As compared with supportive care, RT did not cause further deterioration in KPS, quality of life and cognitive function.*
The efficacy of either radical RT or abbreviated courses of RT has been evaluated in randomized and prospective studies have conducted a trial of patients aged 60 years and older with newly diagnosed GBM randomized to receive standard RT (60 Gy in 30 daily fractions) or an abbreviated course of RT (40 Gy in 15 daily fractions) after surgery. *The median survival time and 6-month survival rates were similar between groups, being 5.1 months and 44.7% after standard RT and 5.6 months and 41.7% after short-term RT (p = 0.57), respectively.*
291 patients older than 60 years with newly diagnosed GBM (Nordic study) randomly assigned to receive RT or chemotherapy with temozolomide (TMZ), RT was given as radical RT or hypofractionated RT (34 Gy given in 3.4 Gy fractions over 2 weeks). *Median overall survival was significantly longer for patients who received TMZ than those who received standard RT (8.3 months vs 6.0 months, hazard ratio 0.7, 95% CI 0.52–0.93, p = 0.01), but not significantly better than those treated with hypofractionated RT (7.5 months, HR 0.82, 95% CI 0.63–1.06, p = 0.12); for patients older than 70 years, median overall survival was better with hypofractionated RT than with standard RT (7.0 months vs 5.2 months, p = 0.02).*
[24/12, 20:40] Dr.Deepika Ch: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477302/#!po=12.8319
[24/12, 21:09] Dr Rakesh Biswas Sir HOD: Do you think the chemo radiotherapy group had any great benefit from those who received supportive care? Just increasing the number of days lived may not be better than improving the quality of whatever days one may live?
[24/12, 21:18] Dr.Deepika Ch: Also mentioned about KPS scoring sir( quality of life)
[24/12, 21:21] Dr Rakesh Biswas Sir HOD: You haven't compared the scores (with numbers)
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