60M postoperative altered sensorium 2 weeks COPD ventilated extubated Telangana PaJR
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Our patient is 60 years old male .
His case history is presented here 👇🏻
Stroke deidentified horcrux case 1 for stroke ProJR focusing on neurorehab. Video link below shows an AIIMS Delhi Physiatrist providing voluntary video consultation.
Sharing the deidentified horcrux EMR case summary prepared by our anonymous intern
Age/Gender : 60 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 04/05/2024 05:35 PM
Discharge Date Date: 3/06/2024 Ward: MMW Unit:GM-6
Readmitted:26/6/2024
Diagnosis
ALTERED SENSORIUM SECONDARY TO Metabolic ENCEPHALOPATHY ( HYPOXIA/SEPSIS) SECONDARY TO HEMORRHAGIC STROKE
ASPIRATION PNEUMONIA ? VAP [ RESOLVED] POST OP DELIRIUM [ RESOLVED]
ANEMIA SECONDARY TO HEMATURIA [ RESOLVED]
HIGH ANION GAP METABOLIC ACIDOSIS MIXED ACIDOTIC PATTERN (RESOLVED), ACUTE KIDNEY INJURY(POST RENAL AND PRE RENAL) [RESOLVED]
GRADE 3 BED SORE ON RIGHT GLUTEAL REGION GRADE 2 BED SORE ON LEFT GLUTEAL REGION DE NOVO HYPERTENSION
POST EXTUBATION DAY-19
Stroke risk factors: Alcoholism, Smoking
Case History and Clinical Findings
CHIEF COMPLAINTS:
A 60YR OLD MALE PATIENT CAME TO CASUALITY WITH ALTERED SENSORIUM ON 04/05/2024
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARTENTLY ALRIGHT AND ASYMPTOMATIC LAST NIGHT AND HE EXPERIENCED SLIP &FALL ON 15/04/2024 TAKEN TO GOVT.HOSPITAL. I/V/O RIGHT IT HIP FRACTURE AND HAD SURGERY AND THEN ON 25/04/2024 SUDDENLY DEVELOPED SHORTNESS OF BREATH AND THEN ADMITTED HOSPITAL AGAIN THEN HE DEVELOPED ALTERED SENSORIUM IN HOSPITAL .AFTER SURGERY PATIENT DEVELOPRD ALTERED SENSORIUM &SO IRRITABLE AFTER 4 DAYS .CONCERNED DOCTORS DIDNOT INFORM ACCURATE CAUSE TO ATTENDERS &DISCHARGED THE PATIENT. AFTER DISCHARGE HE WAS AT HOME WITH SAME IRRITABLE CONDITION &ALTERED SENSORIUM FOR 4 DAYS &SUDDENLY HE DEVELOPED SHORTNESS OF BREATH .UNDERGONE CT BRAIN SUGGESTED AGE RELATED CHANGES.ON 4/5/24 AT 2AM PATIENT LOST CONSCIOUSNESS
.SO THEY SHIFTED PATIENT TO OUR CASUALITY AROUND 5PM HISTORY OF PAST ILLNESS:
NOT A KNOWN CASE OF HTN,DM,TB,EPILEPSY,ASTHAMA,CAD. GENERAL EXAMINATION:
NO SIGNS OF PALLOR,ICTERUS,CYANOSIS,CLUBBING,OEDEMA. TEMP: AFEBRILE
PR:116 BPM RR: 20 CPM
BP: 110/60 MMHG SPO2 : 88%@ RA GRBS: 116 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1S2 HEARD RS: BAE (+)
CNS: NFND
COURSE IN HOSPITAL:
ON DAY1 A 60YR OLD MALE PATIENT CAME TO CASUALITY WITH COMPLAINTS OF ALTERED SENSORIUM SINCE 2AM
THE VITALS AT PRESENTATION WERE PR:116 BPM RR: 20 CPM BP: 110/60 MMHG SPO2:88% @ RA AND 96% ON 2 LITRES O2 GRBS: 116 MG/DL,GCS E4V2M3 ON FURTHER EALUATION HE WAS DIAGNOSED WITH ALTERED SENSORIUM SECONDARY TO ?METABOLIC ? HYPOXIC ENCEPHALOPATHY
TREATMENT WAS STARTED WITH OXYGEN SUPPLEMENTATION AND ANTIOBIOTICS WERE STARTED I/V/O ELEVATED TOTAL COUNTS AND FEVER SPIKES AND SUPPORTIVE TREATMENT WAS GIVEN.2D ECHO WAS DONE,IT SHOWED NO RWMA, MILD LVH+ MODERATE TR + WITH MILD PIH, MILD AR TRIVIAL MR+,MAC+ SCLEROTIC AV,EF=64 RVSP 38+10 48MMHG GOOD IV SYSTOLIC FUNCTIONS GRADE I DIASTOLIC DYSFUNCTIONIVC SIZE
0.7 CM COLLAPSING
ON DAY 3 GCS E3V2M4 UROLOGY REFERRAL WAS DONE I/V/O HEMATURIA ADVISED FOR CT KUB - AND IRRIGATION OF BLADDER WAS DONE AND ADVISED TO CONTINUE SAME TREATMENTMENT AND ADDED INJ TRANEXAMIC ACID TO STOP BLEEDING. PSYCHIATRY REFERRAL WAS DONE I/V/O ALCOHOL WITHDRAWL SYNDROME DIAGNOSED IT AS ENTAL AND BEHAVIOURAL DISORDERS DUE TO USE OF ALCOHOL HARMFUL USE TOBACCO DEPENDENCE SYNDROME WITH ? DELIRIUM DUE TO ORGANICITY AND WAS TREATED ACORDINGLY . ORTHOPEDICS REFERRAL WAS DONE I/V/O PREVIOUS RIGHT HIP FRACTURE AND NO ACTIVE INTERVENTION WAS ADVISED.OPHTHAL REFERRAL WAS I/V/O RAISED ICT, IMPRESSION= RGHT EYE- NO EVIDENCE OF PAPILLOEDEMA LEFT EYE- OPTIC ATROPHY. ON DAY 5 PATIENT WAS INTUBATED I/V/O SUDDEN GFALL IN SATURATIONS AND CONNECTED TO MECHANICAL VENTILATOR ON FIO 60% .BLOOD CULTURE REPORTS SHOWED GROWTH OF ACINETOBACTER ,SO APPROPRIATE ANTIBIOTICS WAS STARTED. ON 14/5/2024 AS SATURATIONS WERE MAINTAING ON FIO2 -21% .WEANING OFF TRIAL WAS DONE AND PATIENT WAS EXTUBATED .EXTUBATION PROCESS WAS UNEVENTFUL.POST EXTUBATION COURSE IN THE HOSPITAL WAS UNEVENTUL. BED SORE DEVELEOPED AND REGULAR DRESSING FOR IT WAS DONE AND SUPPORTIVE TREATMENT WAS GIVEN .
Investigation HEMOGRAM 4/5/24 HB:12
TLC:13,800 PLT:2.74 PCV:34% RBC:3.93
RFT 04-05-2024 06:53:PMUREA 25 mg/dl 42-12 mg/dlCREATININE 0.9 mg/dl 1.3-0.9 mg/dlURIC
ACID 2.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-
2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
101 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 04-05-2024 06:53:PMTotal Bilurubin 1.12 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 25 IU/L 45-0
IU/LALKALINE PHOSPHATASE 191 IU/L 119-56 IU/LTOTAL PROTEINS 5.8 gm/dl 8.3-6.4
gm/dlALBUMIN 2.88 gm/dl 4.6-3.2 gm/dlA/G RATIO 0.99
HBsAg-RAPID 04-05-2024 06:53:PM Negative
Anti HCV Antibodies - RAPID 04-05-2024 06:53:PM Non Reactive HIV:NON REACTIVE
HEMOGRAM 5/5/24 HB:11.2
PCV:31.9 TLC:11,300 RBC:3.69 PLT:2.64
USG ABDOMEN AND PELVIS DONE ON 4/5/24
E/O IRREGULAR WALL THICKENING MEASURING 4-5MM WITH THICK ECHOGENIC INTERNAL ECHOES NOTED IN THE PARTIALLY DISTENDED URINARY BLADDER AND E/O 6MM SLUDGE NOTED AT THE BASE OF BLADDER WITH NO VASCULARITY LIKELY SLUDGE / BLOOD CLOT.
B/L GRADE 1 RPD CHANGES IN KIDNEYS
ABG 05-05-2024 01:05:AMPH 7.43PCO2 34.2PO2 83.1HCO3 22.6St.HCO3 23.8BEB -0.7BEecf -
1.1TCO2 45.7O2 Sat 95.9O2 Count 15.6
COMPLETE URINE EXAMINATION (CUE) 05-05-2024 10:40:AMCOLOUR reddishAPPEARANCE cloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 10-15EPITHELIAL CELLS 4-6RED BLOOD CELLS loadedCRYSTALS NilCASTS +AMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 05-05-2024 11:19:PMUREA 53 mg/dl 42-12 mg/dlCREATININE 1.1 mg/dl 1.3-0.9 mg/dlURIC
ACID 3.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.6 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.1 mg/dl 4.5-
2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
97 mmol/L 98-107 mmol/L HEMOGRAM 6/5/24
2D ECHO WAS DONE -
NO RWMA, MILD LVH PRESENT (1.25 CM) MODERATE TR PRESENT, MILD PAH
MILD AR PRESENT (PHT = 518 M/SEC); TRIVIAL MR PPRESENT MAC PRESENT, SCLEROTIC AV, NO AS/MS
EF = 62% TVSP = 48 MM HG GOOD IV SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNCTION IVC SIZE 0.7CM COLLAPSING
IAS - ANEURYSM
REVIEW 2D ECHO WAS DONE ON 18/5/24 NO PR/IV CLOT
IVC SIZE 0.8 CM COLLAPSING HB:11.7
TLC:12,500 PCV:34.2 RBC:3.98 PLT:2.86
ABG 06-05-2024 09:20:AMPH 7.43PCO2 27.3PO2 69.0HCO3 18.2St.HCO3 20.7BEB -4.5BEecf -
5.2TCO2 36.9O2 Sat 94.3O2 Count 15.1
COMPLETE URINE EXAMINATION (CUE) 06-05-2024 11:14:AMCOLOUR reddishAPPEARANCE cloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 1-2EPITHELIAL CELLS nilRED BLOOD CELLS 12-14CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 06-05-2024 10:07:PMUREA 52 mg/dl 42-12 mg/dlCREATININE 1.0 mg/dl 1.3-0.9 mg/dlURIC
ACID 3.8 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-
2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
104 mmol/L 98-107 mmol/L
COMPLETE URINE EXAMINATION (CUE) 06-05-2024 10:07:PMCOLOUR ReddishAPPEARANCE HazyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS NilRED BLOOD CELLS loadedCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
HEMOGRAM 7/5/24 HB:11.6 TLC:15,200 PCV:33.6
RBC:3.91 PLT:3.45
COMPLETE URINE EXAMINATION (CUE) 07-05-2024 10:04:PMCOLOUR ReddishAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 0-1RED BLOOD CELLS plentyCRYSTALS few
triple phosphate crystals seenCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 07-05-2024 10:04:PMUREA 55 mg/dl 42-12 mg/dlCREATININE 1.2 mg/dl 1.3-0.9 mg/dlURIC
ACID 2.9 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.5 mg/dl 4.5-
2.5 mg/dlSODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
104 mmol/L 98-107 mmol/L
HEMOGRAM 8/5/24 HB:11.4 TLC:17,800 PCV:32.9RBC:3.7 PLT:3.8
ABG 08-05-2024 02:42:PMPH 7.49PCO2 25.1PO2 42.3HCO3 19.3St.HCO3 22.3BEB -2.1BEecf -
3.6TCO2 37.6O2 Sat 79.7O2 Count 15.1
ABG 08-05-2024 02:43:PMPH 7.17PCO2 43.4PO2 96.4HCO3 15.3St.HCO3 14.7BEB -12.7BEecf -
11.6TCO2 32.2O2 Sat 93.0O2 Count 17.9
RFT 08-05-2024 11:37:PMUREA 105 mg/dl 42-12 mg/dlCREATININE 3.2 mg/dl 1.3-0.9 mg/dlURIC
ACID 5.5 mmol/L 7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.9 mg/dl 4.5-
2.5 mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
102 mmol/L 98-107 mmol/L
ABG 08-05-2024 11:37:PMPH 7.385PCO2 30.7PO2 183HCO3 18.0St.HCO3 19.8BEB -5.6BEecf -
6.1TCO2 36.8O2 Sat 98.0O2 Count 16.2 HEMOGRAM 9/5/24
HB:11.3 TLC:22,900 PCV:33.7 RBC:3.8 PLT:3.3
COMPLETE URINE EXAMINATION (CUE) 09-05-2024 12:18:PMCOLOUR BrownishAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 1-2RED BLOOD CELLS loadedCRYSTALS
triple phosphate crystals presentCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Bacteria- present
ABG 09-05-2024 12:37:PMPH 7.19PCO2 46.1PO2 83.7HCO3 17.2St.HCO3 16.2BEB -10.3BEecf -
9.5TCO2 36.9O2 Sat 91.9O2 Count 14.6
SERUM ELECTROLYTES (Na, K, C l) 09-05-2024 12:43:PMSODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 4.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 98 mmol/L 98-107 mmol/L COMPLETE URINE EXAMINATION (CUE) 09-05-2024 11:48:PMCOLOUR reddishAPPEARANCE CloudyREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE SALTS NilBILE
PIGMENTS NilPUS CELLS 1-2EPITHELIAL CELLS 1-2RED BLOOD CELLS 3-5CRYSTALS triple
phosphate crystalsCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
RFT 09-05-2024 11:48:PMUREA 144 mg/dl 42-12 mg/dlCREATININE 3.5 mg/dl 1.3-0.9 mg/dlURIC
ACID 5.0 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 6.7 mg/dl 4.5-
2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
101 mmol/L 98-107 mmol/L
ABG 09-05-2024 11:48:PMPH 7.26PCO2 33.2PO2 49.2HCO3 14.7St.HCO3 15.5BEB -10.9BEecf - 10.9TCO2 33.2O2 Sat 84.2O2 Count 6.5
HEMOGRAM 10/5/24 HB:9.9
TLC:16,400 PCV:29.7 RBC:3.27 PLT:3.12
ABG 10-05-2024 10:24:AMPH 7.26PCO2 39.5PO2 27.1HCO3 17.2St.HCO3 16.6BEB -8.8BEecf -
8.5TCO2 37.3O2 Sat 42.5O2 Count 6.0
ABG 10-05-2024 08:49:PMPH 7.39PCO2 28.7PO2 50.6HCO3 17.1St.HCO3 19.0BEB -6.4BEecf -
6.9TCO2 35.3O2 Sat 87.3O2 Count 13.1
ABG 10-05-2024 11:18:PMPH 7.35PCO2 33.3PO2 40.9HCO3 18.1St.HCO3 18.9BEB -6.5BEecf -
6.4TCO2 41.2O2 Sat 81.5O2 Count 3.8
RFT 10-05-2024 11:18:PMUREA 123 mg/dl 42-12 mg/dlCREATININE 2.4 mg/dl 1.3-0.9 mg/dlURIC
ACID 4.3 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.4 mg/dl 4.5-
2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
97 mmol/L 98-107 mmol/L HEMOGRAM 11/5/24 HB:9.2
TLC:15,700 PCV:26.3 RBC:2.9 PLT:3.0
ABG 11-05-2024 11:31:PMPH 7.42PCO2 22.0PO2 136HCO3 14.1St.HCO3 17.4BEB -8.8BEecf -
9.6TCO2 29.2O2 Sat 97.7O2 Count 13.7
RFT 11-05-2024 11:31:PMUREA 112 mg/dl 42-12 mg/dlCREATININE 2.2 mg/dl 1.3-0.9 mg/dlURIC
ACID 4.6 mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.7 mg/dl 4.5-
2.5 mg/dlSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
103 mmol/L 98-107 mmol/L HEMOGRAM 12/5/24
HB:9.6 TLC:19,400 PCV:28.3 RBC:3.25 PLT:3.35 ABG: PH:7.42 PCO2:22.0 PO2:136 HCO3:14.1
ST.HCO3:17.4 BEB:-8.8 BEECF:-9.6 TCO2:29.2
02 SAT:97.7
O2 COUNT:13.7 RFT:
UREA:112 CREATININE:2.2 URIC ACID:4.6 CA:9.0
P:3.7 NA:135 K:4 CL:103
HEMOGRAM 13/5/24 HB:8.4
TLC:19,400 PCV:25.2 RBC:2.86 PLT:2.65
RFT 13-05-2024 12:00:AMUREA 109 mg/dl 42-12 mg/dlCREATININE 2.4 mg/dl 1.3-0.9 mg/dlURIC
ACID 5.1 mmol/L 7.2-3.5 mmol/LCALCIUM 8.6 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 5.1 mg/dl 4.5-
2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
104 mmol/L 98-107 mmol/L
ABG 13-05-2024 12:01:AMPH 7.34PCO2 30.8PO2 55.1HCO3 16.5St.HCO3 18.0BEB -7.7BEecf - 8.0TCO2 35.3O2 Sat 87.1O2 Count 11.1
POST LUNCH BLOOD SUGAR 13-05-2024 10:08:AM 170 mg/dl 140-0 mg/dl
ABG 13-05-2024 10:10:AMPH 7.36PCO2 33.0PO2 80.0HCO3 18.5St.HCO3 19.9BEB -5.5BEecf -
5.8TCO2 37.7O2 Sat 95.3O2 Count 16.2
ABG 13-05-2024 10:37:PMPH 7.37PCO2 27.2PO2 139HCO3 15.3St.HCO3 17.6BEB -8.5BEecf -
8.9TCO2 32.3O2 Sat 98.0O2 Count 13.3
RFT 13-05-2024 10:37:PMUREA 85 mg/dl 42-12 mg/dlCREATININE 1.7 mg/dl 1.3-0.9 mg/dlURIC
ACID 4.1 mmol/L 7.2-3.5 mmol/LCALCIUM 8.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.4 mg/dl 4.5-
2.5 mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
103 mmol/L 98-107 mmol/L HEMOGRAM 14/5/24 HB:8.7
TLC:13,800 PCV:26.1 RBC:2.9 PLT:1.36
ABG 14-05-2024 06:24:PMPH 7.41PCO2 26.8PO2 66.8HCO3 16.9St.HCO3 19.4BEB -6.0BEecf -
6.8TCO2 34.3O2 Sat 94.2O2 Count 15.3 HEMOGRAM 15/5/24
HB:8.9 TLC:16,800 PCV:26.5 RBC:3.0 PLT:1.3
ABG 15-05-2024 12:29:AMPH 7.40PCO2 26.5PO2 130HCO3 16.4St.HCO3 18.8BEB -6.9BEecf -
7.4TCO2 34.3O2 Sat 98.3O2 Count 13.1
RFT 15-05-2024 12:29:AMUREA 71 mg/dl 42-12 mg/dlCREATININE 1.3 mg/dl 1.3-0.9 mg/dlURIC
ACID 3.9 mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.3 mg/dl 4.5-
2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
102 mmol/L 98-107 mmol/L
ABG 15-05-2024 09:47:PMPH 7.37PCO2 31.7PO2 41.7HCO3 18.3St.HCO3 19.5BEB -5.6BEecf -
5.9TCO2 37.9O2 Sat 76.8O2 Count 11.6
RFT 15-05-2024 09:47:PMUREA 73 mg/dl 42-12 mg/dlCREATININE 1.4 mg/dl 1.3-0.9 mg/dlURIC
ACID 3.2 mmol/L 7.2-3.5 mmol/LCALCIUM 9.7 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.3 mg/dl 4.5-
2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
99 mmol/L 98-107 mmol/L LIPID PROFILE:
TOTAL CHOLESTROL:127 TRIGLYCERIDES:346 HDL:30
LDL:67 VLDL:69.2
APTT 31
BLEEDING TIME :2 MIN CLOTTING TIME:4 MIN CRP:1.2 MG/DL
DENGUE NS1,IGM,IGG:NEGATIVE ESR:130
PT:15 SEC INR:1.11
D-DIMER:660
HEMOGRAM 16/5/24 HB:9.4
TLC:22,500 PCV:27.6 RBC:3.1 PLT:1.0
CUE 16/5/24 COLOUR:PALE YELLOW REACTION:ACIDIC SPEC GRAV:1.010
ALBUMIN:+ PUS CELLS:2-3
EPITHELIAL CELLS:2-3
RFT 16/5/24 UREA:73 CREAT:1.4 URIC ACID:3.2 CA:9.7
P:3.3 NA:136 K:3.8 CL:99
ABG 16/5/24 PH:7.37 PCO2:31.7 PO2:41.7 HCO3:18.3 STHCO3:19.5 BEB:-5.6 BEECF:-5.9 TCO2:37.9 O2 SAT:76.8
CULTURE REPORTS:
BLOOD FROM CENTRAL LINE FOR CULTURE:DIRECT SMEAR 1ST S/C,REPORT:ACINETOBACTER SPECIES ISOLATED
BLOOD FROM PERIPHERY FOR CULTURE :DIRECT SMEAR 1ST S/C,REPORT:ACINETOBACTER ISOLATED
VENOUS DOPPLER DONE ON 16/5/24
NO E/O DVT NOTED IN RIGHT LOWER LIMB
HEMOGRAM 17/5/24 HB:8.4
TLC:14,500 PLT:1.5 PCV:23.7 RBC:2.78 PH:7.43 PCO2:29.2 PO2:62.3 HCO3:19.5 STHCO3:21.6 BEB:-3.3 BEECF:-4.0 TCO2:39.6 O2 SAT:93.8
THROAT SWAB CULTURE AND SESNIIVITY DONE ON 17/5/24. PSEUDOMONAS AERUGINOSA ISOLATED SENSITIVE TO PIPERCILLIN, TOBRAMYCIN, CIPROFLOXACIN, AMIKACIN, PIPTAZ, MEROPENEM.
HEMOGRAM 18 /5/24 HB:8.4
TLC:14,500 PLT:1.5 PCV:23.7 RBC:2.78 RFT UREA:53
CREATININE:1.3 URIC ACID: 3.8 CALCIUM:9.0 P:3.6
NA:135 K:3.9 CL:103
HEMOGRAM 19/5/24 HB:8.5
TLC:14,300 PLT:1.5 PCV:23.8 RBC:2.7
COMPLETE URINE EXAMINATION: COLOR : PALE YELLOW APPEARANCE:CLEAR
REACTION: CLEAR SP GRAVITY: 1.010 ALBUMIN: +
BILE SALTS :NIL BILE PIGMENTS: NIL SUGAR:NIL
PUS CELLS:5-6 EPITHELIAL CELLS:2-3 RBC:8-10 CRYSTALS:NIL CASTS:NIL
AMORPHOUS DEPOSITS:ABSENT HEMOGRAM 20/5/24
HB:8.1 TLC:13,600 PLT:1.54 PCV:24.0 RBC:2.36 ABG PH:7.47 PCO2:32.9 PO2:97.6 HCO3:23.7
ST.HCO3:25.2 BEB:0.9 BEECF:0.4 TCO2:47.8
O2 SAT:97.8
HEMOGRAM 21 /5/24 HB:8.8
TLC:15,800 PLT:1.65 PCV:25.2 RBC:2.93 CUE:
COLOR: PALE YELLOW APPEARANCE : CLEAR REACTION : ACIDIC SP.GRAVITY:1.01 ALBUMIN: ++++ SUGAR: NIL
BILE SALTS: NIL BILE PIGMENTS: NIL PUS CELLS: 14-15 EPITHELIAL:2-3 RBC:2-3
CRYSTALS: NIL CAST:NIL
RFT UREA:38
CREATININE:0.9 URIC ACID:3.2 CA:9.7
P:2.8 NA:136 K:3.8 CL:101
HEMOGRAM 22 /5/24 HB:8.8
TLC:15000 PLT:1.65 PCV:25.2 RBC:2.93
HEMOGRAM 22/5/24 HB:8.0
TLC:12,300 PLT:1.57 PCV:23.6 RBC:2.69
COMPLETE URINE EXAMINATION: 22/05/2024 COLOR : PALE YELLOW APPEARANCE:CLEAR
REACTION: CLEAR SP GRAVITY: 1.010 ALBUMIN: NIL
BILE SALTS :NIL BILE PIGMENTS: NIL SUGAR:NIL
PUS CELLS:2-3 EPITHELIAL CELLS:1-2 RBC:NIL CRYSTALS:NIL CASTS:NIL
AMORPHOUS DEPOSITS:ABSENT RFT
UREA: 27 CREATININE:0.9 URIC ACID:3.0 CA:9.0
P:2.8 NA:136 K:3.7
CL:98
LIVER FUNCTION TEST (LFT) Total Bilurubin 10Direct Bilurubin.20SGOT(AST) 30SGPT(ALT) 32ALKALINE PHOSPHATASE 189 TOTAL PROTEINS 5.0ALBUMIN 2.2A/G RATIO 0.79 HEMOGRAM 22/5/24
HB: 8.2 TLC:12,900 PLT:1.70 PCV:23.8 RBC:2.77 23/05/2024 HEMOGRAM HB: 7.7 TLC:11700 PLT:2.07 PCV:22.2 RBC:2.54
LIVER FUNCTION TEST (LFT) Total Bilurubin: 1.41Direct Bilurubin: 0.60SGOT(AST): 40SGPT(ALT)
: 30ALKALINE PHOSPHATASE: 159TOTAL PROTEINS: 5.0ALBUMIN : 1.8A/G RATIO: 0.47 RFT
UREA: 26
CREATININE: 0.9
URIC ACID: 2.6
CA: 7.5
P: 5.6
NA: 130 K:3.6 CL: 98 CUE:
COLOR: PALE YELLOW APPEARANCE : CLEAR REACTION : ACIDIC SP.GRAVITY:1.01 ALBUMIN: +
SUGAR: NIL
BILE SALTS: NIL BILE PIGMENTS: NIL PUS CELLS: PLENTY EPITHELIAL:2-3
RBC NIL CRYSTALS: NIL CAST:NIL
ABG PH:7.51 PCO2:27.2 PO2:59.4 HCO3:21.9
ST.HCO3:24.3 BEB:-0.0 BEECF: -0.7 TCO2:44.8
O2 SAT:92.9
O2 COUNT-12.8 24/05/2024 HEMOGRAM HB: 7.7 TLC:13,700 PLT:1.80
PCV: 21.4
RBC: 2.54
LIVER FUNCTION TEST (LFT) Total Bilurubin: 0.83Direct Bilurubin: 0.16SGOT(AST): 30SGPT(ALT)
: 30ALKALINE PHOSPHATASE:236 TOTAL PROTEINS: 5.2ALBUMIN : 2.2A/G RATIO: 0.75 RFT
UREA: 32 CREATININE:1.2 URIC ACID: 2.9
CA: 9.3
P: 2.9
NA: 130
K:3.7 CL: 97
URINE CULTURE REPORT ON 24/5/24 REVEALED PERINEAL COMMENSALS GROWTH. 25/05/2024
SERUM ELECTROLTYES NA:133
P: 4.0
CL: 102 CA:1.02 HEMOGRAM HB: 7.7 TLC:13,600 PLT:1.80 PCV: 21.4
RBC: 2.52
LIVER FUNCTION TEST (LFT) Total Bilurubin: 0.83Direct Bilurubin: 0.16SGOT(AST): 30SGPT(ALT)
: 30ALKALINE PHOSPHATASE:236 TOTAL PROTEINS: 5.2ALBUMIN : 2.2A/G RATIO: 0.75 RFT
UREA: 32 CREATININE:1.2 URIC ACID: 2.9
CA: 9.3
P: 2.9
NA: 130 K:3.7 CL: 97
26/05/2024
RFT UREA: 28
CREATININE:1.2 URIC ACID: 2.7
CA: 9.8
P: 2.7
NA: 134
K:3.9 CL: 97 LFT
TOTAL BILIRUBIN: 0.70 DIRECT BILIRUBIN:0.16 AST:27
ALY:29
ALKALINE PHOSPAHTASE:230 TOTAL PROTEIN : 5.1 ALBUMIN: 2.2
A/G RATIO- 0.75 HEMOGRAM HB- 7.4
PCV - 21.3 RBC-2.47 PLT-2.39 28/05/2024 HEMOGRAM- HB- 7.0
PC- 19.6
RBC- 2.28
PLT- 2.65 CUE
COLOUR- PALE YELLOW APPEARANCE- CLEAR REACTION- ACIDIC SPECIFIC GRAVITY-1.010 ALBUMIN- +
SUGAR- NIL BILE SALTS- NIL BILE PIGMENT- NIL
PUS CELL-3-4 E CELLS- 2-3 RBC- NIL
CRYSTALS-0 NIL
CAST- NIL
ON 18/05/2024
BLOOD CULTURE FROM PERIPHERAL LINE - ACINETOBACTER ISOLATED. SENSITIVE TO COTRIMOXAZOLE
BLOOD CULTURE FROM CENTRAL LINE - ACINETOBACTER ISOLATED. SENSITIVE TO COTRIMOXAZOLE
ON 29/05/2024
URINE CULTURE - ENTEROCOCCUS SPS. >10^5 CFU/ML OF URINE ISOLATED, SENSITIVE TO LINOZOLID . INTERMEDIATELY SENSITIVE TO NITROFURONTINE AND PIPTAZ
BLOOD CULTURE FROM CENTRAL AND PERIPHERAL LINES WERE NEGATIVE 29/05/2024
CUE
COLOUR Pale yellowAPPEARANCE Clear Clear REACTION Acidic SP.GRAVITY 1.010 ALBUMIN
++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 4-5 EPITHELIAL CELLS 3-4 RED BLOOD CELLS Nil CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil HEMOGRAM
HAEMOGLOBIN 7.8 gm/dl TOTAL COUNT 10,000 cells/cumm NEUTROPHILS 76 % LYMPHOCYTES 18 % EOSINOPHILS 02 % MONOCYTES 04 % BASOPHILS 00 % PCV 24.1 vol % M C V 86.9 fl M C H 28.2 pg M C H C 32.4 %RDW-CV 15.8 % RDW-SD 51.5 fl RBC COUNT 2.78
millions/cumm PLATELET COUNT 3.32 lakhs/cu.mm SERUM ELECTROLYTE
SODIUM 134 mmol/L POTASSIUM 4.4 mmol/L CHLORIDE 99 mmol/L CALCIUM IONIZED 1.05
mmol/L 30/05/2024 CUE
COLOUR Pale yellowAPPEARANCE ClearREACTION Acidic SP.GRAVITY 1.010 ALBUMIN ++ SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil
HEMOGRAM
HAEMOGLOBIN 7.2 gm/dl TOTAL COUNT 8,600 cells/cumm NEUTROPHILS 70 % LYMPHOCYTES 20 %EOSINOPHILS 02 %MONOCYTES 08 % BASOPHILS 00 %PCV 21.7 vol % M C V 86.5 fl M C H 28.4 pg M C H C 32.9 % RDW-CV 15.8 % RDW-SD 51.2 fl RBC COUNT 2.51
millions/cumm PLATELET COUNT 3.34 lakhs/cu.mm 31/05/2024
CUE
COLOUR Pale yellowAPPEARANCE ClearREACTION AcidiSP.GRAVITY 1.010 ALBUMIN
++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4 EPITHELIAL CELL S2-3 RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS Absent NilOTHERS Nil HEMOGRAM
HAEMOGLOBIN 7.7 gm/dlTOTAL COUNT 10,200 cells/cumm NEUTROPHILS 70 %
LYMPHOCYTES 20 % EOSINOPHILS 02 % MONOCYTES 08 % BASOPHILS 00 % PCV 23.3 vol % M C V 89.3 flM C H 29.5 pg M C H C 33.0 %RDW-CV 14.7 %RDW-SD 48.5 fl 3RBC COUNT 2.61
millions/cumm PLATELET COUNT 3.82 lakhs/cu.mm 1/6/24
CUE
COLOUR Pale yellowAPPEARANCE Clear
REACTION AcidicSP.GRAVITY 1.010 ALBUMIN ++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS Absent OTHERS Nil
HEMOGRAM
HAEMOGLOBIN 7.2 gm/dlTOTAL COUNT 8,600 cells/cumm NEUTROPHILS 70 % LYMPHOCYTES 20 % EOSINOPHILS 02 % MONOCYTES 08 % BASOPHILS 00 % PCV 21.7 vol % M C V 86.5 flM C H 28.4 pg M C H C 32.9 %RDW-CV 51.2 %RDW-SD 51.2 fl 3RBC COUNT 2.51 millions/cumm
PLATELET COUNT 3.34 lakhs/cu.mm 2/6/24
HEMOGRAM
HAEMOGLOBIN 7.5 gm/dlTOTAL COUNT 10,100 cells/cumm NEUTROPHILS 70 %
LYMPHOCYTES 20 % EOSINOPHILS 00 % MONOCYTES 18 % BASOPHILS 00 % PCV 22 vol % M C V 86.6 flM C H 29.5 pg M C H C 34.1 %RDW-CV 14.3 %RDW-SD 45.7 fl 3RBC COUNT 2.54
millions/cumm PLATELET COUNT 3.44 lakhs/cu.mm CT KUB PLAIN DONE 13/5/24
B/L MILD HYDROURETERONEPHROSIS [RT>LT]DUE TO OVERLY DISTENDED URINARY BLADDER
DEPENDENT DENSITY NOTED WITHIN THE BLADDER POSTEROLATERALLY
? URINARYBLADDER SLUDGE ? MASS CT KUB CONTRAST DONE ON 24/5/2024
B/L MILD HYDROURETERONBEPHROSIS [RT>LT]
OOVERLY DISTENDED URINARY BLADDER WITH INCREASEED WALL THICKNESS MRI BRAIN PLAIN ON 8/5/2024
HEMOSIDERIN STAINING IN LEFT BASAL GANGLIA
SEQUALAE OF OLD HEMORRHAGE
FEW MICROHEMORRHAGES IN B/L CEREBRAL HEMISPHERES ON SWI LIKE HYPERTENSIVE MICRO HEMORRHAGES
CT BRAIN PLAIN ON 10/5/2024
HYPODENSE LESION IN LEFT BASAL GANGLIA SEQUALAE OF OLD INFARCT OR HEMORRHAGE
URINE CYTOLOGY REPORT ON REVEALED FEW SCATTERED DISPERSED EPITELIAL CELLS IN THE BACKGROUND SHOWING NUMEROUS DEGENERATED NEUTROPHILS, BACTERIAL COLONIES HAEMORHHAGIC , NONATYPICAL CELLS WERE SEEN.
URINE CYTOLOGY REPORT ON 31/5/24 REVEALED NUMEROUD DEGENERATED NEUTROPHILS, EOSINOPHILS, FUNGAL ELEMENTS - HYPHAE, BUDDING YEAST, PROBABLY CANDIDA SPECIES IN BACGROUND SHOWING BACTERIAL COLONIES. NO EVIDENCE OF ATYPICAL CELLS
Treatment Given(Enter only Generic Name)
RYLES FEEDS: 100ML WATER 2ND HOURLY
200ML MILK 4TH HOURLY WITH 2 SPOONS OF PROTEIN POWDER IV FLUIDS -NS &RL @ 50ML/HR
INJ. MEROPENEM 1GM IV/BD INJ. CLINDAMYCIN 500MG IV/BD INJ. PIPTAZ 4.5GM IV/TID
INJ. NEOMOL 1GMIV/SOS INJ.TRANEXA 500 MG /IV/BD
INJ.THIAMINE 200MG IN 100ML NS /IV/BD INJ.OPTINEURON 1AMP IN 100 ML NS/IV/OD INJ.PAN 40MG IV/OD
INJ. MIDAZOLAM 30MG + FENTANYL 200MG IN 16ML NS IV @ 4ML/HR INJ. VECURONIUM 50MG IN 50ML NS IV @3.5 ML/HR
INJ. LEVIPILL 500MG IV/BD INJ. LASIX 20MG IV/BD TAB.DOLO 650 MG /PO/SOS
TAB. OLANZAPINE 2.5MG RT/BD
TAB. COTRIMAXAZOLE 800/160MG RT/BD FOR 12 DAYS
TAB. MET-XL 50ML RT/OD
NEB.MUCOMIST 2 RESP 6TH HOURLY AND BUDECORT 6TH HRLY NEOSPORIN POWDER L/A GLUTEAL REGION
ORAL SUCTION 2ND HOURLY POSITION CHANGE 2ND HOURLY CHEST PHYSIOTHERAPY
C-PAP INTERMITTENTLY TAB SPOROLAC RT/TID
Advice at Discharge
RYLE TUBE FEEDINGS 100ML WATER EVERY 2ND HOURLY,
RYLE TUBE FEEDINGS 200ML MILKEVERY 4TH HOURLY WITH 2 SCOOPS OF PROTEIN POWDER
TAB. COTRIMOXAZOLE 200/160MG RT BD X 1 WEEK TAB. BENFOMET PLUS RT OD X 1 WEEK
TAB. NEUROBION FORTE RT OD X 1 WEEK TAB. PAN 40MG RT OD X 1 WEEK
TAB. DOLO 650MG RT SOS
ROTAHALER FORACORT 200MG 2 PUFFS BD HOME BP MONITORING
T.BACT OINTMENT FOR LA REGULAR BEDSORE DRESSINGS AIR BED
2HRLY POSITION CHANGING
Follow Up
REVIEW TO GM, GS, UROLOGY OPDS AFTER 1 WEEK OR SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 3/06/2024 Ward: MMW Unit:GM-6
Post discharge PaJR discussion Transcripts:
[12/06, 12:04] Patient Advocate 60M Delirium Resp: Sir todays we gave bread with milk little ,cough came then we stop to give orally
[12/06, 12:52] Rakesh Biswas: Yes we have to be very careful and slow
[14/06, 15:26] Patient Advocate 60M Delirium Resp: Sir my father ate 3 biscuits in the afternoon, can we give idly
[14/06, 15:28] Patient Advocate 60M Delirium Resp: Fruit?
[14/06, 16:07] Rakesh Biswas: Only fruit. No juice 🙂
[14/06, 16:07] Rakesh Biswas: Juice contains lots of sugar
[14/06, 18:35] Patient Advocate 60M Delirium Resp: Sir bed source is like this
[15/06, 08:37] Rakesh Biswas: Healing well 👏
[20/06, 09:52] Rakesh Biswas: @Aneef Elective May 2024 Can you share the case report link of this patient prepared in your portfolio where you have documented his initial acinetobacter isolated in peripheral venous blood and blood from cvp catheter?
A good discussion on correlation between acinetobacter as commensal v pathogen is pending with references
I have also lost all the previous discussions here and it would be important to see it all archived as illustrated with other patients before
[20/06, 10:44] Aneef Elective May 2024: Yes Sir, will share them
[20/06, 16:49] Rakesh Biswas: Is it getting daily dressing?
Please share the image daily
[20/06, 16:50] Patient Advocate 60M Delirium Resp: Yes sir times before sitting
[20/06, 16:50] Patient Advocate 60M Delirium Resp: 2
[21/06, 15:15] Patient Advocate 60M Delirium Resp: Sir this is bed source
[21/06, 15:17] Kmcq: Healing well..
Give it some time and share here regularly.
Is he walking?
[21/06, 15:19] Patient Advocate 60M Delirium Resp: When we come for check up?
[21/06, 15:24] Kmcq: Is he able to walk,talk,eat and drink?
[21/06, 15:26] Patient Advocate 60M Delirium Resp: Not able to walk sir, he can sit with support, can talk with less sound ,can eat little not much, drinking time once coughing is coming
[21/06, 15:27] Kmcq: Able to stand?
[21/06, 15:28] Patient Advocate 60M Delirium Resp: No sir
[21/06, 15:30] Kmcq: Is there still ryles tube?
[21/06, 15:33] Patient Advocate 60M Delirium Resp: Through that tube only we giving 700ml milk, 500ml of water, 150ml of Raggi jawa
[21/06, 15:35] Patient Advocate 60M Delirium Resp: He is chewing well sir apple, biscuits, bread but swallow is difficult now
[21/06, 15:37] Patient Advocate 60M Delirium Resp: He asking rice with mutton or chicken, can we feed spicy food sir?
[21/06, 16:16] Rakesh Biswas: Can bring him here to OPD anyday
I'm here in the hospital daily
@Genau PaJR CEO CFHE IIT would you like to arrange someone to evaluate him locally at home? Can we establish a network with his local doctors?
[21/06, 16:17] Rakesh Biswas: Can take in the same manner very very slowly without much spice
[24/06, 07:12] Patient Advocate 60M Delirium Resp: Sir today we will be meet in hospital ,pls observe my patient physical and mentally that how the brain is function.
[24/06, 12:47] Rakesh Biswas: Reviewed the patient in the OPD casualty
Consciousness remarkably better in eye opening and motor responses to verbal cues although still unable to speak
Also his swallowing hasn't improved and he still needs the ryles tube through which he is surviving on ragi java and milk as his only calorie source
His left abducens palsy that we suspected was due to his raised ICT causing neuropraxia is now fully recovered @Aneef Elective May 2024
[24/06, 12:48] Rakesh Biswas: Bed sore. Intern @meghana will share further from surgery OPD as scheduled after this
[24/06, 12:52] Rakesh Biswas: Right lower limb fixed flexion deformity with persistent left external rotation of hip joint. @meghana @Vivek Kurma 2022 KIMs Pg Med will share his x-ray pelvis with bilateral hip joint images here soon along with the orthopedic notes today. He could benefit from a right knee scaffold as an orthotic splint to keep him standing and enable him to walk that will also benefit his bedsore once we have also sorted the mystery of his left hip external rotation
[24/06, 12:53] Rakesh Biswas: His urinary bladder bleeds appear to have stopped and foleys is functioning well although urology review today would be useful
[24/06, 16:11] Patient Advocate 60M Delirium Resp: Sir ,pls write the medicine as prescription ,all doctor's leave at 5 o clock, not available .. there is no 3way cathedral tube in pharmacy that is in side hospital and out side . My brother went to narkatpally he is try to get it .
[24/06, 16:12] Patient Advocate 60M Delirium Resp: Because of that we in urology cabin
[24/06, 16:13] Patient Advocate 60M Delirium Resp: For Cathedral change
[24/06, 16:16] Rakesh Biswas: @Lohith Varma PG Kims 2022 @Chandana KIMS 2020 SR Can you please check and let me know the current status?
[24/06, 17:07] Lohith Varma PG Kims 2022: Patient got his foleys changed and dressing for bedsore is being done in the surgery OPD sir
[24/06, 17:12] Lohith Varma PG Kims 2022: Patient is conscious, oriented to place and person
obeying commands
He is able to answer basic questions with one word answers
BP-120/80mmhg
PR- 70bpm
Auscultation-
S1s2 heard; no murmurs
Normal vesicular breath sounds heard; no added sounds
[24/06, 17:16] Lohith Varma PG Kims 2022: He is not able swallow food, still on Ryles feeds
[24/06, 17:17] Patient Advocate 60M Delirium Resp: Sir try to write medicine for all for one month because will do physiotherapy for sit and work in this month along with medication. If possible provide ear michan for proper hearing
[24/06, 18:09] Rakesh Biswas: What medicines is he currently taking?
Do you think he needs different medicines now?
[24/06, 18:54] Lohith Varma PG Kims 2022: He is not on any medication now sir
[24/06, 19:06] Rakesh Biswas: Since how many days?
Can you list his problems that would necessitate any medication?
[24/06, 19:08] Rakesh Biswas: 👆 Problem 1:
Altered sensorium @Pushed Communicator 1N21 thesis
Medical management is various forms of positive stimulation therapy ranging from touch, talk, etc to even as exotic as melodic intonation therapy to enable him to heal
[24/06, 19:10] Rakesh Biswas: 👆 Problem 2:
Swallowing difficulty due to possible posterior circulation stroke causing 9, 10, 11 supranuclear cranial nerve pathway damage which we can only hope will improve with time and cortical reprogramming
[24/06, 19:15] Pushed Communicator 1N21: Yes sir
[24/06, 19:16] Pushed Communicator 1N21: Cortical reprogramming in terms of melodic intonation sir??
[24/06, 19:17] Rakesh Biswas: 👆Problem 3
Discussed solution above
@Vivek Kurma 2022 KIMs Pg Med needs to tell us what orthopedic surgeons suggest from their side
[24/06, 19:18] Rakesh Biswas: Also where is his x-ray hip joint that we ordered?
@Genau PaJR CEO CFHE IIT tagging you only to understand the care coordination issues that need to be addressed
[24/06, 19:23] +91 93903 07971: They suggested physiotherapy and stretching exercises sir
[24/06, 19:24] Rakesh Biswas: Why is the left femur externally rotated?
What did they suggest for that?
[24/06, 19:25] Rakesh Biswas: 👆@Aneef Elective May 2024 gentle reminder
[24/06, 19:52] Patient Advocate 60M Delirium Resp: Sir for this nerve damage, can u give any medicine?to get recovery in normal status
[24/06, 22:24] Rakesh Biswas: Science hasn't found anything yet. Many doctors would give placebos while the body itself does the actual healing
[25/06, 04:25] Aneef Elective May 2024: Apologies for the delay sir. Will update at the earliest
[01/07, 17:02] Patient Advocate 60M Delirium Resp: Sir,my my father bed source getting very deep day by day ,pls give him any treatment to get recovery 🙏 , this is today's picture vedio
[01/07, 19:05] Rakesh Biswas: How much is he able to walk at home?
Is he lying in bed all the time?
The bed sore can only heal with mobilization so that there is better blood supply there
There are no scientifically proven useful medicines separately for bed sores
[02/07, 11:18] Rakesh Biswas: [01/07, 18:56] Rakesh Biswas: How much is he able to walk at home?
[02/07, 11:05] Patient Advocate 60M Delirium Resp: He is not able to stand with legs sir
[02/07, 11:15] Rakesh Biswas: That's the reason his other issues are not improving
We have to make him stand asap
If you check my notes in the group after I evaluated him few weeks back here, I had made this point where I had suggested that he needs an external splint support to straighten his legs so that he can stand and be mobilized.
Check out how its done in the video here 👇
https://youtu.be/Xh7nOPY_VQw?feature=shared
[02/07, 11:19] Rakesh Biswas: Here's another easier way to start doing the knee flexion deformity correction but needs a trained physiotherapist to guide the patient.👇
https://youtube.com/shorts/tGmtVpbwx1E?feature=shared
[02/07, 11:20] Rakesh Biswas: I've added Dr @Madhavi Rawat one of the physiotherapists in our team to guide us further online
[02/07, 11:22] Patient Advocate 60M Delirium Resp: Ok sir ,can I call to this number sir
[02/07, 11:24] Rakesh Biswas: No
I'm not sure but most of our team members are busy working professionals who are doing this voluntary work as a calling
Let them first provide an appointment if at all
[02/07, 11:26] Patient Advocate 60M Delirium Resp: Ok sir
[02/07, 12:35] Madhavi Rawat: Thank you so much sir, it's my pleasure to help them
[02/07, 12:42] Madhavi Rawat: Can you share patient post operative procedure and Drs advice so that i can help you..
[02/07, 12:45] Rakesh Biswas: @Genau PaJR CEO CFHE IIT @Aneef Elective May 2024 please share here
[02/07, 12:46] Rakesh Biswas: @Madhavi Rawat a little bit is available in the case report link in the description box here
It will remind of your own online learning portfolio during 2015-16
[02/07, 12:46] Madhavi Rawat: Ok sir
[02/07, 12:48] Rakesh Biswas: Do feel free to ask any queries you have about the patient here
[02/07, 12:48] Madhavi Rawat: Sure sir
[02/07, 14:57] Patient Advocate 60M Delirium Resp: Madam shall we come to hospital tomorrow
[02/07, 15:18] Madhavi Rawat: Which Hospital?
[02/07, 16:51] Rakesh Biswas: It's easier if you talk on phone with @Madhavi Rawat
Once done you can share the salient points gained from your telephonic conversation here
[02/07, 18:44] Rakesh Biswas: @Genau PaJR CEO CFHE IIT we will need to check if someone from orthotics department khl can provide support for this in conjunction with good physiotherapy to relieve his knee flexion contracture so that he can stand and walk
[03/07, 04:17] Aneef Elective May 2024: Yes sir. I will connect with the residents to share the accurate advice
[03/07, 11:30] Rakesh Biswas: Please share yesterday's updates about your patient's mobilization activities
[03/07, 20:19] Rakesh Biswas: Thanks for sharing this although it's always better to take care not to capture the face in the video to protect patient privacy and confidentiality.
@Ganesh Joshi @Madhavi Rawat your inputs on what would be the best way to move forward in making the patient stand and walk
[06/07, 13:00] Ganesh Joshi: Not ready to stand at present.
Contractures and Weakness in Lower Limbs.
Hard base bed with 4" thick mattress - cotton/coir
Turning schedule 2 hourly with more time prone
ROM exercise for major joints H/K/A
Assisted strengthening of lower limb in lateral lying one after other
Diet - protein, iron, calcium (if not renal issues), calories
Wheeled ambulation at present to show outsides
[06/07, 16:48] Rakesh Biswas: Thanks Dr Joshi.
@Genau PaJR CEO CFHE IIT @Patient Advocate 60M Delirium Resp We are fortunate to have the topmost Physiatrist in the country guiding us.
Please share any practical queries you may have in implementing the above suggestions
@Genau PaJR CEO CFHE IIT what about adding our medical superintendent and orthopedic surgeon Prof to coordinate this part?
[06/07, 16:50] Rakesh Biswas: @Madhavi Rawat please share if you can guide how @Patient Advocate 60M Delirium Resp may implement the above suggestions with her local physiotherapists near her home
[06/07, 17:01] Ganesh Joshi: @Patient Advocate 60M Delirium Resp may DM or contact here
[06/07, 17:02] Ganesh Joshi: Available after 1pm tomorrow🙏🏻
[06/07, 18:20] Rakesh Biswas: @Genau PaJR CEO CFHE IIT please coordinate
[16/07, 10:12] Genau PaJR CEO CFHE IIT: Ok sir
[16/07, 10:13] Genau PaJR CEO CFHE IIT: I will coordinate
[19/07, 10:03] Patient Advocate 60M Delirium Resp: Sir pls right limb not able to stand ,pls arrange physiotherapist in hospital sir
[19/07, 10:20] Rakesh Biswas: Yes please bring him to our hospital
Please try not to capture patient faces in the videos to protect the patient's and the family's privacy and confidentiality
[21/07, 16:02] Ganesh Joshi: Share recent discharge notes without personal identity data...
[21/07, 16:06] Rakesh Biswas: The picture shows the right knee.
The site of operation was different?
He has contractures of the knee and perhaps some amount of unscrupulous mobilization without professional help could be causing an osteoarthritis of the right knee
చిత్రం కుడి మోకాలి చూపిస్తుంది.
ఆపరేషన్ సైట్ భిన్నంగా ఉందా?
అతనికి మోకాలి యొక్క సంకోచాలు ఉన్నాయి మరియు వృత్తిపరమైన సహాయం లేకుండా కొంత మొత్తంలో నిష్కపటమైన సమీకరణ కుడి మోకాలి యొక్క ఆస్టియో ఆర్థరైటిస్కు కారణం కావచ్చు
Citraṁ kuḍi mōkāli cūpistundi.
Āparēṣan saiṭ bhinnaṅgā undā?
Ataniki mōkāli yokka saṅkōcālu unnāyi mariyu vr̥ttiparamaina sahāyaṁ lēkuṇḍā konta mottanlō niṣkapaṭamaina samīkaraṇa kuḍi mōkāli yokka āsṭiyō ārtharaiṭisku kāraṇaṁ kāvaccu
[21/07, 17:57] Rakesh Biswas: Thanks @Ganesh Joshi for pointing out that the discharge summary is not available in the EHR case report link in the description box.
@Genau PaJR CEO CFHE IIT we never managed to find an intern for this patient who could as per our PaJR protocol, paste all the PaJR team based learning discussions sequentially after admission along with the discharge summary post admission and the post discharge PaJR discussions as illustrated here👇
https://userdrivenhealthcare.blogspot.com/2024/04/cbble-case-report-60-year-old-woman.html?m=1
Was at Home for a month since discharge on 3/6/24 and then returned on 26/7/24 to address his requirements of inability to walk due to fixed flexion contractures and a Mumbai based AIIMS Delhi trained MD Physiatrist consultation was taken in our OPD as linked below:
https://youtu.be/WT8AFSgev-0?feature=shared
Following admission he is making steady progress in terms of his fixed flexion contractures and walking potential that will go a long way to heal his bed sores
[26/07, 09:14] Patient Advocate 60M Delirium Resp: Sir Good morning 🙏, today we r coming to medical check up for my father
[26/07, 09:21] Ganesh Joshi: I can be available on VC @Rakesh Biswas
[26/07, 09:22] Patient Advocate 60M Delirium Resp: VC means ?
[26/07, 09:33] Ganesh Joshi: Video Conferencing
ভিডিও কনফারেন্সিং
[26/07, 09:39] Rakesh Biswas: @Genau PaJR CEO CFHE IIT please set up a video call between @Ganesh Joshi @Patient Advocate 60M Delirium Resp @Dr RAVI KUMAR Kims PG 2023 @Communicating Learner 2N21 today in the OPD ASAP
[26/07, 10:34] Rakesh Biswas: @Pushed Communicator 1N22 will video call Professor Joshi @Ganesh Joshi once the patient arrives in the OPD and we start examining him
[26/07, 12:14] Rakesh Biswas: @Ganesh Joshi we are taking you now into the video call
[26/07, 12:15] Ganesh Joshi: 2 min
[26/07, 12:44] Rakesh Biswas: Thanks for the very interesting session.
[26/07, 13:23] Ganesh Joshi: 1. Maintain range of motion
2. Slight painless stretch beyond available range only towards extension
3. 6 times a day, 5 repetition each time, every stretch held for 8-12 seconds
[27/07, 13:51] Patient Advocate 60M Delirium Resp: Sir, Good morning 🙏, why he is not able to seat by own strength till today? Is it brain problem or because of weakness? Pls give us proper information to serve him
[27/07, 14:11] Ganesh Joshi: Both. Mainly weakness, but understanding is required to follow and comply with doctor's instructions.
[27/07, 14:38] Patient Advocate 60M Delirium Resp: For this what we should as attenders of patient
[27/07, 15:19] Ganesh Joshi: For attenders👆🏻
Passive doesn't require understanding.from patient
[27/07, 15:20] Ganesh Joshi: Pain will be visible by wincing. Don't allow it to be excess
[30/07, 20:36] Rakesh Biswas: @Pushed Communicator 1N22 and treating team, please ensure that he's not discharged. They were worried as someone apparently informed them in the ward that they may be discharged tomorrow!
[30/07, 20:53] Pushed Communicator 1N22: Okay sir
[31/07, 09:42] Patient Advocate 60M Delirium Resp: Sir ,My father infection in left leg (which was broken ) that's what it is getting swelling for that give any treatment .
[31/07, 10:23] Patient Advocate 60M Delirium Resp: My father Having infection infection in x-ray report pls confirm it sir
[31/07, 11:50] Patient Advocate 60M Delirium Resp: Sir, pls check up brain condition from present scan report, mummy is facing problem to sit him for eating.and feed . Help us sir
[31/07, 12:36] Rakesh Biswas: They are Telugu not Bengali
[31/07, 12:42] Rakesh Biswas: All these infection in leg and brain problems are evaluated by clinical examination and not through x-ray or MRI! Unfortunately our current system of healthcare gives a wrong impression to patients and even doctors that these are a substitute for clinical examination!
I have been going to the ward every afternoon to meet him but that's the time he's going to physiotherapy.
Will he be able to meet me in the ICU today afternoon before proceeding for his physiotherapy or else he can even come to our OPD to meet me in the morning tomorrow so that I can examine him and tell you what is wrong in his left leg and brain?
లెగ్ మరియు మెదడు సమస్యలలో ఈ ఇన్ఫెక్షన్ అంతా క్లినికల్ ఎగ్జామినేషన్ ద్వారా అంచనా వేయబడుతుంది మరియు ఎక్స్-రే లేదా MRI ద్వారా కాదు! దురదృష్టవశాత్తూ మన ప్రస్తుత ఆరోగ్య సంరక్షణ వ్యవస్థ రోగులకు మరియు వైద్యులకు కూడా ఇవి క్లినికల్ పరీక్షలకు ప్రత్యామ్నాయమని తప్పుడు అభిప్రాయాన్ని కలిగిస్తుంది!
నేను అతనిని కలవడానికి ప్రతి రోజు మధ్యాహ్నం వార్డుకు వెళుతున్నాను కానీ అతను ఫిజియోథెరపీకి వెళ్తున్నాడు.
అతను ఫిజియోథెరపీకి వెళ్లే ముందు ఈ రోజు మధ్యాహ్నం నన్ను ఐసియులో కలవగలడా లేదా రేపు ఉదయం నన్ను కలవడానికి అతను మా OPD కి కూడా రావచ్చు, నేను అతనిని పరీక్షించి అతని ఎడమ కాలులో ఏమి తప్పు ఉందో చెప్పగలను మరియు మె ద డు?
Leg mariyu medaḍu samasyalalō ī inphekṣan antā klinikal egjāminēṣan dvārā an̄canā vēyabaḍutundi mariyu eks-rē lēdā MRI dvārā kādu! Duradr̥ṣṭavaśāttū mana prastuta ārōgya sanrakṣaṇa vyavastha rōgulaku mariyu vaidyulaku kūḍā ivi klinikal parīkṣalaku pratyāmnāyamani tappuḍu abhiprāyānni kaligistundi!
Nēnu atanini kalavaḍāniki prati rōju madhyāhnaṁ vārḍuku veḷutunnānu kānī atanu phijiyōtherapīki veḷtunnāḍu.
Atanu phijiyōtherapīki veḷlē mundu ī rōju madhyāhnaṁ nannu aisiyulō kalavagalaḍā lēdā rēpu udayaṁ nannu kalavaḍāniki atanu mā OPD ki kūḍā rāvaccu, nēnu atanini parīkṣin̄ci atani eḍama kālulō ēmi tappu undō ceppagalanu mariyu me da ḍu?
[01/08, 09:37] Patient Advocate 60M Delirium Resp: Sir Good morning my father is in medical ward ,pls examine physically his brain condition, he is not sit his own strength
[01/08, 10:10] Rakesh Biswas: Yes I'm reaching there
[01/08, 10:52] Rakesh Biswas: Doing well.
He doesn't have any infection in his legs.
It's just a bedsore that will improve on walking.
We tried to make him walk but he's still not able to do that although he's more enthusiastic about it.
His brain function is absolutely fine. He's unable to speak due to a condition called Broca's aphasia and even that will also recover with time
Will review his cranial MRI images now
[01/08, 10:58] Rakesh Biswas: I shall prepare this case report ASAP
[01/08, 10:59] Rakesh Biswas: Lost a lot of documents of this patient since i changed my phone but will manage with what I captured after that in my phone
[01/08, 11:03] Rakesh Biswas: MRI BRAIN PLAIN ON 8/5/2024
HEMOSIDERIN STAINING IN LEFT BASAL GANGLIA
SEQUALAE OF OLD HEMORRHAGE
FEW MICROHEMORRHAGES IN B/L CEREBRAL HEMISPHERES ON SWI LIKE HYPERTENSIVE MICRO HEMORRHAGES
CT BRAIN PLAIN ON 10/5/2024
HYPODENSE LESION IN LEFT BASAL GANGLIA SEQUALAE OF OLD INFARCT OR HEMORRHAGE
[01/08, 11:06] Patient Advocate 60M Delirium Resp: Is is not cure inside sir?
[01/08, 11:07] Patient Advocate 60M Delirium Resp: New skin will get form like previous skin?
[01/08, 11:08] Patient Advocate 60M Delirium Resp: Is there any possibility to get new over that wund?
[01/08, 11:11] Patient Advocate 60M Delirium Resp: Can we give non-vegetarian food to patient health or not to give? He is having interest to eat because of that bed sour we did give that non-vegetarian items
[01/08, 11:14] Rakesh Biswas: He can take if interested but it's not essential
[01/08, 11:15] Rakesh Biswas: Yes new skin will form. He just needs to walk
[01/08, 11:21] Ganesh Joshi: Bed sore care -
Attendant shall start turning schedule once every 2 hours and patient shall never lie on the bedsore area.
Ensure that there are no seams on clothes or bedsheets.
May get an alternative pumped air mattress but still turning schedule has to be followed.
Standing/sitting with support whatever possible is desired.
Iron supplements as advised by treating doctor
[01/08, 11:26] Patient Advocate 60M Delirium Resp: Sir can he walk in future? With these two legs
[01/08, 11:44] Rakesh Biswas: Why would we try so hard to make him walk if we didn't believe that he can?
[8/1, 12:11 PM] +patient advocate: 🙏
[8/1, 12:15 PM] PaJR PHR Moderator: Sharing the deidentified horcrux EMR case summary prepared by our anonymous intern
Age/Gender : 60 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 04/05/2024 05:35 PM
Discharge Date Date: 3/06/2024 Ward: MMW Unit:GM-6
Readmitted:26/6/2024
https://www.facebook.com/share/p/vjAFKrL8AYQ29iTt/?mibextid=oFDknk
[8/1, 12:41 Pm] patient advocate: If he is not made to Sit/Stand with support, the bedsore will worsen for sure. Hence you don't have any other option but to think positive
[8/1, 12:51 PM] patient advocate: Write in telugu I this matter , properly i can not understand what u have written
[8/1, 1:21 PM] pajr doctor: అతను మద్దతుతో కూర్చునేలా/నిలుచుకోని పక్షంలో, నొప్పి ఖచ్చితంగా తీవ్రమవుతుంది. కాబట్టి మీకు సానుకూలంగా ఆలోచించడం తప్ప వేరే మార్గం లేదు
If he cannot sit/stand with support, the pain will definitely worsen. So you have no choice but to think positively
[8/1, 2:27 PM] patient advocate: Ok sir, tq
[8/1, 2:50 PM] pajr doctor: Google Translate App will help you @~pajr_member
[8/1, 2:51 PM] +pajr_doctor: Our translation may be imperfect as we are not knowing the language and script
[8/1, 3:24 PM] patient advocate: Tq sir
[8/3, 11:12 AM] PaJR PHR Moderator: @~Pajr_member @~patient_member the intramedullary nail is visible!
Please get Orthopedic opinion ASAP!
Also get a plastic surgery opinion for skin grafting ASAP today
[8/3, 12:10 PM] PAJR_member: Okay sir
[8/3, 2:21 PM] PaJR PHR Moderator: They have not mentioned implant exposed in their note?
[8/3, 2:22 PM] PaJR PHR Moderator: The first year PG surgery has mentioned it!
[8/3, 2:22 PM] PaJR PHR Moderator: 👆No signature
[8/4, 6:37 PM] +patient_advocate: Madam pls send person who can do dressing, today Sunday because this if will not come smell will form more.
Sir while dressing time we have seen rod came back, it touch to
[8/4, 9:17 PM] +patient advocate: It touchs to the wall muscle
[8/4, 9:17 PM] PaJR PHR Moderator: @~pajr_doctor: please get an Orthopaedic review ASAP
[8/4, 9:17 PM] patient_advocate: Sir pls send any orthopedic duty doctor
[8/4, 9:23 PM]pajr_member : Okay sir
[8/4, 9:27 PM] +patient _advocate: Sir he feel very painful at time
[8/5, 8:27 AM] PaJR PHR Moderator: @~Dr.pajr Please get the Orthopedics to evaluate ASAP and insist for the removal of this foreign body ASAP. I know it's a very demanding thing but again the patient is in a lot of pain and distress. I'm on sick leave today
[8/5, 8:31 AM] PaJR PHR Moderator: Please ensure that the patient has adequate short term opioid analgesia. He must be already on Tablet Ultracet 1/2 every 6 hours along with Paracetamol 500 mg every 6 hours.
[8/5, 9:06 AM] +doctor: Spoke to ortho pgs sir they said Harinath sir will come and review the case during his rounds sir at 9:30-10AM sir
[8/5, 9:10 AM] PaJR PHR Moderator: Please ask them to put this note in the file now.
How is his pain at present?
[8/5, 10:01 AM] pajr_doctor: Harinath sir has seen the case and they said they will take him up for transplant removal after PAC sir
[8/5, 10:04 AM] PaJR PHR Moderator: Thanks. Let's get the PAC done ASAP. Share their notes
He's already high risk for GA given his past history of post operative delirium 3 months back
[8/5, 10:09 AM] +pajr_doctor: They said procedure will be under spinal anesthesia mostly sir
[8/5, 10:10 AM] +pajr_doctor: Sending some routines required sir PAC sir
[8/5, 12:42 PM] PaJR PHR Moderator: Even his previous OT was under spinal following which he went into delirium?
[8/5, 12:58 PM] pajr_doctor: Yes sir
[8/5, 12:58 PM] +pajr_doctor: Now they are doing it under local anesthesia
[8/5, 2:00 PM] pajr_doctor : Implant removal done under LA by doctor sir
[8/5, 2:01 PM] PaJR PHR Moderator: Can reshare the note after removing institutional identifiers
[8/5, 3:25 PM] pajr doctor: Tq sir for ur all cooperation (all doctor's) who are involved in right time decision to do operation for to removal rod from leg ,my father may get relief from his yesterday's pain
[8/5, 6:17 PM] PaJR PHR Moderator: Please share his previous chest X-ray serially from our radiology archives
[8/5, 6:17 PM] PaJR PHR Moderator: Urine cue?
[8/5, 6:20 PM] PaJR PHR Moderator: The clinical evaluation and findings such as:
Respiratory rate
SpO2
Auscultation sounds
Throw more light on how to interpret the chest X-ray. No X-ray should be interpreted without the clinical findings
In this chest X-ray we can see evidence of emphysema, which is consistent with his history of smoking
[8/5, 6:23 PM] pajr member: Xray at admission sir
[8/5, 6:23 PM] PaJR PHR Moderator: Admission this time or three months back?
[8/5, 6:24 PM] pajr member: This time sir
[8/5, 6:28 PM] PaJR PHR Moderator: Can you try retrieving the ones from the previous admission?
[8/5, 7:02 PM] pajr member: Ok sir
[8/5, 8:48 PM] PaJR PHR Moderator: The next step in the therapeutic approaches we need to offer for his non fluent aphasia is https://en.m.wikipedia.org/wiki/Music_therapy_for_non-fluent_aphasia
@pajr_doctor would you be able to suggest someone who can guide us to deliver it to our patient using online suggestions?
[8/6, 9:22 AM] PaJR PHR Moderator: Urine culture sent?
[8/6, 9:23 AM] PaJR PHR Moderator: Remove old foleys. Send fresh urine culture from the first few drops of urine that come out while putting in the new foleys catheter
[8/6, 9:32 AM] +pajr_member: Yes sir
[8/6, 9:44 AM] PaJR PHR Moderator: After removing old foleys? How old was it?
[8/6, 9:46 AM] pajr member: Yesterday s sir
[8/6, 9:48 AM] PaJR PHR Moderator: 👆This catheter was inserted when?
Was the urine culture collected after removing this and reinserting a fresh one?
Can you share an image of the freshly inserted one?
[8/6, 9:57 AM]pajr_member: Yesterday after inserting foleys turbid urine came which was sent for cue and urine c/s and after sometime urine became normal sir
[8/6, 10:17 AM] PaJR PHR Moderator: That's strange!
[8/6, 10:20 AM] pajr member: 60M needs an USG? perhaps abscess near bladder neck?
[8/6, 10:22 AM] PaJR PHR Moderator: Yes given his past history of intermittent Hematuria also mentioned in his EMR horcrux here: https://www.facebook.com/share/p/vjAFKrL8AYQ29iTt/?mibextid=oFDknk
@pajr_doctot please get a urology opinion again today and remind them of all the ordeals they had during the last admission 3 months back to stop his hematochezia
[8/6, 10:26 AM] pajr member: Ok sir
[8/7, 12:34 PM] PaJR PHR Moderator: @pajr_member please share the plastic surgery notes from yesterday and his wound images along with his post op xray after the nail removal ASAP
[8/7, 12:49 PM] PaJR PHR Moderator: Thanks. Share the plastic surgery notes and current plan
[8/7, 12:49 PM] PaJR PHR Moderator: Also share the x-ray
[8/7, 12:49 PM] PaJR PHR Moderator: Post op xray
[8/7, 2:12 PM] PaJR PHR Moderator: @patient_advocate Can you share the patient's x-ray prior to his first operation immediately after his injury?
[8/7, 2:42 PM] patient_advocate: Sir I have these only
[8/7, 2:56 PM] pajr_doctor: X ray after fitting the nail is not there?
[8/7, 2:56 PM] patient advocate:Not there sir
[8/7, 2:58 PM]pajr_doctor : Whether it was done or not?
[8/7, 3:04 PM] pajr_doctor: Ok
[8/7, 3:04 PM] patient advocate: Not done sir
https://www.facebook.com/share/p/vjAFKrL8AYQ29iTt/?mibextid=oFDknk
[8/7, 4:15 PM] PaJR PHR Moderator: Thanks. These are the ones i needed. I have cropped out his name and added it to his EHR
[8/8, 7:40 PM] PaJR PHR Moderator: Growing organisms in the bed sore doesn't prove that they have any role in the delayed healing of the bed sore. It's just that these organisms are also in his bed
[8/8, 7:42 PM] PaJR PHR Moderator: Inspite of the E coli grown in his urine, he hasn't had any symptoms due to this UTI except for one episode of pus showing in the catheter.
@Meta AI can this be labeled as asymptomatic bacteriuria?
[8/8, 7:42 PM] Meta AI: Yes, this scenario can be labeled as asymptomatic bacteriuria (ASB). ASB is a condition where bacteria are present in the urine, but the person does not exhibit any symptoms of a urinary tract infection (UTI).
In this case, the presence of E. coli in the urine, without any symptoms except for a single episode of pus in the catheter, meets the criteria for ASB. The lack of symptoms such as pain, burning during urination, frequent urination, or fever suggests that the bacteria are not causing an active infection.
However, it's important to note that the presence of a catheter can increase the risk of developing a UTI, and the episode of pus in the catheter may indicate a potential risk of developing symptoms. Regular monitoring and follow-up with a healthcare provider is recommended to ensure the situation doesn't progress to a symptomatic UTI.
[8/9, 10:50 AM] PaJR PHR Moderator: Today's update: Traction applied for the right femur post nail removal with continued intermittent physiotherapy to relieve the right knee fixed flexion contractures
[8/9, 6:29 PM] patient advocate: Sir come for dressing for my patient bedsore today
[8/9, 6:43 PM] patient advocate: If we delay to do dressing that will be increased more
[8/9, 8:57 PM] patient advocate: Sir send dressing persons today, ieven we giive one day gap that bedsore will get increase, pls sir or vaishnavi help to my father
[8/9, 8:59 PM] +patient advocate: Vaishnavi madam pls send any dressing person 🙏
[8/9, 9:22 PM] patient advocate: Sir pls any duty doctor's to do dressing to my father 🙏, within one day gap only it increases
[8/10, 1:55 PM] +patient advocate: 🙏, tq sir
[8/10, 1:55 PM] patient advocate: For ur support
[8/12, 2:53 PM] PaJR PHR Moderator: Yesterday's chest X-ray
[8/12, 2:58 PM] PaJR PHR Moderator: On Saturday afternoon patient had severe cough and shortness of breath after eating bread soaked in milk following which he became hypoxic and was shifted to AMC.
Currently respiratory rate 30 per minute
SpO2 93% at 2 litres of oxygen
Sensorium unresponsive
No spontaneous eye opening
Dolls eye normal and inducing wakefulness
Last he made eye contact with his wife was yesterday
[8/12, 2:59 PM] PaJR PHR Moderator: Saturation falling to 86% on room air
[8/12, 4:27 PM] patient advocate: Sir why patient is able to eat and swallow solids but not swallow liquids
[8/12, 4:42 PM] patient advocate: Sir u all have done excellent performance regarding treatment to my father's recovery till today but his body is not supporting to be stable , in this situation what we haveto do we can't understanding .pls guide us to do outside performance 🙏
[8/12, 4:51 PM] PaJR PHR Moderator: This is because of his stroke that has also paralysed his speech
[8/12, 4:52 PM] +patient advocate: How it will come back mean get recovery
[8/12, 4:54 PM] PaJR PHR Moderator: Till now whatever current science knows he is getting those solutions. Science is also limited that it knows very little. Unfortunately science is projected by many as if it has all the answers but in reality it doesn't. We simply need to move slowly supporting his trillion celled body to heal day by day. How these trillion cells in his body are going to heal him no one in this world can explain yet and more research is needed
[8/12, 4:59 PM] patient advocate: That's what sir we kept him in God's hands and look at him what is going on
[8/12, 5:01 PM] PaJR PHR Moderator: God always does what is best for all of us
[8/12, 5:02 PM] +patient advocate: Yes sir 🙏
[8/12, 8:29 PM] +pajr_doctor: And swallow mechanism perhaps
[8/12, 8:30 PM] PaJR PHR Moderator: Yes disturbed swallowing is due to the paralysis
Similar to how his speech has also been paralysed
[8/13, 3:26 PM] PaJR PHR Moderator: The knee flexion appears to be better
[8/13, 3:27 PM] PaJR PHR Moderator: 👆we need a foot splint to keep it dorsiflexed @pajr_member. Please ask Orthopedics where to obtain one
[8/13, 4:50 PM] pajr_member: Okay sir
[8/14, 2:58 PM] pajr_doctor: Knees appearing much straight or it is wrong angle of photo?
[8/14, 2:58 PM] PaJR PHR Moderator: 👆
[8/14, 3:00 PM] PaJR PHR Moderator: Yes noticed this straightening since three days after the traction
[8/14, 3:03 PM] pajr_doctor: If physiotherapist available, daily goniometry record may be kept
[8/14, 3:03 PM] PaJR PHR Moderator: Trying to make him stand now
[8/14, 3:04 PM] pajr_doctor: Support the waist with waist belt, support his knees with the knees of a person in front. Lateral and AP stabilization will be better achieved this way
[8/14, 3:35 PM] PaJR PHR Moderator: Standing with support
[8/14, 3:36 PM] PaJR PHR Moderator: Sitting
Patient advocate: Sir, pls provide regular dressing to my father and also ortho check up
[8/17, 10:58 AM] PaJR PHR Moderator: Asked staff sister Renuka to indent the dressing set and she will train and supervise the patient to perform the dressing daily
[8/17, 11:14 AM] PaJR PHR Moderator: This was our intelligent sister's idea!
[8/17, 11:15 AM] PaJR PHR Moderator: Right knee extension using support
[8/17, 11:35 AM] PaJR PHR Moderator: They are in the picture as archived in her EHR in the description box
@pajr_trainee can you also archive the same content plus the regular updates here in your online learning portfolio ASAP?
[8/17, 11:52 AM] pajr_trainee: Sure sir
Seen along with the general surgeon today.
Adviced patient advocate@patient_adv to buy this 👇
https://www.amazon.in/Newgen-Rubber-Ring-Air-Cushion/dp/B0D21NG81T/ref=asc_df_B0D21NG81T/?tag=googleshopmob-21&linkCode=df0&hvadid=686131539076&hvpos=&hvnetw=g&hvrand=7600508418896008967&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=9197649&hvtargid=pla-2304067164890&psc=1&mcid=16c63c072cc4374480816f4fd4304d70&gad_source=1
For his sacral sore
@PaJR Coordinator can you facilitate it after discussion with the patient advocate
[8/19, 10:02 AM] PaJR PHR Moderator: Sitting with support.
[8/19, 10:05 AM] PaJR PHR Moderator: Current CNS evaluation reveals marked, hypotonic quadriparesis that wasn't there earlier during this admission! Patient's relative says he's unable to move his limbs since 12th August since he also had the episode of hypoxia for which he was shifted to AMC
@pajr_trainee looking forward to all your updates about this patient in your case report
[8/19, 10:14 AM] PaJR PHR Moderator: Right sided limb weakness is more than left.
Also has again developed bilateral lateral rectus palsy left much more than right
[8/19, 10:24 AM] pajr_doctor: No please
[8/19, 10:24 AM] pajr_doctor: Only airbed is useful
[8/19, 10:25 AM] PaJR PHR Moderator: Alright let's hold this
[8/19, 10:26 AM] pajr_doctor: Ring hault the nutrition inflow and excrement outflow worsening the pressure ulcer
[8/19, 10:28 AM] PaJR PHR Moderator: I wanted the surgeons to train her to do the dressing herself for similar periods of leave or protests or once discharged but they were not keen. So she will be observing them closely and learning only by observing and perhaps filling in when there are no surgeons either due to leave or if when he's discharged
[8/19, 10:29 AM] pajr_doctor: Pressure Ulcer -
1. Remove pressure (turning, no seams/creases on clothes and bedsheets)
2. Improve oxygen (iron supplement, protein supplement)
3. Keep wet with saline gauze but avoid maceration.
4. Debridement as needed
[8/19, 12:01 PM] pajr_trainee: Updating ASAP
[8/20, 10:27 AM] PaJR PHR Moderator: Morning physio.
[8/20, 10:27 AM] PaJR PHR Moderator: Note the unilateral limb edema
[8/20, 10:31 AM] PaJR PHR Moderator: Even as his flexion contractures have loosened, we are still unable to make him stand due to his current lower limbs hypotonia
[8/20, 11:45 AM] patient advocate: Sir please orthopedic doctor check his operated leg ( right one).still stitches are there .
[8/20, 11:48 AM] +patient advocate: sir, yesterday they send blood for test . When will come results .
[8/20, 11:49 AM] +pajr doctor: Hypotonia?
[8/20, 12:22 PM] PaJR PHR Moderator: @pajrmemberplease share the Ortho review notes
[8/20, 12:23 PM] : PHR Moderator: Also please share the test values @~pajr_member
[8/20, 12:24 PM] PaJR PHR Moderator: 👆Yes as mentioned yesterday he may have had another recent stroke after admission few days ago on and above his previous post op stroke three months back
[8/20, 12:35 PM] PaJR PHR Moderator: https://24fpatientblog.blogspot.com/2024/08/60m-postoperative-altered-sensorium-2.html
[8/20, 2:12 PM] PaJR PHR Moderator: 👆@pajr_member please get an x-ray of his knee joints bilateral AP and lateral view of his right knee
[8/21, 11:13 AM] patient advocate: Sir pls check up the leg which had operation 🙏, the leg had stitches (right)
[8/21, 12:11 PM] PaJR Coordinator: Hi today I spoke to patient daughter for help she wants to get an attendant helper we are trying to get from narketpally who will help the old women and patient
[8/21, 12:12 PM] PaJR PHR Moderator: We have already arranged a person who is a ward boy, who is helping them daily but yes it would be nice to streamline this process
[8/21, 12:12 PM] PaJR Coordinator: Please kindly provide your guidance and suggestions if any thing else can be done for the benifit of the patient and his old wife (she is going to be sick if she is running arround)
[8/21, 12:14 PM] PaJR Coordinator: Yes sir if duty doctor resident can guide them it will be very helpful kindly help them I am going to take this situation to the notice of administration and try to clear if we have any road blocks
[8/21, 12:15 PM] PaJR Coordinator: 🙏
[8/21, 12:17 PM] PaJR PHR Moderator: Yes the residents are trying. @pajr_member today introduced me to Dr Akhil from Orthopedics, who evaluated the wound and we are trying to plan the next step in his treatment for the non united bone fragments
[8/21, 12:20 PM] PaJR Coordinator: @pajr_member please kindly guide us let us know what else we could do to get the patient better and help his wife old lady to get some rest. I spoke to nurse also took her advice as well
[8/21, 12:21 PM] PaJR Coordinator: I would like to compile all the suggestions and get the needful to be done to provide better care for our old couple 🙏
[8/21, 12:31 PM] PaJR PHR Moderator: List of suggestions for the list of problems (already shared in our daily posts above):
1) Empower the patient's relative to do the daily routine dressings such that she's less distressed when the surgery residents are on leave
Action taken: talked to surgeons
Asked ward sister to indent the daily dressing for her in the ward
The other option is to get the patient's relative to buy disposable dressings, which she declined
2) The fracture site with current non union
Action taken:
Orthopedics informed. Next plan is to use an external fixator if not have another go at internal fixation. @~डॉ गणेश मुक्ता अरुण जोशी what would be your take on that as we are unable to mobilize him well now that we realise the bone fragments have been separated once we removed the previous implant
3) Broca's aphasia and speech therapy. We are trying that daily normal
[8/21, 12:32 PM] PaJR PHR Moderator: @pajr_trainee please update to case report archives whenever free
[8/21, 12:54 PM] pajr_trainee: Sure
Pajr_ trainee : The case report has been updated
[8/22, 12:10 PM] PaJR PHR Moderator: Well done 👏
[8/22, 12:14 PM] PaJR PHR Moderator: One ray of hope:
I discussed just now with Orthopedic Professor Dr pajr doctor and he says the right limb fracture doesn't need any further intervention toward splintage and we can make him use a walker and mobilize him using his left limb. @PaJR Coordinator can you arrange for a walker for him
[8/22, 1:04 PM] PaJR PHR Moderator: 3 point crutch gait with Walker.
[8/22, 1:08 PM] PaJR PHR Moderator: Can we get an occupational therapist to suggest a limb brace that can provide some external splintage to the fractured limb and some splintage to the hypotonic left limb so that it's able to take his standing weight?
https://youtu.be/Z-M2AF8u05U?feature=shared
[8/22, 1:09 PM] PaJR PHR Moderator: @PaJR Coordinator can you contact Rohit admin to make our physiotherapy guide here regularly for this patient
[8/22, 1:14 PM] pajr_doctor : This means 10% body weight on the limb with max taken up by upperlimbs through crutch/walker. The other limb if possible takes full weight alone when it has power and no contractures remain
[8/22, 2:18 PM] PaJR PHR Moderator: Is it easier to use a crutch to distribute the weight in this manner or a walker is better?
[8/22, 2:20 PM] pajr_doctor : He will need walker
[8/22, 2:20 PM ] pajr_doctor: Crutch for uneven surface with better power in limbs. Hence not for him
[8/22, 2:27 PM] PaJR Coordinator: Ok sir I will arrange for it
[8/23, 10:20 AM] PaJR PHR Moderator: Need an ophthal opinion for this patient ASAP
[8/23, 10:22 AM] pajr_member2: Corneal ulcer sir..?
[8/23, 10:27 AM] pajr_member 1
: Okay sir
PAJR PHR MODERATOR: We are getting ready for his three point walk for the first time after an internal fixation of his fracture neck 4 months back and then nail removal and back to square one with an additional bedsore through which now the distal fracture fragment of the femur is protruding but we are optimistic we shall be able to gradually mobilize him.
[8/24, 9:02 AM] patient advocate: Sir , doctor madam has written ring for bedsore, that is not available in anywhere, pls help
[8/24, 9:04 AM] patient advocate: Today doctor's are preparing him for surgery for leg fracture
[8/24, 9:06 AM] patient advocate: Try to get from Kamineni pharmacy
[8/24, 9:30 AM] PaJR PHR Moderator: Its not required for the surgery. Our specialist from AIIMS Delhi here @pajr_doctor feels the ring is not necessary so we are holding on to that. Yesterday the surgeons had ordered a vaccum dressing which they needed the patient's advocate to buy.
PAJR PHR MODERATOR: Romovac put by the surgeons yesterday for this ward patient on stroke rehab with a right femur fracture non union jutting out from his bedsore
Romovac full view
Patient advocate:
[8/24, 10:15 AM] PaJR PHR Moderator: @pajr_doctor we have been trying to make him stand on his left leg alone yesterday but the biggest issue now is that his fractured right leg is getting in the way. Is there a way to get an orthotic support designed that will support his legs when he stands?
[8/24, 10:16 AM] PaJR PHR Moderator: 👆 Noticed by relative since one week
[8/24, 2:45 PM] pajr_doctor: The pressure ulcer comes in the way of orthosis
[8/24, 2:50 PM] PaJR PHR Moderator: Even something just till above the knees could be useful to make him stand?
[8/24, 2:53 PM] PaJR PHR Moderator: Also can you suggest how to make him stand on his left leg and not allow the right leg to get in the way as that too is automatically touching the ground. For other patients we could have just asked them to flex the right leg slightly and that would have taken care of the problem
[8/24, 3:55 PM] pajr_doctor: 3 point crutch gait training by a skilled PT will take care
Pajr_member :
[8/24, 5:02 PM] PaJR PHR Moderator: Thanks
[8/24, 5:03 PM] PaJR PHR Moderator: @PaJR Coordinator can you coordinate with administration to provide us with a dedicated and skilled physiotherapist for this patient?
[8/24, 5:40 PM] PaJR Coordinator: Ok sir
[8/25, 10:36 AM] PaJR PHR Moderator: 👆@pajr_member please check the date and IP number of this report if it matches this patient's ASAP.
It's strange that it's showing a Hb of 14.5 while another one just a few days later is showing an Hb of 6!
Please ask the duty interns to check the postural BP asap
[8/25, 10:38 AM] +pajr_member: This report is of 19th August sir
[8/25, 10:58 AM] pajr_member: Hb on 26thjuly 8.5
5thAug 8.4
11thAug 7
13thAug 6.4
15thAug 7.1
19thAug 14.5
23rd Aug 6
[8/25, 11:05 AM] PaJR PHR Moderator: So the 19th August report is unlikely to belong to this patient? @PaJR Coordinator we need a easier mechanism to communicate with our labs to clarify these kind of reports that are way off the mark
[8/25, 2:34 PM] +pajr_member: Today's hemogram sir
[8/25, 3:15 PM] PaJR PHR Moderator: Was this after blood transfusion?
[8/25, 3:16 PM] pajr_member2: Yes sir
[8/26, 9:36 AM] patient advocate: Vaishnavi madam we arrange one unit , pls try to transfuse it if it need to him now
[8/26, 10:54 AM] PaJR PHR Moderator: The corneal inflammation appears to have spread to becoming iridocyclitis? Please get another Ophthal opinion ASAP
[8/26, 10:56 AM] PaJR PHR Moderator: @pajr_trainee can you update his Case report EMR incorporating his recent Ophthal problem shared above and earlier?
Three point standing
[8/26, 2:34 PM] PaJR PHR Moderator: Prominent left abducens palsy
[8/27, 8:03 AM] PaJR PHR Moderator: @pajr_member @pajr_member @pajr_doctor Have the Orthopedic planned any surgery today? Please share their yesterday's notes if they have documented any such plan asap. Check their OT list
[8/27, 8:05 AM] pajr_member: Yes sir they have planned for external fixation under local anesthesia sir
[8/27, 8:37 AM] PaJR PHR Moderator: When today? Please share their notes ASAP
[8/27, 8:38 AM] +pajr_member: They said to shift case at 12:30pm sir
[8/27, 8:58 AM] PaJR PHR Moderator: Even if they are doing it in local as it's being done in OT the Anesthesiologist will be on standby
[8/27, 2:54 PM] PaJR PHR Moderator: Thanks @~pajr_member
Please ask them in how many days can we start mobilizing him
[8/27, 2:55 PM] +pajr_member: They said from today evening itself can start mobilizing him sir
[8/27, 4:15 PM] PaJR PHR Moderator: Fluoroscopic picture showing the placement of the uppermost pin in his fixator which has been fixed to the iliac bone with the fractured neck of the femur left alone
[8/28, 8:20 AM] +patient advocate: Sir Good morning 🙏, after surgery that bone part was visible from bedsore as previous that was find out while dressing time at night .pls absorve this .
[8/28, 9:20 AM] PaJR PHR Moderator: Yes all our recent efforts of Orthopedic external fixation etc is essentially to mobilize him to revascularize his bedsore area to promote their healing.
I talked to the Orthopedic Professor just now and he's not too keen for an orthotic brace to support his left leg and this means our three point walking plan to mobilize and revascularize his bed sore will become even more challenging as his power in both upper limbs as well as left lower limb is not great somewhere between 3/5 to 4/5 apparently reducing markedly when we try to make him stand.
I guess it will be more pragmatic to train him on a wheel chair especially ones that are available with toilet functions but then again his bed sores will lose the only chance of revascularization we could have provided
Pajr phr MODERATOR: 
[8/28, 12:31 PM] PaJR PHR Moderator: 👆 Standing on one leg for the first time!
[8/28, 12:33 PM] PaJR PHR Moderator: Yesterday's fixators
[8/28, 12:33 PM] +patient advocate: Tq sir ,this is good news to glad at it
[8/28, 12:34 PM] PaJR PHR Moderator: Yesterday's fixator driven splintage
[8/28, 12:35 PM] PaJR PHR Moderator: The femoral greater trochanter is bulging out from his bedsore
[8/29, 11:57 AM] PaJR PHR Moderator: This Plantar splintage was finally done by the patient's wife while we kept looking for the tech solutions!
[8/30, 7:57 PM] patient advocate:Sir pls send dressing doctor today still now they didn't come . If we gap to dressing that bed sore, those spread very fast.
If we give gap to dressing one , those increasing more
[8/31, 12:43 PM] PaJR PHR Moderator: While evaluating him in the rounds now I realised that in this well made case report by @pajr_trainee a few x-rays of his before and after his first surgery for the fracture neck of femur is missing here
https://24fpatientblog.blogspot.com/2024/08/60m-postoperative-altered-sensorium-2.html
[8/31, 12:44 PM] PaJR PHR Moderator: I'm sharing them again here @pajr_trainee Please add them to the part where you describe his initial fracture in the timeline. This one is before the first operation
[8/31, 1:02 PM] PaJR PHR Moderator: This one is after his first operation @pajr_tainee
