Case based OSCE along with BLOOM’S learning levels Achieve

 4)Case based OSCE along with BLOOM’S learning levels Achieved 

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

A 65 year old female came to OPD with -

CHIEF COMPLAINTS-

fever since 4 days.

HOPI-

patient was apparently asymptomatic 5 days back then she developed fever , which is high grade associated with chills and rigor, continuous type, no diurnal variation, associated with vomitings, cold, cough, loss of appetite, generalised body pains.

H/o vomitings since 5 days , sudden in onset, food as content, non bilious, non projectile, non blood stained, 4 to 5 episodes.

H/o cough since 5 days , which is productive whitish sputum thick consistency.

H/o chest pain left sided associated with SOB grade - 2 according to mMRC .

H/o right hypochondriac abdominal pain since 5 days.

H/o loose stools, burning micturition.

PAST HISTORY-

K/C/O HTN since 2 years and is on medication (unknown)

Not k/c/o DM, TB, asthma, epilepsy, thyroid disorders.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- normal 

Sleep- adequate 

Bowel and bladder movements- regular 

No known allergies 

Addictions-  used to consume pan one or twice daily but stopped from past 4 months.

FAMILY HISTORY- not significant 

GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

Vitals -

BP- 130/80 mmHg

PR- 92 bpm

RR- 18 cpm

TEMP- 98.2 F

PRESENCE OF PALLOR.

NO SIGNS ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.

SYSTEMIC EXAMINATION-

1) CVS- S1, S2 heard, no murmurs.

2) RS- BAE present, NVBS 

3) PER ABDOMEN- diffuse tenderness 

 no organomegaly 

4) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs

INVESTIGATIONS-

CHEST X-RAY-

1/10/23

5/10/23

5/10/23

7/10/23

9/10/23

ECG-

ULTRASOUND-

PROVISIONAL DIAGNOSIS- 

PYREXIA UNDER EVALUATION WITH LEFT LOWER ZONE COLLAPSE.

PRE RENAL ACUTE KIDNEY INJURY.

HYPOKALEMIA SECONDARY TO GE , KNOWN CASE OF HTN SINCE 2 YEARS.

TREATMENT-

1. INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/OD

3. IV. FLUIDS - 2NS @ 75ML/HR

                           - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5. TAB. DOLO 650MG PO/TID

6.  SYP. ASCORIL-LS 15ML/PO/TID.

[02/10/23, 10:01:09 PM] sowmika marru: Date- 3/10/23

ICU

Unit-6

Date of admission 30/9/23

S- c/o fever since 5 days 

O- on examination, patient is conscious, coherent, cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.

Vitals- 

Bp- 130/90mmhg

Temp- 98.2 F

PR- 77 bpm

RR- 17cpm

CVS - s1, s2 heard

RS - BAE present, NVBS

P/A- diffuse tenderness 

CNS - 

Higher mental functions - intact

Cranial nerves - intact

Motor examination - normal  

Sensory examination:Normal

No meningeal signs

A- 

PYREXIA UNDER EVALUATION WITH LEFT LOWER ZONE COLLAPSE.

PRE RENAL ACUTE KIDNEY INJURY.

HYPOKALEMIA SECONDARY TO GE , KNOWN CASE OF HTN SINCE 2 YEARS.

P - 

1. INJ. PAN 40MG IV/OD

2. INJ. ZOFER 4MG IV/OD

3. IV. FLUIDS - 2NS @ 75ML/HR

                           - 1 RL 

4. INJ. NEOMOL 1GM IV/SOS

5. TAB. DOLO 650MG PO/TID

6.  SYP. ASCORIL-LS 15ML/PO/TID.

[05/10/23, 1:23:36 PM] Himaja PGY1: Sir amc fourth bed

[05/10/23, 1:24:12 PM] Himaja PGY1: Aki is in increasing trends sir not responding to fluids

Stool for occult blood positive

Symptoms are not subsiding

[05/10/23, 1:24:20 PM] Himaja PGY1: Sputum for AFB turned out negative

[05/10/23, 1:24:34 PM] Himaja PGY1: I am worried are we missing on something

[05/10/23, 1:24:47 PM] Himaja PGY1: @919989643309 post the fever chart here please

[05/10/23, 1:31:48 PM] Devendra 2018: ‎This message was deleted by admin Himaja PGY1.

[05/10/23, 1:42:00 PM] Himaja PGY1: Investigation chart photo aswell

[05/10/23, 2:11:59 PM] Rakesh Biswas Sir GM HOD: Sharing patient identifiers in social media!! 🧐😳😨👺

First time I saw Picasso drawing our fever charts!! 

Where are the data points!!

[05/10/23, 2:13:09 PM] Rakesh Biswas Sir GM HOD: It's clear as daylight!

[05/10/23, 2:15:30 PM] Rakesh Biswas Sir GM HOD: Share it again asap!!

[05/10/23, 2:15:35 PM] Himaja PGY1: Mycobacterium?

[05/10/23, 2:17:07 PM] Rakesh Biswas Sir GM HOD: In the case report has @919100206300 left out the patient's HRCT chest images or was it another patient? 

Also the uploaded LFT there doesn't match the LFTs in the fever chart!

[05/10/23, 2:17:18 PM] Himaja PGY1: We haven’t got HRCT done sir

[05/10/23, 2:18:15 PM] Rakesh Biswas Sir GM HOD: Which patient's was that who had a right lower lobe apical bronchopulmonary segment consolidation? ‎<This message was edited>

[05/10/23, 2:19:17 PM] Himaja PGY1: This patient sir

[05/10/23, 2:19:29 PM] Devendra 2018: ‎This message was deleted.

[05/10/23, 2:20:18 PM] Himaja PGY1: Please crop the identifies

[05/10/23, 2:20:22 PM] Rakesh Biswas Sir GM HOD: 🧐😳😨👺

[05/10/23, 2:21:00 PM] Rakesh Biswas Sir GM HOD: 👆

‎[05/10/23, 2:21:16 PM] Himaja PGY1: ‎<attached: 00000037-PHOTO-2023-10-05-14-21-16.jpg>

[05/10/23, 2:21:23 PM] Himaja PGY1: This patient sir

‎[05/10/23, 2:21:25 PM] Devendra 2018: ‎<attached: 00000039-PHOTO-2023-10-05-14-21-25.jpg>

‎[05/10/23, 2:21:31 PM] Himaja PGY1: ‎<attached: 00000040-PHOTO-2023-10-05-14-21-31.jpg>

‎[05/10/23, 2:21:44 PM] Himaja PGY1: ‎<attached: 00000041-PHOTO-2023-10-05-14-21-44.jpg>

[05/10/23, 2:23:45 PM] Rakesh Biswas Sir GM HOD: No I don't think so and in response to questions like that you are supposed to share the patient's case report or PaJR link not their chest X-rays as this way you are corrupting the data in this PaJR!!

[05/10/23, 2:24:28 PM] Himaja PGY1: Sorry sir

[05/10/23, 2:24:56 PM] Rakesh Biswas Sir GM HOD: Delete from here if it's not this PaJR

[05/10/23, 2:25:06 PM] Rakesh Biswas Sir GM HOD: Delete from here if it's not this PaJR

[05/10/23, 2:25:12 PM] Rakesh Biswas Sir GM HOD: Delete from here if it's not this PaJR

[05/10/23, 2:25:14 PM] Himaja PGY1: This PaJR sir

[05/10/23, 2:25:19 PM] Himaja PGY1: All the x rays

[05/10/23, 2:26:47 PM] Rakesh Biswas Sir GM HOD: Then what about the one in the DP? Who's is that?

[05/10/23, 2:27:17 PM] Himaja PGY1: This is from time of admission sir

[05/10/23, 2:27:29 PM] Himaja PGY1: This was taken yesterday

[05/10/23, 2:27:30 PM] Rakesh Biswas Sir GM HOD: Please mention the dates

[05/10/23, 2:28:02 PM] Himaja PGY1: 30-09-2023

[05/10/23, 2:28:14 PM] Himaja PGY1: 04-10-2023

[05/10/23, 2:28:18 PM] Rakesh Biswas Sir GM HOD: I remember asking for right lateral but they have repeated left lateral and written right on the chest X-ray

[05/10/23, 2:28:21 PM] Himaja PGY1: 04-10-2023

[05/10/23, 2:28:30 PM] Rakesh Biswas Sir GM HOD: And the DP?

[05/10/23, 2:29:44 PM] Rakesh Biswas Sir GM HOD: Liver ultrasound video??

[05/10/23, 2:29:56 PM] Rakesh Biswas Sir GM HOD: History of alcohol intake?

[05/10/23, 2:31:42 PM] Rakesh Biswas Sir GM HOD: Daily stool output? Weight? Images?

[05/10/23, 2:31:56 PM] Rakesh Biswas Sir GM HOD: Urine intake output?

[05/10/23, 2:32:09 PM] Himaja PGY1: No history of alcohol intake sir

[05/10/23, 2:32:18 PM] Rakesh Biswas Sir GM HOD: Share the fever timeline again with all the above data asap

[05/10/23, 2:32:18 PM] Himaja PGY1: 2200/1800

‎[05/10/23, 2:32:47 PM] Himaja PGY1: ‎<attached: 00000065-PHOTO-2023-10-05-14-32-47.jpg>

[05/10/23, 2:32:50 PM] Rakesh Biswas Sir GM HOD: We want to know everyday's since admission along with creatinine

[05/10/23, 2:33:41 PM] Rakesh Biswas Sir GM HOD: This is just one small sample. What did we buy that glass jar for along with the electronic weighing machine!?

[05/10/23, 2:34:24 PM] Rakesh Biswas Sir GM HOD: ‎Rakesh Biswas Sir GM HOD changed this group's icon

[05/10/23, 2:34:41 PM] Prachathan Sir Pg: ‎Devendra 2018 added Prachathan Sir Pg

[05/10/23, 2:35:40 PM] Rakesh Biswas Sir GM HOD: Make me admin

[05/10/23, 2:39:42 PM] Rakesh Biswas Sir GM HOD: 👆

[05/10/23, 2:39:47 PM] Rakesh Biswas Sir GM HOD: 👆

[05/10/23, 2:40:07 PM] Himaja PGY1: @919989643309 please help to post the fever chart again

[05/10/23, 2:40:13 PM] Himaja PGY1: Without the identifiers

[05/10/23, 2:40:38 PM] Rakesh Biswas Sir GM HOD: He'll need another thirty days

[05/10/23, 2:45:11 PM] ~ Mikhitha Reddy: ‎~ Mikhitha Reddy joined using this group's invite link

‎[05/10/23, 2:43:01 PM] Himaja PGY1: ‎<attached: 00000077-PHOTO-2023-10-05-14-43-01.jpg>

[05/10/23, 2:43:24 PM] Himaja PGY1: He is plotting it again sir

[05/10/23, 2:43:26 PM] Himaja PGY1: On a new one

[05/10/23, 2:44:09 PM] Rakesh Biswas Sir GM HOD: Either way what is clear as daylight here is that the patient is having multisystem involvement including hepatic inflammation, non oliguric renal failure and post admission post antibiotic associated diarrhoea. 

We need to continue supportive therapy amidst all the differentials of viral, bacterial, protozoal etc 

Leptospira, Ricketssia are commonly well known here to cause this other than viruses

[05/10/23, 2:44:57 PM] Rakesh Biswas Sir GM HOD: Ask him to add the daily intake output to it

[05/10/23, 2:45:19 PM] Rakesh Biswas Sir GM HOD: From Picasso to Rembrandt!

[05/10/23, 2:45:41 PM] Rakesh Biswas Sir GM HOD: 👆

[05/10/23, 2:53:10 PM] ~ Madeeha Abrar: ‎~ Madeeha Abrar joined using this group's invite link

[05/10/23, 2:55:42 PM] ~ Shiv Deshmukh: ‎~ Shiv Deshmukh joined using this group's invite link

[06/10/23, 9:07:55 AM] Lohith Sir Pg Gm: ‎Lohith Sir Pg Gm joined using this group's invite link

‎[06/10/23, 12:00:23 PM] Devendra 2018: ‎<attached: 00000087-PHOTO-2023-10-06-12-00-23.jpg>

‎[06/10/23, 12:00:23 PM] Devendra 2018: ‎<attached: 00000088-PHOTO-2023-10-06-12-00-23.jpg>

[06/10/23, 1:02:29 PM] Prachathan Sir Pg: @919121046928 sir can it be salmonella infection

[06/10/23, 2:00:49 PM] Swathi 2018: ‎Swathi 2018 joined using this group's invite link

[06/10/23, 2:04:15 PM] Rakesh Biswas Sir GM HOD: It can be 

Viral 

Bacterial 

Protozoal 

Which one can be found out if the organism is grown

[06/10/23, 2:59:26 PM] Rakesh Biswas Sir GM HOD: ‎Rakesh Biswas Sir GM HOD changed the group name to “65F FEVER SINCE 5 DAYS , Telangana PaJR”

[06/10/23, 2:59:51 PM] Rakesh Biswas Sir GM HOD: Stool output and pea soup image today?

[07/10/23, 9:43:02 AM] Rakesh Biswas Sir GM HOD: Update?

[07/10/23, 9:56:39 AM] Prachathan Sir Pg: Sir pt is having continuous fever spikes with normal leucocye count 

Pt is having tachypnoea with RR of 30-34 cpm 

Pt is having decreased urine output since yesterday 

I/O-2300/300

Today:

Sr creat-3.1

B urea-109

‎[07/10/23, 9:57:14 AM] Prachathan Sir Pg: ‎<attached: 00000096-PHOTO-2023-10-07-09-57-14.jpg>

[07/10/23, 9:57:59 AM] Prachathan Sir Pg: 6/10

‎[07/10/23, 9:58:28 AM] Prachathan Sir Pg: ‎<attached: 00000098-PHOTO-2023-10-07-09-58-28.jpg>

[07/10/23, 9:58:49 AM] Prachathan Sir Pg: C/o loose stools and vomitings decreased

‎[07/10/23, 10:02:23 AM] Prachathan Sir Pg: ‎<attached: 00000100-PHOTO-2023-10-07-10-02-23.jpg>

[07/10/23, 10:06:30 AM] Prachathan Sir Pg: Current problem :

Worsening renal failure with acidosis and decreased urine output

[07/10/23, 10:32:42 AM] Lohith Sir Pg Gm: Nephro opinion - advised for Hemo dialysis I/v/o severe metabolic acidosis

[07/10/23, 2:28:00 PM] Rakesh Biswas Sir GM HOD: Agree

[07/10/23, 2:30:18 PM] Rakesh Biswas Sir GM HOD: Now she appears to have developed pleural effusion. If it's due to associated heart failure it should be transudative. @919989643309 Do the ultrasound and share the video to see if she has pleural effusion

[07/10/23, 2:30:33 PM] Devendra 2018: Kk sir

‎[07/10/23, 3:37:45 PM] Devendra 2018: ‎video omitted

[07/10/23, 3:40:44 PM] Rakesh Biswas Sir GM HOD: You should have also gotten someone to show where you were keeping the probe on her body

[07/10/23, 3:41:33 PM] Rakesh Biswas Sir GM HOD: The last part of the video showed the effusion very briefly but I guess it's not a lot that needs tapping

[07/10/23, 3:42:39 PM] Devendra 2018: ‎This message was deleted.

[07/10/23, 3:42:58 PM] Devendra 2018: Okay sir

[07/10/23, 3:43:31 PM] Rakesh Biswas Sir GM HOD: Now do the video of the other patient with liver abscess asap and share in his group

[07/10/23, 3:43:54 PM] Rakesh Biswas Sir GM HOD: Hey you learned English!!! 👏👏

[07/10/23, 3:44:37 PM] Rakesh Biswas Sir GM HOD: @918790889907 's opd appears to have cleared?

[07/10/23, 3:44:46 PM] Himaja PGY1: Yes sir

[07/10/23, 3:45:11 PM] Rakesh Biswas Sir GM HOD: One upside to the new opd protocol?

[07/10/23, 3:46:01 PM] ~ Gautham: ‎Devendra 2018 added ~ Gautham

[07/10/23, 3:46:16 PM] Himaja PGY1: Patients still has to accommodate to the new protocol they are dissatisfied currently

[07/10/23, 3:50:57 PM] Rakesh Biswas Sir GM HOD: Any change has to go through these stages, ridicule, opposition and then acceptance. 

It's for their own good and everyone's good

[07/10/23, 4:00:43 PM] Rakesh Biswas Sir GM HOD: What happened to the Casualty mri patient that Prachetan was supposed to inform about

[07/10/23, 4:01:42 PM] Himaja PGY1: Mri appears to be normal sir

[07/10/23, 4:08:11 PM] Rakesh Biswas Sir GM HOD: Who wants to know that!! 

We wanted to know about the patient and what's been done for her!!

[08/10/23, 12:19:19 PM] Faran: ‎Faran joined using this group's invite link

[08/10/23, 12:19:23 PM] Faran: Make me admin

[09/10/23, 1:56:54 PM] sowmika marru: ‎You deleted this message.

[09/10/23, 2:18:36 PM] Prachathan Sir Pg: Date- 9/10/23

ICU- bed no- 1

Unit-6

Date of admission 30/9/23

S- c/o breathlessness decreased post dialysis 

O- on examination, patient is conscious, coherent, cooperative.

pallor present .

B/L lower limb pitting type edema (till Ankle)

No signs of icterus, cyanosis, clubbing, lymphadenopathy.

Vitals- 

Bp- 110/80 mmhg

Temp- 99.6 F

Fever spikes present but decreased compared to yesterday 

PR- 104 bpm

RR- 13 cpm

GRBS - 128 mg/dl

CVS - s1, s2 heard, no murmurs 

RS - BAE present, NVBS heard

P/A- soft,non tender

Bowel sounds heard 

CNS - NFND

ABG Today:

PH-7.5

Pco2-23

Po2-79

Hco3-22

Hb-6.2

TLC-6000

Plt-3L

A- 

? ATYPICAL PNEUMONIA 

OLIGURIC RENAL FAILURE

METABOLIC ACIDOSIS ( resolving) with 

SEVERE ANEMIA 

K/c/o HTN SINCE 2 YEARS 

Thrombophlebitis of left hand

S/P 1 SESSION OF HEMODIALYSIS on 7/10/23.

P - 

1. IV FLUIDS NS, DNS @ 50 ml/hr

2. INJ. PCM 1G IV/SOS

4.TAB. PCM 650 mg PO/QID

5.INJ. LASIX 20mg IV/BD

6.INJ. KCl 2 ampules in 500ml NS IV/STAT 

7.Protein powder 2tbsp in a glass of water PO/BD

8.BP, PR ,temp monitoring 4 th hourly 

Can we plan for one more session of hemodialysis today with prbc transfusion?

Sir what is the further plan of management from here 

Shall we stick to the current conservative symptomatic treatment with regular vitals monitoring and the renal failure will come down gradually?

[09/10/23, 2:19:00 PM] Prachathan Sir Pg: @919100206300 share the fever chart

[09/10/23, 2:23:15 PM] Rakesh Biswas Sir GM HOD: Share the fever chart asap to allow us to understand at a glance what we have done and found differently each day since last 10 days asap

[09/10/23, 2:23:41 PM] Rakesh Biswas Sir GM HOD: Share the serial hb since admission

[09/10/23, 2:24:59 PM] Rakesh Biswas Sir GM HOD: Why hasn't she been transferred to nephro yet? Do they allow us to keep our AKI patients and get them dialyzed without transferring?

[09/10/23, 2:26:11 PM] Rakesh Biswas Sir GM HOD: Was she having CKD since last two years and no one tested her target organs even after finding her hypertensive two years back?

[09/10/23, 2:26:31 PM] Rakesh Biswas Sir GM HOD: USG kidney video

[09/10/23, 2:27:09 PM] Rakesh Biswas Sir GM HOD: Serial stool Images since admission? Daily stool volume?

[09/10/23, 2:28:08 PM] Rakesh Biswas Sir GM HOD: 👆

[09/10/23, 2:29:20 PM] Rakesh Biswas Sir GM HOD: Hb from 9.4 to 6.1 since last ten days 

Maximal fall post dialysis

[09/10/23, 2:30:56 PM] Rakesh Biswas Sir GM HOD: Share the serial creatinine values since admission! Other than on 6/10 none of the other creatinine values are visible @919989643309

[09/10/23, 2:32:28 PM] Rakesh Biswas Sir GM HOD: How much was the creatinine on 1/10/23?

[09/10/23, 2:34:33 PM] Rakesh Biswas Sir GM HOD: Stool culture sent for Salmonella? Please mention Salmonella in the requisition 

Oh it was asked for the other male patient with the classical pattern? What about his updates? 

Although looking at this lady's chart it may not be either well represented data or it may not be Salmonella

[09/10/23, 2:34:39 PM] Prachathan Sir Pg: she is not having any structural abnormalities of kidney sir

She never got tested for renal parameters and other end organ damage in the past sir

[09/10/23, 2:35:29 PM] Rakesh Biswas Sir GM HOD: 👆

[09/10/23, 2:35:45 PM] Prachathan Sir Pg: 1.9 sir

[09/10/23, 2:35:53 PM] Rakesh Biswas Sir GM HOD: Keep the machine ready. I will do it now

[09/10/23, 2:36:02 PM] Prachathan Sir Pg: Yes sir

[09/10/23, 2:36:45 PM] Prachathan Sir Pg: Initially it was 1.9 sir

Which gradually progressed to 3.1 before dialysis

[09/10/23, 2:37:40 PM] Prachathan Sir Pg: We have sent the stool for c&s sir

Will collect the report

[09/10/23, 2:38:45 PM] Rakesh Biswas Sir GM HOD: With a respiratory rate of 13 and other stable vitals why is she in ICU? There's something missing in this data you shared that doesn't convey the criticality of her situation or is it the fact that she had worsened respiratory rate and someone doesn't know how to see it?

‎[09/10/23, 2:41:33 PM] sowmika marru: ‎<attached: 00000146-PHOTO-2023-10-09-14-41-33.jpg>

[09/10/23, 2:41:56 PM] Prachathan Sir Pg: Sry sir it was 23cpm

Her tachypnea has decreased sir

She had hypotension during the dialysis even though we put on UF of zero ,so we put her on norad and gradually tapered it and stopped sir

[09/10/23, 2:42:10 PM] Prachathan Sir Pg: @919100206300 join both the charts

[09/10/23, 2:42:30 PM] sowmika marru: Yes sir

[09/10/23, 2:43:43 PM] sowmika marru: ‎You deleted this message.

[09/10/23, 2:44:01 PM] Rakesh Biswas Sir GM HOD: 👆Add everyday's creatinine values here since admission

[09/10/23, 2:45:01 PM] Rakesh Biswas Sir GM HOD: 👆7/10 Do we have any chest X-ray after that?

[09/10/23, 2:49:30 PM] sowmika marru: ‎You deleted this message.

[09/10/23, 2:50:22 PM] Prachathan Sir Pg: @919100206300 add these in fever chart itself

‎[09/10/23, 3:15:42 PM] Devendra 2018: ‎video omitted

[09/10/23, 4:22:20 PM] Rakesh Biswas Sir GM HOD: 👆Hospital identifiers are visible!! 🧐😳

[09/10/23, 4:22:52 PM] Rakesh Biswas Sir GM HOD: 👏

[09/10/23, 4:23:14 PM] Rakesh Biswas Sir GM HOD: Share the best way to do the size calculations

[09/10/23, 4:24:55 PM] Devendra 2018: Okay sir

‎[09/10/23, 4:27:45 PM] sowmika marru: ‎<attached: 00000160-PHOTO-2023-10-09-16-27-45.jpg>

[09/10/23, 4:29:59 PM] Rakesh Biswas Sir GM HOD: Can you calculate the efficacy of dialysis using the before and after creatinine values @919989643309 @919100206300

[09/10/23, 4:31:24 PM] sowmika marru: It’s already written sir

[09/10/23, 4:32:04 PM] sowmika marru: ‎You deleted this message.

‎[09/10/23, 4:32:46 PM] sowmika marru: ‎<attached: 00000164-PHOTO-2023-10-09-16-32-46.jpg>

[09/10/23, 4:32:55 PM] Rakesh Biswas Sir GM HOD: 👆

[09/10/23, 4:33:54 PM] Rakesh Biswas Sir GM HOD: All her serial chest X-rays keep changing!! 

Now all of a sudden we have one that shows a cardiomegaly!

[10/10/23, 11:44:08 AM] Himaja PGY1: Date- 10/10/23

ICU- bed no- 1

Unit-6

Date of admission 30/9/23

S- subjectively feeling better and caught up better sleep 

Complains of cough- productive 

O- on examination, patient is conscious, coherent, cooperative.

pallor present .

B/L lower limb pitting type edema (till Ankle)

No signs of icterus, cyanosis, clubbing, lymphadenopathy.

Vitals- 

Bp- 110/80 mmhg

Temp- 99.6 F

Fever spikes present but decreased compared to yesterday 

PR- 104 bpm

RR- 13 cpm

GRBS - 128 mg/dl

CVS - s1, s2 heard, no murmurs 

RS - BAE present, NVBS heard

P/A- soft,non tender

Bowel sounds heard 

CNS - NFND

Hb-8.5

TLC- 7900

Plt-2.1

UREA - 41

CREATININE- 1.4

Na- 133

K-3.2

Cl-99

A- 

? ATYPICAL PNEUMONIA 

OLIGURIC RENAL FAILURE

METABOLIC ACIDOSIS ( resolving) with 

SEVERE ANEMIA 

K/c/o HTN SINCE 2 YEARS 

Thrombophlebitis of left hand

S/P 2 SESSION OF HEMODIALYSIS with one PRBC transfusion

P - 

1. IV FLUIDS NS 30ml+urine output

2. INJ. PCM 1G IV/SOS

3.INJ METHYLPREDNISOLONE 1G IV/OD

4.TAB. PCM 650 mg PO/QID

5.INJ. LASIX 20mg IV/BD if BP>110mmhg

6. TAB SODIUM BICARBONATE 500MG PO/BD

7.Protein powder 2tbsp in a glass of water PO/BD

8.BP, PR ,temp monitoring 4 th hourly

Levels of Blooms:

Level 1:Remembering 

It’s all about recollecting and remembering the history of the patient.

SEPSIS SYMPTOMS-

Sepsis is a severe and life-threatening condition that occurs when the body's response to an infection causes widespread inflammation. The symptoms are-

1. Fever

2. Increased Heart Rate

3. Rapid Breathing

4. Confusion or Altered Mental State.

5. Low Blood Pressure

6. Low Urine Output

7. Blood tests may reveal an elevated white blood cell count or abnormalities in other blood markers.

8. Organ Dysfunction

9. Skin may be cold and pale, or even discolored.

WHY METHYLPREDNISOLONE WAS GIVEN?

Methylprednisolone works by suppressing the immune system and reduces inflammation, which reduces the  symptoms and prevents the progression of the conditions.

 In cases of severe infections, it may lead to septic shock. Hence  Methylprednisolone was administered to reduce the excessive inflammatory response.

Level 2:

Understanding:

It is all about understanding the disease pattern , it’s pathology and its associations.

STAGES OF SEPSIS-

1) Infection

2) Systemic Inflammatory Response Syndrome (SIRS)-

[SIRS criteria include two or more of the following]-

   - Fever or hypothermia

   - Elevated heart rate

   - Rapid breathing

 - Abnormal white blood cell count (high or low)

3) Sepsis- 

In this stage, there may be organ dysfunction, but it's not as severe as in severe sepsis or septic shock.

4) Severe Sepsis-

Severe sepsis is characterized by organ dysfunction, often involving the heart, lungs, kidneys, liver, or blood clotting.

5) Septic Shock- 

Septic shock is the most critical and life-threatening stage of sepsis. It occurs when there's a severe drop in blood pressure, which can lead to multiple organ failure.

Level 3:

Application:

It is applying the level 1 and 2 knowledge so as to provide a holistic approach of treatment to the patient.

CAUSES OF METABOLIC ACIDOSIS-

1. Increased Acid Production

   - Excessive Ketone Production. Ketones are acidic, leading to a decrease in blood pH.

   - Lactic acidosis can occur when there's an overproduction of lactic acid. This can result from issues like poor tissue oxygenation, as seen in severe infections, shock, etc.

2. Decreased Acid Excretion

   - Renal Dysfunction

3. Loss of Bicarbonate

   - Gastrointestinal Disorders- Conditions like severe diarrhea or a loss of bicarbonate-rich fluids from the digestive tract can lead to metabolic acidosis.

4. Toxic Ingestions or Medications

  

Level 4:

Analysis

Acute pyelonephritis is a type of urinary tract infection (UTI) that specifically affects the kidneys.

1. Symptoms-

Symptoms of acute pyelonephritis may include high fever, chills, back pain, flank pain (pain on the side of the lower back), frequent urination, pain or discomfort during urination, cloudy or bloody urine, and general malaise. It can also cause nausea and vomiting.

INDICATIONS FOR DIALYSIS-

1. End-Stage Renal Disease (ESRD)

This is often due to conditions like chronic kidney disease, diabetes, or hypertension.

2. Severe Acute Kidney Injury (AKI)

 In some cases of severe and sudden kidney damage, temporary dialysis might be necessary until the kidneys recover their function.

3. Uremic Symptoms

 Dialysis may be done if an individual experiences severe symptoms due to the accumulation of waste products in the blood (uremia).

4. Electrolyte Imbalance

5. Volume Overload

6. Intoxication

Level 5

Evaluation

AKI AND CKD ?

https://www.researchgate.net/figure/Differences-between-AKI-and-CKD_tbl3_41895379  

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531835/

 

AKI is a sudden and often reversible decrease in kidney function, while CKD is a long-term, usually irreversible loss of kidney function. The two conditions have different causes, symptoms, and diagnostic criteria, and they require distinct approaches to treatment and management. CKD may develop as a consequence of recurrent or severe AKI, emphasizing the importance of timely management of AKI to prevent its progression.

OPD Case:

A 75 year old male patient came to OPD with chief complaints of SOB since 6 months

HOPI:

The patient was apparently asymptomatic 6 months ago and then he developed SOB grade - 3,  which is insidious in onset and gradually progressive

Aggravated on activity and not Relieved with rest.

Orthopnea present, no H/o PND

C/o wheezing since 6 months 

H/o cough, productive, whitish sputum, thick in consistency since 1 month 

No h/o fever

No h/o sweating, palpitations

No h/o  loose stools, vomiting

Past history: k/C/o of HTN since 6 years [ on medication]

K/C/o DM since 2 years [ on medication]

N/k/c/o asthma,TB, Epilepsy, CAD, CVA 

Personal history -

Appetite -Decreased

Diet- mixed

Sleep- Disturbed

Bowel and bladder movements - normal and regular

Addictions- Consumes alcohol (once a week- 180 ml -since one year)

Daily routine: 

He wakes up around 6:00 am. He is a fruit seller and he works from 9 Am till 9 pm. He goes to his home some time around 9:30 pm and sleeps by 10.

General examination: 

Patient is c/c/c

Moderately built and nourished

Pallor+

Iceterus+

No signs of cyanosis, clubbing, lymphadenopathy and pedal edema

Vitals:

Bp- 140/100 mmHg 

Pr- 92 bpm rrnv

Rr- 18 cpm

Temperature - afebrile

CVS: S1,S2 +; No Murmurs

RS: BAE+

B/L rhonchi in ICA, MA, AA, IAA

P/A: Soft, Non Tender

CNS: NFND

Provisional diagnosis- heart failure with bronchial asthma 

Treatment- TAB. LASIX 20MG PO/OD

1————X————-X

TAB. TELMA 20MG PO/OD

1————X————-X

ROTA CAP IPRAVENT 200 MCG SOS