1) Self reflective writing on their medical student career
I AM K NIKHIL SAI OF the 2018 batch presently an INTERN.
This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts to solve those patients' clinical problems with collective current best evidence-based information.
This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.
BLOG:-
https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-85-year-old-male-patient-came-with.html
This is me Nikhil posted in the medicine department on August 15 Th and was sitting in the casualty on my 2 nd day of posting i.e.,
And was terrified to see a patient coming to the casualty with shortness of breath for 2 days
morning.
Complaints of bloating since yesterday
Complaints of decreased urine output since Morning.
Then I had a talk with his son to get a proper sequence of events and was fascinated to get the following history from him:-
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic 2 days back then developed difficulty in breathing which is insidious in onset gradually progressive
H/O PND, orthopnea present
H/o pedal edema present
H/o abdominal distension present
No H/o fever with pain, sore throat
No H/o involuntary movement
NoH/o skin manifestations like rash, nodules
No H/o Recurrent respiratory infection
Syncope
No H/o Hemoptysis
No History of chest pain; palpitations; loss of consciousness
PAST HISTORY:-
No similar complaints in the past
Not a known case of DM; HTN; CAD; CVA; Thyroid; TB; asthma epilepsy.
Personal history:-
Diet - mixed
Appetite- normal
Sleep - adequate
Micturition:- decreased
Addictions:- chronic smoker of chute which he stopped 6 years back due to a complaint of hemoptysis which was investigated?? And found no pathology!
Allergic history:- No history of any kind of allergies to food/drugs
Family history:- no significant family history
Then I went through his general examination:-
GENERAL EXAMINATION:-
At the time of examination:- 7/9/23
THE PATIENT IS CONSCIOUS COHERENT AND CO COOPERATIVE
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY
EDEMA - present
TEMPERATURE:- AFEBRILE
PR:110bpm
BP:140/80mmHg
RR:32cpm
Then my first priority was his Respiratory system so I examined:-
RESPIRATORY SYSTEM:-
INSPECTION:- Chest appears symmetric
No Dilated veins, scars, sinuses
INSPECTION:
1. Shape of Chest - normal
2. Trachea position central
3. Apical Impulse - no visible
4. Movements of the chest: Respiratory rate:- 34cpm.
5. Skin over the chest: NO engorged veins, sinuses, subcutaneous nodules, intercostal scars, or intercostal swellings.
6. All the areas appear normal.
PALPATION:
1. No local rise in Temperature and tenderness
2. All inspector findings confirmed. (Tracheal position, apex beat)
3. Expansion of the chest- equal in all planes
PERCUSSION:
Resonant all over the chest except the infraxillary area and infrascapular area.
AUSCULTATION:
1. Normal breath sounds were heard in all areas except IAA AND ISA.
Crepts are heard in IAA And ISA.
CVS EXAMINATION:-
S1 S 2 heard ; NO MURMURS
PER ABDOMEN:-
no tenderness
no palpable organs
bowel sounds - present
CNS EXAMINATION:-
The patient is conscious.
No focal deformities.
cranial nerves - intact
sensory system - intact
motor system - intact
Then I ordered the following investigations:-
INVESTIGATIONS:-
On the day of admission 6/9/23:-
Serology:- NEGATIVE
RBS - 134 mg/dl
B.urea - 53 mg/dl
S.Cr - 2.4 mg/dl
Na - 140 mEq/L
K - 4.3mEq/L
Cl- 103mEq/L
CUE -
Albumin ++++
Sugar - Nil
Pus cells - 8-9 cells
Epi cells - 2-3 cells
RBC:- 10-12 cells
Hb- 13.0
TLC - 18,000
MCV - 92
MCH - 30.7
МCHC - 34.0
PLT - 2.56 LAKHS
7/9/23 :-
Hb:- 13.5
TLC:- 20,500
PLT :- 2.6 lakhs
ECG was done
CXR:-
We're also done
And finally, I came to a diagnosis of
DIAGNOSIS:- ACUTE EXACERBATION OF COPD WITH ACUTE COR PULMONALE WITH DE NOVO DM II AND HTN.
Then I planned to start him on
- INJ LASIX 40 mg IV/BD IF SDP >110mmHg
- INJ AUGMENTIN 1.2 gm IV/BD
- Intermittent BiPAP
- TAB AZITHROMYCIN 500 mg PO/OD
- INJ HYDROCORT 100 mg IV/TID
- Inj aminophylline 500 mg IV / SOS
- INJ HAI S/C TID ( inform Grbs)
- Salt restriction < 2g / day; fluid restriction < 1.5
- Nebulisation with budecort; mucous
- Inj N ACETYL CYSTEINE 400mg IV / SOS
- TAB ECOSPIRIN AV 75/10 Po/HS
Date:- 8/7/23
INVESTIGATIONS:- TROP I :- 9,693
Hb:- 13.3
TLC:- 24,500
PLT:- 2.3
Sr CREAT:- 2.9
SOAP NOTES
08-09-2023:
ICU BED1
S:
Bloating of stomach
Shortness of breath grade 3
O:
I/o - 1000/1400 ml
Bp- 140/90 mmHg
Pr - 103 bpm
Rr- 24 cpm
Spo2 - 99% at 4L O2
Grbs - 183
CVS - S1 S2 + No murmurs
RS - BAE+ ,B/l wheeze+ ,crepts+ in Rt IAA and Rt ISA
P/A - Soft and NT
CNS - NFND HMF+
A:
DIAGNOSIS:-
HF with reduced EF(EF=30%) secondary to CAD (NSTEMI )with acute exacerbation of COPD with type 1 Resp Failure with Acute Cor pulmonale with AKI (renal) with Lenovo DM 2 and HTN
P:
1. Inj Heparin 5000Us/c TID
2. INJ LASIX infusion 10 mg/hr
3. Intermittent BiPAP
4. INJ HYDROCORT 100 mg IV/TID
5. Inj aminophylline 500 mg IV / BD
6. INJ HAI S/C TID ( inform Grbs)
7.Inj MgSo4 1gm IV/OD
8. Nebulisation with budecort; mucous
9. Inj N ACETYL CYSTEINE 400mg IV / BD
10.Tab Ecosprin AV (75/10) PO/HS
11.Tab Met - XL 25 mg PO/OD
12. GRBS 7-point profile
And continued the treatment;
PaJR:- discussion
07/09/23, 12:55:20 PM] Rakesh Biswas Sir Hod Med: Location?
How many days since admission?
Add the case report to the description box
Share this PaJR link in the 2018 ward group
[07/09/23, 12:59:08 PM] Nikhilsai Karnati: Location :- ICU bed 1
Admission:- yesterday ( 6/9/23)
[08/09/23, 9:33:35 AM] Rakesh Biswas Sir Hod Med: Unfractionated heparin?
What's the efficacy of magnesium sulfate here? @919505766290
[08/09/23, 9:35:52 AM] Navya Mam Gm Pg 1: Unfractionated heparin because he has RWMA LAD, LCx, RCA hypokinesia
[08/09/23, 9:37:19 AM] Rakesh Biswas Sir Hod Med: Then why is he largely getting treated as COPD as per @918978523448 's description when your diagnosis suggests acute LVF!
[08/09/23, 9:37:34 AM] Rakesh Biswas Sir Hod Med: Make me admin
[08/09/23, 9:51:52 AM] Khushi : 08-09-2023:
ICU BED1
S:
Bloating of stomach
Shortness of breath grade 3
O:
I/o - 1000/1400 ml
Bp- 140/90 mmHg
Pr - 103 bpm
Rr- 24 cpm
Spo2 - 99% at 4L O2
Grbs - 183
CVS - S1 S2 + No murmurs
RS - BAE+ ,B/l wheeze+ ,crepts+ in Rt IAA and Rt ISA
P/A - Soft and NT
CNS - NFND HMF+
A:
DIAGNOSIS:-
HF with reduced EF(EF=30%) secondary to CAD (NSTEMI )with acute exacerbation of COPD with type 1 Resp Failure with Acute Cor pulmonale with AKI (renal) with Lenovo DM 2 and HTN
P:
1. Inj Heparin 5000Us/c TID
2. INJ LASIX infusion 10 mg/hr
3. Intermittent BiPAP
4. INJ HYDROCORT 100 mg IV/TID
5. Inj aminophylline 500 mg IV / BD
6. INJ HAI S/C TID ( inform Grbs)
7.Inj MgSo4 1gm IV/OD
8. Nebulisation with budecort; mucous
9. Inj N ACETYL CYSTEINE 400mg IV / BD
10.Tab Ecosprin AV (75/10) PO/HS
11.Tab Met - XL 25 mg PO/OD
12. GRBS 7-point profile
[08/09/23, 9:55:45 AM] Rakesh Biswas Sir Hod Med: What are the features of COPD in this patient? @918978523448 @917386956954
[08/09/23, 10:12:47 AM] Rakesh Biswas Sir Hod Med: Chest X-ray not suggestive of COPD
Any clinical findings suggesting COPD and acute cor pulmonale? @918978523448
[08/09/23, 10:30:13 AM] Nikhilsai Karnati: Sir patient has been a chronic smoker of Chuttas for around 40 years stopped 6 years back due to blood-stained sputum ;( which was investigated outside and said no pathology)
And came with complaints sob with Orthopnea;
The patient had raised JVP suggestive of right heart failure
And pleural effusion ( right >left)
On the 2nd day patient showed t-wave inversions which may be any subendocardial ischemia; so trop I was sent to see 11,160 yesterday and treated accordingly
And trop I values today are 9,863.
So he is getting treated accordingly, sir ;
This patient may have a case of acute exacerbation of COPD; with cor pulmonale which later leads to sub-endocardial ischemia and getting treated accordingly, sir
[08/09/23, 10:32:13 AM] Rakesh Biswas Sir Hod Med: Corpulmonale leading to subendocardial ischemia? Any review of the literature around that (at the risk of expanding the ontology)?
[09/09/23, 10:13:45 AM] Nikhilsai Karnati: 09-09-2023:
ICU BED1
S:
Bloating of the stomach decreased
Shortness of breath grade 3 decreased
When compared to yesterday
O:
I/o - 750/2900ml
Bp- 130/80mmhg
Pr - 88 bpm
Rr- 20 cpm
Spo2 - 94 at RA
Grbs - 143 mg/dl
CVS - S1 S2 + No murmurs
RS - BAE+ ,NVBS
P/A - Soft and NT
CNS - NFND HMF+
A:
DIAGNOSIS:-
HF with reduced EF(EF=30%) secondary to CAD (NSTEMI )with acute exacerbation of COPD with type 1 Resp Failure with Acute Cor pulmonale with AKI (renal) with Lenovo DM 2 and HTN
P:
1. Inj Heparin 5000Us/c TID
2. INJ LASIX infusion 10 mg/hr
3. Intermittent BiPAP
4. Inj aminophylline 500 mg IV / BD
5. INJ HAI S/C TID ( inform Grbs)
6. Nebulisation with budecort; mucomist 4 Th hourly
7. Inj N ACETYL CYSTEINE 400mg IV / BD
8. Tab Ecosprin AV (75/10) PO/HS
9.Tab Met - XL 25 mg PO/OD
10. GRBS 7-point profile
11.SYP LACTULOSE 15 ml PO/BD
12. SYP POTKLOR 15 ml in one glass of water
[10/09/23, 8:28:21 PM] Rakesh Biswas Sir Hod Med: Treated accordingly for what with what? Be specific
[10/09/23, 8:29:17 PM] Rakesh Biswas Sir Hod Med: At least tell us what are the indications of each of the drugs mentioned in the planned list here! @918978523448
[10/09/23, 8:44:05 PM] Nikhilsai Karnati: 1) HEPARIN:- When intravenous heparin is administered for myocardial infarction with non-ST elevation and unstable angina, an initial bolus of 60 to 70 U/kg (maximum, 5000 U) followed by a 12- to 15-U/kg/h infusion is recommended. The goal is to achieve an activated partial thromboplastin time of 50 to 70 seconds.
https://pubmed.ncbi.nlm.nih.gov/11382373/#:~:text=When%20intravenous%20heparin%20is%20administered,of%2050%20to%2070%20seconds.
2)AMINOPHYLLINE:-
May be used in cases of Pulmonary edema and
pulmonary congestion secondary to heart failure.
https://pubmed.ncbi.nlm.nih.gov/837650/
3) INJ HAI according to Grbs
4) N ACETYLCYSTEINE:-
NAC can effectively inhibit myocardial cell apoptosis caused by ischemia-reperfusion injury (IRI) and improve cardiac function.
https://www.hindawi.com/journals/dm/2021/3625662/#
5) MET XL FOR HIGH BP DE NOVO HYPERTENSION.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952407/
6) SYP LACTULOSE As the patient did not pass stools for 3 days from admission
7) SYP POTKLOR - as potassium levels decreased to 3.2.
8) LASIX:-
furosemide to treat conditions with volume overload and edema secondary to congestive heart failure exacerbation.
https://www.ncbi.nlm.nih.gov/books/NBK499921/
MY LEARNING POINTS:-
I learned to integrate multiple systems to help a patient
COPD; Heart failure
Heart failure:-
https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142
SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the patient's case:
Strengths:
- He has a supportive family who provides financial stability and assistance.
- He can sleep better with the use of medication.
- He is on good attender care.
Weaknesses:
1. The patient experiences severe shortness of breath
2. He was unable to tolerate BiPAP
3. The patient has been unable to find relief even on continuous medication
4. He has been experiencing sleep disturbances.
5. The patient's condition may deteriorate
Opportunities:
1. Further evaluation and cardiologist/pulmonologist referral provide an opportunity for a comprehensive assessment and management of her condition.
Threats:
1. The patient's dependence on medication and BIPAP may deteriorate to go into to ventilator.
2. There is more chance of death in the patient.
3. As he is hospitalised he may develop bed sores.
4. Exacerbation of the condition may be seen near future.
Comments
Post a Comment