2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links

 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 with an aim 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.

CASE 1 :- 

PaJR Group:- 

https://chat.whatsapp.com/E0d1vuSmwdiIQLRcyOcfqF

Blogspot :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-85-year-old-male-patient-came-with.html

[07/09/23, 11:20:36 AM] Nikhilsai Karnati: https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-85-year-old-male-patient-came-with.html

[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 sulphate 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 denovo 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; mucomist

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 is 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; 

Patient had raised Jvp suggestive of right heart failure 

And pleural effusion ( right >left) 

And on the 2 nd 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 be a case of acute exacerbation of copd ; with  cor pulmonale which later lead 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 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 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 denovo 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 ACETYL CYSTEINE :- 

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 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/

CASE 2 :- 

PaJR grp :- 

https://chat.whatsapp.com/GqOKxIsIg8sGgpBP8ZQajG

Blog :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-78-ym-with-ho-cad.html

[14/09/23, 4:36:08 PM] Rakesh Biswas Sir Hod Med: Update?

[15/09/23, 10:35:05 AM] Nikhilsai Karnati: Sir the patient is discharged at his request .

He came to the hospital mainly for the cataract surgery but was referred to the medicine for his high sugars and his previous history of CAD 

But wants to leave to if he is not fit for surgery but he is under high risk if he undergoes surgery so we explained the patient the same thing so they wanted to leave as for the CAD he is under follow up of a cardiologist so they want to be treated there itself and there also decided against the cataract surgery as of now the main priority is his heart and regarding his CAD and Diabetes we adviced him

1. TAB ECOSPIRIN - AV (75/10) PO/HS AT 9PM

2. TAB LASIX 20 MG PO/OD AT 8 AM AND 4PM

3. TAB METFORMIN 500 MG PO/BD

CASE 3 :- 

PaJR grp :- 

https://chat.whatsapp.com/KUzeL4lDCmzIH2b1omqUvq

Blog :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-63ym-with-loss-of-consciousness-6.html?m=1

[14/09/23, 2:22:51 PM] Nikhilsai Karnati: SOAP 

14/09/2023-

DR NIKITHA (SR)

DR PAVAN (PGY2) 

DR VIVEK (PGY1) 

ICU BED 2 

DOA - 13/09/2023

S :- 

No hypoglycaemic symptoms 

O:

Pt is c/c/c

Bp - 120/70 mmhg

Pr- 87 bpm

Cvs - S1 S2 heard no murmurs

Rs - Bae+ Nvbs

Pa- soft and non tender

Cns -

     Tone 

       Right                     Left 

U.L   N.                           N

L.L.   N.                           N

Power 

        Right   Left 

U.L    5/5.    5/5

L.L.    5/5.    5/5

Reflexes 

         Right     left 

B        +++.      +++

T.       +++.      +++

S.       +++        +++ 

K.        +++.      +++

A.              +.          + 

PLANTAR :- flexor.    Flexor 

A:

HYPOGLYCAEMIA secondary to OHA ? CERVICAL MYLEOPATHY ; NEUROGENIC BLADDER 

?AKI ON  CKD K/C/O DM since 6 MONTHS 

P:

1. WITHHOLD OHA 

2. ENT. 25% DEXTROSE IV / STAT infusion @10ml/hr  increase/decrease  depending upon Grbs accordingly

3. Monitor vitals 4 Th hourly 

4. GRBS - 2 hrly monitoring

[14/09/23, 2:24:03 PM] Rakesh Biswas Sir Hod Med: How and why CKD since 20 yrs?

[14/09/23, 2:24:47 PM] Rakesh Biswas Sir Hod Med: Mechanism of vildagliptin hypoglycemia?

[14/09/23, 2:29:46 PM] Medha 2k19: According to the patient history sir , she said has some kidney problem which was diagnosed by some local doctor; 20 yrs ago.

[14/09/23, 2:30:54 PM] Medha 2k19: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3144769/#:~:text=The%20dipeptidyl%20peptidase%2D4%20inhibitor,while%20maintaining%20good%20glucose%20control.

[14/09/23, 2:31:19 PM] Medha 2k19: Sir it is actually known to minimise the risk of hypoglycaemia

[14/09/23, 2:45:04 PM] Rakesh Biswas Sir Hod Med: So no one knows what it was then? 

What have we found in her kidneys at present?

[14/09/23, 2:47:25 PM] Rakesh Biswas Sir Hod Med: How? Just because it doesn't work well in reducing glucose? Is it's incompetence being marketed as a virtue? 

Any scientific studies showing how it works and how it's pharmacological actions are different from sulphonylurea!

[14/09/23, 2:51:42 PM] Medha 2k19: Sir, her blood urea levels are 54 mg/dl and S.creat is 2.7 

(Dated 13/9/23)

[14/09/23, 2:53:54 PM] Rakesh Biswas Sir Hod Med: USG kidneys? 

Urinary albumin? 

Serum albumin!

[14/09/23, 2:56:54 PM] Medha 2k19: Sir, she’s been sent for usg, will update as soon as report comes

[14/09/23, 2:57:22 PM] Medha 2k19: And for, CUE her sample has been already sent, we will get the report soon sir

[14/09/23, 2:59:18 PM] Rakesh Biswas Sir Hod Med: 👍

[14/09/23, 2:59:26 PM] Rakesh Biswas Sir Hod Med: 👆

[14/09/23, 2:59:51 PM] Rakesh Biswas Sir Hod Med: Quote the relevant portion

[14/09/23, 3:04:39 PM] Rakesh Biswas Sir Hod Med: Quote doesn't mean webshot!! 

It means 

"copy paste"

[14/09/23, 3:05:17 PM] Rakesh Biswas Sir Hod Med: It's just opinion you are sharing! 

Science contains experimental data

[14/09/23, 3:05:36 PM] Medha 2k19: Yes sir, working on it

[14/09/23, 3:52:45 PM] Rakesh Biswas Sir Hod Med: USG images! 

What in the images suggest grade 2 or 3?

[14/09/23, 4:48:44 PM] Medha 2k19: https://link.springer.com/article/10.2165/0003495-200868160-00009

[14/09/23, 4:49:27 PM] Medha 2k19: Mechanism of action 

Vildagliptin (Galvus®️) is an antihyperglycaemic agent that selectively inhibits the dipeptidyl peptidase-4 (DPP-4) enzyme. Such inhibition prevents the degradation of the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). This results in improved glycaemic control as determined by glycated haemoglobin (HbA1c) and fasting plasma glucose (FPG) levels, and, in addition, an enhancement of pancreatic α- and β-cell function.

[14/09/23, 4:50:01 PM] Medha 2k19: Therapeutic Efficacy

In well designed monotherapy trials of 24–108 weeks’ duration (n = 131–786), vildagliptin provided effective glycaemic control as assessed by the change from baseline in HbA1c and FPG levels relative to placebo. Vildagliptin was as effective as acarbose and rosiglitazone, but not metformin, in terms of lowering HbA1c when noninferiority criteria were met. A pooled analysis of data from five monotherapy trials (n = 1138) further confirmed that vildagliptin provided effective glycaemic control after 24 weeks of treatment.

In combination therapy trials of 24 weeks’ duration in patients with type 2 diabetes for whom hyperglycaemia was inadequately controlled with prior metformin monotherapy, vildagliptin used as an adjunct to metformin provided better glycaemic control than placebo plus metformin (n = 416) and was as effective as pioglitazone plus metformin (n = 510) in improving glycaemic control in a noninferiority trial.

In other combination therapy studies also of 24 weeks’ duration (n = 296–408), vildagliptin was more effective than placebo as add-on therapy to insulin, glimepiride or pioglitazone in patients with type 2 diabetes inadequately controlled by monotherapy despite receiving maximum effective doses

[14/09/23, 4:51:33 PM] Rakesh Biswas Sir Hod Med: Tell us more detail about the glucose numbers in the vildagliptin and placebo group and metformin group

[14/09/23, 4:53:03 PM] Medha 2k19: Sir, it seems that the images weren’t taken. 

But, they asked for a review with full bladder, so we can get pictures then

[14/09/23, 6:32:37 PM] Medha 2k19: https://www.researchgate.net/publication/6323540_Comparison_between_vildagliptin_and_metformin_to_sustain_reductions_in_HbA_1c_over_1year_in_drug-nave_patients_with_Type2_diabetes

[14/09/23, 6:34:26 PM] Medha 2k19: “At the study end, significant HbA(1c) reductions from baseline were seen with both vildagliptin (-1.0 +/- 0.1%, P < 0.001) and metformin (-1.4 +/- 0.1%, P < 0.001); however, statistical non-inferiority of 50 mg vildagliptin twice daily to 1000 mg metformin twice daily was not established”

[14/09/23, 6:34:45 PM] Medha 2k19: “A clinically meaningful decrease in HbA(1c) that was sustained throughout a 1-year treatment in drug-naïve patients with Type 2 DM was seen with both metformin and vildagliptin monotherapy.”

[14/09/23, 6:35:50 PM] Medha 2k19: “The incidence of hypoglycaemia was similarly low in both groups (< 1%).”

CASE 4 :- 

PaJR grp 

https://chat.whatsapp.com/GQcbsMAV3m4Lvwh03eVKBd

Blog :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/09/a-71-year-old-male-with-complaints-of.html

A 71 year old male with complaints of loss of consciousness 30 mins back . (Nephro case) 

A 71 year old male patient came to the casuality with the complaints 

  - Swelling to the right leg since 6 days 

  - loss of consciousness 30 mins back.

HISTORY OF PRESENTATING ILLNESS :- 

A 71 years old male patient was apparently well 5 days back, patient had injury to right leg - thorn prick followed which patient developed swelling and pain right leg. 

H/o decreased urine output consulted locally, evaluated found to have increased TLC and increased serum creatinine( 7.0 mg/dl) , He was initially evaluated outside where US doppler of both lower limb showed right lower limb cellulitis with no DVT. 

USG abdomen showed Bilateral grade I RPC changes. 

Then he was referred to a higher centre 

There he  was hypotensive ; fluid resuscitation done and started on vasopressor support.

And ABG Was sent and ABG showed severe metabolic acidosis. And he was Started on IV Antibiotics Inj. Meropenam and Inj. Teicoplanin, Inj. Metrogyl) and other medication. And was adviced for  hemodialysis in view of severe metabolic acidosis. SLED ( Sustained low-efficiency dialysis ) was done for 8 hours. 

And for the swelling of the right leg debridement was done . 

And then due to some financial issues they thought of shifting the patient to other hospital and when he was being shifted to our hospital  then patient lost his consciousness for 15 mins 

With sweating  and way bought here.; and primary resuscitation was done .

no c/o decreased urine output 

no c/o fever, soB, palpitation, chest pain, orthopnea.

PAST HISTORY:- 

Known case of DM TYPE 2 since 15 years and on medication METFORMIN 500 mg since then 

( OD) .

15 years back patient had an episode of loss of consciousness and was investigated to find diabetes mellitus ( type 2) and is on med since then 

Not a known case of HTN; CAD; CVA ; Thyroid ; TB ; asthma epilepsy 

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

At the time of examination 3/9/23:- 

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY 

TEMPERATURE:- AFEBRILE

PR:98bpm

BP:140/80mmhg

RR:18cpm

CVS:S1 S2+,NO MURMURS

RS:BAE+ ; NVBS ; No added sounds 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

CNS :- 

Tone 

       Right                     Left 

U.L   N.                           N

L.L.   N.                           N

Power 

        Right   Left 

U.L    5/5.    5/5

L.L.    5/5.    5/5

Reflexes 

         Right     left 

B        ++.      ++

T.       ++.      ++

S.     ++           ++ 

K.                   ++

A.                       + 

Planter - right can not be elicited 

Left flexor 

PROVISIONAL DIAGNOSIS:- 

AKI SECONDARY TO SEPSIS WITH RIGHT LOWER LIMB CELLULITIS WITH KNOWN CASE OF DM TYPE II SINCE 15 years 

INVESTIGATIONS:- 

HAEMOGLOBIN

11.2 

TOTAL COUNT

23,300

NEUTROPHILS

89

LYMPHOCYTES

06

EOSINOPHILS

01

MONOCYTES

04

BASOPHILS

00

CV

31.9

MCV

90.6 

MCH

31.8

MCHC

# 35.1

RDW-CV

14.2 

RDW-SD

47.8

RBC COUNT

3.52

PLATELET COUNT 96,000

SERUM MAGNESIUM:- 1.8 

CUE :- 

Albumin :-    ++ 

Sugars :- nil 

Pus cells :- 6-8 

RFT :- 

Urea :- 158 

Creatinine:- 4.2 

Uric acid :- 1.9 

Sodium :- 135

Potassium:- 3.0

Chloride :- 98 

Total Bilirubin 2.69

Direct Bilirubin 0.87 

SGOT(AST) 72

SGPT(ALT) 32 

ALKALINE PHOSPHATE  274

TOTAL PROTEINS :- 4.5 

USG :- 

GRADE I Fatty liver 

Raised echogenecity of bilateral kidneys 

X RAY :- chest PA VIEW 

FINAL DIAGNOSIS:- 

AKI SECONDARY TO SEPSIS WITH RIGHT LOWER LIMB CELLULITIS WITH KNOWN CASE OF DM TYPE II SINCE 15 years 

TREATMENT GIVEN :- 

Dialysis was done on 3/9/23 in our hospital:- 

1. Iv fluids U.O+ 30 ml/hr 

2. INJ. PIPTAZ 2.25 gM IV / BD

3. INJ. METROGYL. 500 mg IV/ TID 

   4.HUmAN ACTRAPID INSULIN

      S/C TID  before MEALS 

5. Inj. LASIX 40 mg IV/BD 

        (IF SBP > 110 mmHg )

CASE 5:- 

PaJR :

https://chat.whatsapp.com/CuPY84nR4KvC4BoH9bj2JD

Blog :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/08/a-27-year-old-male-patient-with.html

[31/08/23, 1:52:44 AM] Nikhilsai Karnati: COMPLAINTS :- 

complaints Fever since 5 days .

Patient was apparently asymptomatic 5 days 

back, then developed

Fever, high grade, associated with

chills and

rigors, relieved with medication .

- No c/o Vomitings , bed urine output /burning micturition/ cough/cold /Loose stool.

No c/o PainAbdomen/Or any bleeding manifestations

i.e., Nohematuria/ Melena or  blood

in stool/Bleading gums

Petechiae /rash.

No SOB/chest pain/palpitations

0/E :- Petechiae + over the palatal mucosa

Not a k/c/o HTN, DM, CVA, CAD, TB, Asthma, thyroid disorders. 

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

 

GENERAL EXAMINATION:- 

PATIENT IS CONSCIOUS COHERENT AND CO OPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY 

TEMPERATURE:- AFEBRILE

PR:81bpm

BP:120/80mmhg

RR:18cpm

CVS:S1 S2+,NO MURMURS

CNS:NAD

RS:BAE+ ; NVBS 

P/A:SOFT ; NON TENDER ; NO ORGANOMEGALY 

PROVISIONAL DIAGNOSIS:- 

? Viral hemorrhagic fever 

? Dengue 

INVESTIGATIONS:- 

NS 1 - POSITIVE 

HAEMOGLOBIN

15.4

TOTAL COUNT

4,000

NEUTROPHILS

60

LYMPHOCYTES

32

EOSINOPHILS

01

MONOCYTES

07

BASOPHILS

00

POV

43.8

MCV

# 81.9

MCH

28.8

MCHC

# 35.2

RDW-CV

12.7

RDW-SD

38.5

RBC COUNT

5.35

PLATELET COUNT 36.000

Total Bilirubin 0.91 

Direct Bilirubin 0.18 

SGOT(AST) 19

SGPT(ALT) 57

ALKALINE PHOSPHATE  133 

USG :- NO SONOLOGICAL ABNORMALITY DETECTED.

[31/08/23, 1:54:22 AM] Nikhilsai Karnati: https://nikhilsaikarnatirollno69.blogspot.com/2023/08/a-27-year-old-male-patient-with.html

[31/08/23, 7:05:09 AM] Rakesh Biswas Sir Hod Med: Fever chart?

[31/08/23, 7:05:27 AM] Rakesh Biswas Sir Hod Med: Clinical image in DP?

[31/08/23, 7:59:24 AM] Rakesh Biswas Sir Hod Med: Added to case report?

[31/08/23, 8:05:55 AM] Nikhilsai Karnati: Yes sir

CASE 6 :- 

PaJR :- 

https://chat.whatsapp.com/Gi0CNiapAPd1WlInklzoif

Blog :- 

https://nikhilsaikarnatirollno69.blogspot.com/2023/08/36year-male-with-pain-abdomen.html

[26/08/23, 8:33:30 AM] Nikhilsai Karnati: COURSE IN HOSPITAL:- 

The patient presented to the casualty on 21/8/23 with complaints of  Pain abdomen (right hypochondrium) from 20/8/23

And distension of abdomen (84cm) previously around 71cm.

Then was admitted under general surgery for further evaluation and was investigated further for the evaluation of pain abdomen and causes of distension. The patient has not passed Flatus and feces for the past 2 days so the below investigations are ordered and the emus further evaluated.

Then an emergency ultrasound was done to rule out gallstones but the report was given as normal.

Then the patient was taken to the x-ray and a chest x-ray was done to rule out gas under the diaphragm and any hollow viscus perforation but the x-ray was normal. An erect abdomen was done which showed some dilated loops but were not significant for any obstruction.

And was started conservatively.

Then patient was investigated with amylase and lipase levels which were found to be raised ( 104 IU/L ) but the levels of lipase were normal and in the suspicion of pancreatitis CT was advised and it showed 

IMPRESSION:

- ACUTE EDEMATOUS INTERSTITIAL PANCREATITIS CONFINED TO THE HEAD AND UNCINATE PROCESS

⁃   NO CALCIFICATIONS

⁃   MILD ASCITES

⁃   NO VASCULAR COMPLICATIONS

⁃   MILD RIGHT PLEURAL EFFUSION

⁃   MODIFIED CT ST SCORE 4/10.

But then was transferred to the Gen medicine for the further management of pancreatitis.

THE PATIENT WAS GIVEN SYMPTOMATIC TREATMENT AND  WAS NBM FOR 3 DAYS AND THEN STARTED ON A SOFT DIET. 

And now PATIENT HAS NO COMPLAINT OF THE PAIN ABDOMEN.

THE PATIENT IS HEMODYNAMICALLY STABLE AND ADVISED FOR DISCHARGE.

WHEN THE PATIENT WAS ADMITTED THE BISAP SCORE WAS AROUND 2 WHICH MEANS THE MORTALITY WAS AROUND 3.6 PERCENT AND AT THE TIME OF DISCHARGE THE BISAP SCORE IS 0 WHICH MEANS THE MORTALITY IS 0.1 PERCENT.

On the day of admission, abdominal girth was around 84 cm, and now at the time of discharge 70 cm ( that means the distension is also resolved)

And PATIENT WAS ADVISED TO

# stop alcohol. 

# Take plenty of water

[26/08/23, 8:34:40 AM] Nikhilsai Karnati: PROBLEM THAT LEAD TO PRESENT ILLNESS:- 

The patient is an occasional alcoholic drink with his peers (functions, parties:- 90-180ml).

But from 3 before the illness, the patient started drinking (binge drinking) (whiskey).

So the cause may be chronic consumption of alcohol and present binge drinking from past 3 days before illness.

[26/08/23, 8:37:29 AM] Rakesh Biswas Sir Hod Med: Process the information in the case report and list the known and unknown learning points (questions) as per the guidelines here👇

https://medicinedepartment.blogspot.com/2023/08/project-illustration-of-how-to-process.html?m=0

CASE 7:- 

PAJR :- 

60F swelling of left lower  limb 5days, Diabetes 10 years Telangana PaJR. 

[15/08/23, 9:03:46 AM] Nikhilsai Karnati: 14/08/2023

Ward :  ward

Unit : 2

DOA : 9/8/23

Dr LOHITH PG Y1 

Dr NARSIMHA PG 2Y

Dr ZAIN SR

S:

Altered sensorium improved ; patient is conscious but not oriented to time place and person ; stool passed 

O: SUPERFICIAL BURNS OVER LEFT THIGH WITH ULCER OVER LEFT MEDIAL MALLEOLUS WITH GRAFE II BED SORE OVER LEFT GLUTEAL REGION 

A

No icterus,cyanosis,clubbing,

lymphadenopathy

Bp-140/70mmHg

Pr-  88bpm

Temperature - 99.9 F

Rr- 18cpm

Spo2- 96 % on RA

CVS-S1,S2 heard ,no murmurs

RS- BAE present 

NVBS 

CNS-NO FND

Pupils- B/L NSRL

P/A- Soft, NT

L/A-Dressing intact,edema decreased ,minimal Slough present ,granulation tissue present 

P:

1.RT FEEDS 2 SCOOPS OF PROTEIN POWDER 4TH HRLY

2.IV FLUIDS NS @75 ML/HR

3.INJ PAN 40 MG IV OD

4.INJ LASIx 40 MG IV BD

5.INJ HAI SC TID.

6.TAB NODOSIS 1 GM /RT /TID

7.TAB DOLO 650 MG RT SOS

8.TAB CHYMEROL FORTE PO TID

9.TAB MVT PO OD

10.TAB VIT C PO OD

11.OINTMENT MUPIROCIN FOR LA

12.LEFT LOWER LIMB ELEVATION

13.ACTIVE AMBULATION

14.DRESSING

15. HRLY POSITION CHANGE

[15/08/23, 11:17:38 AM] Rakesh Biswas Sir Hod Med: What is the efficacy of nodosis or chymoral?

[15/08/23, 11:25:23 AM] Nikhilsai Karnati: Conclusion

Treatment of metabolic acidosis with sodium bicarbonate may slow the decline rate of kidney function and potentially significantly improve vascular endothelial function in patients with CKD.

Objective

Oral sodium bicarbonate is often used to correct acid-base disturbance in patients with chronic kidney disease (CKD). However, there is little evidence on patient-level benign outcomes to support the practice.

Methods

We conducted a systematic review and meta-analysis to examine the efficacy and safety of oral sodium bicarbonate in CKD patients. A total of 1853 patients with chronic metabolic acidosis or those with low-normal serum bicarbonate (22–24 mEq/L) were performed to compare the efficacy and safety of oral sodium bicarbonate in patients with CKD.

Results

There was a significant increase in serum bicarbonate level (MD 2.37 mEq/L; 95% CI, 1.03 to 3.72) and slowed the decline in estimated glomerular filtration rate (eGFR) (MD −4.44 mL/min per 1.73 m2, 95% CI, −4.92 to −3.96) compared with the control groups. The sodium bicarbonate lowered T50-time, an indicator of vascular calcification (MD −20.74 min; 95% CI, −49.55 to 8.08); however, there was no significant difference between the two groups. In addition, oral sodium bicarbonate dramatically reduced systolic blood pressure (MD −2.97 mmHg; 95% CI, −5.04 to −0.90) and diastolic blood pressure (MD −1.26 mmHg; 95% CI, −2.33 to −0.19). There were no statistically significant body weight, urine pH and mean mid-arm muscle circumference.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8665881/

[15/08/23, 11:26:27 AM] Nikhilsai Karnati: Efficacy of NODOSIS Sir

[15/08/23, 11:26:43 AM] Nikhilsai Karnati: Trypsin:Chymotrypsin in Accidental, Surgical, and Orthopedic Injuries—Clinical Appraisal Goel and Sengupta [15] studied the efficacy of trypsin:chymotrypsin (Chymoral) in accidental soft tissue injuries. They included 156 patients (age between 14 and 45 years) presenting in the casualty department with bruises, lacerations, hematomas, and sprains and strains. The patients were randomized into two groups: the Chymoral group (n = 79), which received trypsin:chymotrypsin therapy along with standard emergency treatment, and the control group (n = 77), which received emergency treatment only. The recommended dosage of Chymoral was employed, i.e., 2 tablets 4 times a day × 7 days, 30 min before a meal. The patients were followed either once weekly or twice weekly and their progress was documented. Trypsin:chymotrypsin use resolves bruises within 8–12 days, which otherwise cleared in 10–15 days. In patients with lacerations, it improved the appearance of scarring due to stitches. Also, hematomas of the forehead and knees, which usually take 2–3 weeks to clear, resolved within 10–12 days in the Chymoral group. Ankle sprains normally take 2–3 weeks to recover. However, speedy recovery was documented with trypsin:chymotrypsin use, clearing as quickly as within 7–12 days. Additional benefits associated with the use of the enzyme preparation included relief in pain and lower incidence of infection. It was concluded that trypsin:chymotrypsin treatment in patients with accidental soft tissue injuries hastens the healing process and significantly reduces the recovery time. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778189/

[15/08/23, 11:29:04 AM] Nikhilsai Karnati: Sir ,therefore  it is concluded that chymotrypsin ( chymoral forte) treatment is significantly better tolerated and more effective than other enzyme preparations in resolving symptoms of inflammation and therefore promotes better healing.

[15/08/23, 1:16:32 PM] Rakesh Biswas Sir Hod Med: Share some of the RCTs from this review one by one in a PICO format to understand how the individual studies are much smaller than the summative systematic review that possibly pools apples and oranges. 

Even if you look at the numbers that you shared you will realize they are not at all clinically significant inspite of the author's rhetoric!

[15/08/23, 1:38:11 PM] Nikhilsai Karnati: oral bicarbonate( nodosis)  is widely used to correct acidosis in advanced CKD, 

this is not underpinned by any trial evidence, 

real uncertainty exists regarding the balance of benefit and risk for this intervention. 

As most patients with CKD are old, and many are frail, it is critical that trials testing such interventions enrol typical patients and use outcome measures that are relevant to older people. Few older people with even advanced CKD will progress to end-stage renal disease; the risk of death from cardiovascular disease or infection often supervenes long before the need for renal replacement therapy. The range of outcomes selected for this trial will allow an estimation of overall net benefit or harm across a range of disease outcomes including renal, bone and vascular disease, as well as focusing on outcomes that are important to patients (function and quality of life) and policymakers (cost-utility analysis).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4522127/

[15/08/23, 1:39:32 PM] Nikhilsai Karnati: Many trails are being performed and are still awaited sir but it is not proved or supported by any trail as such.

[15/08/23, 1:43:07 PM] Nikhilsai Karnati: Sodium Bicarbonate is an alkalizer. It works by increasing the pH of blood and urine, thereby correcting metabolic acidosis (high acid levels in the body). It also speeds up the removal of toxic substances from the body in certain types of poisoning.

Sir, As it is an  alkalizer which increases the pH it is used widely in correction of acidosis but no trail based proof is  published as of now to support use of nodosis.

[15/08/23, 1:46:48 PM] Rakesh Biswas Sir Hod Med: How was the randomization done here? Were the study participants including the evaluators blinded? Doesn't appear so. Again how clinically significant is an advantage of two day earlier healing? How did they decide the healing time? 

Good find. Now answer the above questions. 

Are you an exam going intern or exam gone intern?

[15/08/23, 1:48:04 PM] Rakesh Biswas Sir Hod Med: Dont worry about that. Just discuss one RCT to understand why there is no evidence

[15/08/23, 1:49:26 PM] Nikhilsai Karnati: 2018 intern posted in unit 3 from today sir

[15/08/23, 2:03:16 PM] Nikhilsai Karnati: No sir ,the Evaluators are not blinded I guess . so there may be selection bias at the end of the trail to pick it up 2 days earlier but even though the only clinical significance of this early recovery for the patient is “ he will be out of pain 2 days earlier “ which will be the main complaint of many patients . 

And mostly they would have decided the recovery time by assessing the pain of the patient and decreased incidence of infections at the site there after …

They randomly divided the patient grp in to the chymoral forte grp and non chymoral grp . There is no criteria used to divide them .

[15/08/23, 2:07:44 PM] Nikhilsai Karnati: The main limitation of the above analysis is the lack of long-term follow-ups of oral sodium bicarbonate on patient-centered endpoints, including mortality.

There was significant clinical heterogeneity of the included trials, such as sodium bicarbonate dose, control strategy, baseline eGFR and serum bicarbonate levels, and treatment duration, so it was difficult to obtain an exact conclusion.

So due to the above limitations till date there may not be a proper evidence for nodosis.

[15/08/23, 2:22:20 PM] Rakesh Biswas Sir Hod Med: The second para appears to be your opinion or assumption going by your choice of words? 

Instead of saying: mostly they would have...why not check what they have actually done?

[15/08/23, 2:39:09 PM] Rakesh Biswas Sir Hod Med: Please quote the relevant portions instead of screen shooting them as it's more difficult to archive screen shots.

One of the things we tried to emphasize in the 2017 internship completion online portfolio assessments is the intern logging his her work daily in a manner to leave regular online traces to their work, which can be verified with the date of logging. 

For example you can put all the above discussion around the current evidence for this particular patient's treatment into her case report that will automatically also show the date and time of your logged inputs. If we need to evaluate your performance at a later date during internship completion extension decision making, you would have sufficiently logged evidence of your work on this date. Pĺease share this with other 2018 interns and please ask them to seek any clarifications in the main group 

@919604701505 I guess often it's more about the users adapting to existing tech rather than anything else. Presence of audit trails in google blogspot where are current dynamic EHRs are housed would surely be a big value add!

[15/08/23, 2:40:08 PM] Rakesh Biswas Sir Hod Med: Most of their conclusions appear very subjective!

[15/08/23, 2:46:41 PM] Nikhilsai Karnati: Yes sir