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

Case 1

[21/11, 11:02] Vineela: 21/11/23

ICU 

Vitals 

Bp-160/90 mm hg

Pr-98bpm

Rr -20cpm

Temp-99.4 F

GRBS-87MG/dl 

I/O-2000/100ml

Examination 

RS-BLAE ,NVBS

CNS-NFND

CVS-S1 S2 heard no murmurs 

P/A-Soft  NT

Diagnosis-Type 2 DM,K/C/O  CAD S/P CABG I 2020,K/C/O HTN,AKI on CKD ,Diabetic foot ulcer ,candidial intertrigo +frictional dermatitis

Treatment-

1.Oxygen inhalation to maintain saturation greater than 95%

2.Injection Meropenem 1gm IV/BD (12th hrly)

3.Injection linezolid 600mg IV/BD(12th hrly)

4.Tab ecospirin 75mg od

5.Ryles feeds-100ml water-2nd hrly

                          50ml milk 3th hrly

6. TAB clopidogrel 75mg RT /OD 

7.TAB Atorvastatin 40mg RT/OD

8.Inj Dopamine infusion 2.5mg/min/

9.inj pcm 1g IV/SOS

10.Inj pantop 40mg IV/OD BBF 

11.TAB Pcm 650mg po/8hrly

12.TAB Acebrophylline 100mg rt/12 hrly

13.TAB Nodosis 500mg rt/bd

14.TAB Shelcal CT rt/od

15.Cap BIOD3 RT/Once a week

16.TAB Orofer xt RT/od

17.nebulisation with IPRAVENT 6

hourly,BUDECORT 8 hourly 

18.TAB ENOXAPARIN 60mg SC/od

19.mgso4 dressing for rt lower limb 

20.Iv fluids ns @30ml/ hr

21.I/O charting 

22.CLOTRIMAZOLE 1% cream LA BD 1 week

23.Absorb dusting powder LA/BD

24.TAB Sporolac ds RT/TID

25.Inj Moxifloxacin 400mg IV/OD 

26.Inj.Hydrocortisone 100mg IV prior to dialysis 

27.Inj metrogyl 500mg IV /TID

[21/11, 15:50] Rakesh Biswas Sir: ICU patient?

[21/11, 15:51] Rakesh Biswas Sir: Case report link? 

When are you finishing @⁨Vineela⁩ ?

[21/11, 15:53] Vineela: By tomorrow morning sir

[22/11, 09:56] Himaja Medicine Pg: Stop Ecospirin

[22/11, 14:29] Rakesh Biswas Sir: @⁨Himaja Medicine Pg⁩ Can you share your thoughts on this patient?

[22/11, 17:12] Himaja Medicine Pg: Was cabg necessary in 2021 ? What are outcomes of cabg

What is mechanism of acute mi? Which plaques sudden rupture?

Difference between chronic obstructive airway disease and obstructive sleep apnea

[22/11, 19:08] Rakesh Biswas Sir: Those were the questions that were asked by us 

What were your own questions about her? 

What are your current answers or thoughts about those?

[22/11, 20:57] Himaja Medicine Pg: How should we manage her current situation? 

Is everyday dialysis recommended? What are the complications of everyday dialysis?

[22/11, 21:04] Rakesh Biswas Sir: Complications are largely similar to not everyday dialysis 

For any such patient of renal and heart failure, the dialysis is just symptomatic support to reduce symptoms of heart failure by reducing pre load and symptoms of renal failure toxemia and acidosis 

So the duration of dialysis is governed by the response of the patient aka outcomes of dialysis 

Did you find out the answer to the question why do we prefer providing bicarb through a dialyzer than direct iv if the membrane may not make much difference to bicarb inputs or sodium load during infusion? 

If not ask Chandana and Manasa

[23/11, 07:08] Rakesh Biswas Sir: Also please share one of the most valuable insights you obtained about this patient's precipitating factor for all her current events:

The peripheral neuropathic exacerbation possibly due to her hyperglycemic fluctuations that she tried to douse with hot water

[23/11, 10:06] Vineela: 23/11/23

ICU 

Vitals 

Bp-160/70 mm hg

Pr-100bpm

Rr -20cpm

Temp-98.9 F

GRBS-159MG/dl 

I/O-2000/300ml

Examination 

RS-BLAE ,NVBS

CNS-NFND

CVS-S1 S2 heard no murmurs 

P/A-Soft  NT

C/O -No fever ,stools passed Bed sore grade 2

Diagnosis-Type 2 DM,K/C/O  CAD S/P CABG S/P in  2020,K/C/O HTN,AKI  ,candidial intertrigo +frictional dermatitis,S/P 6 sessions of  hemodialysis done.

Treatment-

1.Oxygen inhalation to maintain saturation greater than 95%

2.Injection Meropenem 1gm IV/BD (12th hrly)

3.Injection linezolid 600mg IV/BD(12th hrly)

4.GRBS monitoring, Vitals monitoring 

5.Ryles feeds-

                          50ml milk 3th hrly

6.TAB Atorvastatin 40mg RT/OD

7.inj pcm 1g IV/SOS

8.Inj pantop 40mg IV/OD BBF 

9.TAB Pcm 650mg RT/TID

10.TAB Acebrophylline 100mg rt/12 hrly

11.TAB Nodosis 500mg rt/12th hrly

12.TAB Shelcal CT Rt/od

13.Cap BIOD3 RT/Once a week

14.TAB Orofer xt RT/od

15.nebulisation with IPRAVENT 6

hourly,BUDECORT 8 hourly 

16.Right lower limb elevation 

17.mgso4 dressing for rt lower limb 

18.Inj Lasix 40mg IV/BD

19.I/O charting 

20.CLOTRIMAZOLE 1% cream LA BD 1 week

21.Absorb dusting powder LA/BD

22.Regular positioning change 2nd hrly

23.Alpha bed 

24.Inj metrogyl 500mg IV /TID (8th hrly)

25.Inj moxifloxacin 400mg IV/OD 

26.Inj hydrocortisone 100mg IV/ prior to dialysis

[23/11, 10:37] Himaja Medicine Pg: Please also mention the days of antibiotics

[23/11, 11:04] Himaja Medicine Pg: Yes sir

[23/11, 11:07] Vineela: Inj meropenem 1g IV/BD  -Day8

Inj linezolid 600mg IV/BD-Day 8

Inj metrogyl 500mg IV/TID -Day 7

Inj moxifloxacin 400mg IV/OD-Day 4

[23/11, 14:49] Rakesh Biswas Sir: Fever chart daily soap updates at a glance?

[23/11, 20:22] Rakesh Biswas Sir: Thanks 

Merge the two charts 

Please mention each day's sensorium on top

[23/11, 20:23] Rakesh Biswas Sir: 👆Case report link?

Please upload the fever charts too

[23/11, 20:30] Vineela: Yes sir

[24/11, 16:23] Himaja Medicine Pg: Sir can fungal infection cause raise in TLC

If so does her raise in tlc correlate to her candidiasis intretigo?

[24/11, 16:47] Rakesh Biswas Sir: Share the image of her fungal lesions macroscopic as well as microscopic. 

Share the clinical images first asap 

Ask the Dermatologist to take the fungal scrapings and share an image of the microscopy

[24/11, 19:39] Rakesh Biswas Sir: Share the properly merged version of the graph

[24/11, 20:09] Rakesh Biswas Sir: Any other interventions missing in the chart?

Since when is she on CPAP? 

Dialysis?

[24/11, 20:13] Vineela: From 5 days she is on CPAP sir 

She underwent 6 sessions of hemodialysis sir

[24/11, 20:16] Rakesh Biswas Sir: Please enter those interventions day wise in the graph and upload again 

Also upload it to the case report once you share here and we review the Chart

[24/11, 20:42] Vineela: Okay sir

[25/11, 00:18] Vineela: Dual Antiplatelet Therapy After Drug-eluting Stent Implantation - PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808681/

[25/11, 00:18] Vineela: PICO format

P-population selected

Patients who underwent PCI with Stent implantation.

I-Intervention

In PRODIGY trial ,consisting of population predominantly presenting with unstable coronary artery disease the use of DAPT for 24 months in patients who had received drug eluting Stent was not significantly more effective  than a 6 month clopidogrel regimen followed by aspirin monotherapy in reducing the risk of MI or cardiac death 

C-comparison

In safety and efficacy of 6 months Dual antiplatelet therapy after drug eluting stenting trial ,6months of DAPT were related to similar net clinical outcome compared with 12 months of DAPT after PCI with drug eluting stenting 

Outcome-

Reduced DAPT duration regimen after PCI with drug eluting stenting was associated with significant reduction in rate of major bleeding .

DAPT therapy reduced the incidence of thrombotic complications and major bleeding

[25/11, 00:18] Vineela: https://onlinelibrary.wiley.com/doi/abs/10.1111/jocs.12074

[25/11, 10:27] Rakesh Biswas Sir: I guess you couldn't find any PGs who could guide you. 

In PICO please share the absolute numbers (not percentages) of the 

P (in your first study shared you didn't tell us this : How many total people were studied) 

I :

Among the P how many received I (intervention aspirin) and 

C : 

How many received a comparator (placebo)

O :

What happened in terms of the absolute numbers of morbidity and mortality in the two groups (I and C)?

[25/11, 10:31] Rakesh Biswas Sir: Thanks for sharing this 

The PaO2 has gone through the roof at times! 

What was the FiO2 before each ABG was taken? 

Contrary to expectations I find the SpO2 not touching 100% inspite of the very high PaO2s in some of the serial ABGs!! 

How do we explain that? @⁨Himaja Medicine Pg⁩ @Deepika

[25/11, 16:02] Rakesh Biswas Sir: No active infection?

[25/11, 16:02] Rakesh Biswas Sir: 👆fever Chart update?

[26/11, 12:18] Vineela: 26/11/23

ICU 

Vitals 

Bp-170/80 mm hg

Pr-102bpm

Rr -22cpm

Temp-98.4F

GRBS-203MG/dl at 8 am 

I/O-1500/1050ml

Examination 

RS-BLAE ,NVBS

CNS-NFND

CVS-S1 S2 heard no murmurs 

P/A-Soft  NT

C/O -No fever ,stools passed Bed sore grade 2

Diagnosis-Type 2 DM,K/C/O  CAD S/P CABG S/P in  2020,K/C/O HTN,AKI  ,candidial intertrigo +frictional dermatitis,S/P 8sessions of  hemodialysis done.

Gangrene of right 5th toe and ulcer over dorsum of foot and right calf,grade 2 bedsore of B/Lgluteal region ,S/P dysarticulation of right 5th toe and debridement of ulcer and bed sore under S.A(POD2)

Treatment-

1.Oxygen inhalation to maintain saturation greater than 95%

2.Injection Meropenem 1gm IV/BD (12th hrly)-DAY 11

3.Injection linezolid 600mg IV/BD(12th hrly)-DAY 11

4.GRBS monitoring, Vitals monitoring 

5.TAB Atorvastatin 40mg RT/OD

6.inj pcm 1g IV/SOS

7.Inj pantop 40mg IV/OD BBF 

8.TAB Pcm 650mg RT/TID

9.TAB Acebrophylline 100mg rt/12 hrly

10.TAB Nodosis 500mg rt/12th hrly

12.TAB Shelcal CT Rt/od

12.TAB Orofer xt RT/od

13.Right lower limb elevation 

14.Inj Lasix 40mg IV/BD

15.I/O charting 

16.CLOTRIMAZOLE 1% cream LA BD 1 week

17.Absorb dusting powder LA/BD

18.Regular positioning change 2nd hrly

19.Alpha bed 

20.Inj metrogyl 500mg IV /TID (8th hrly)-DAY 10

21.Inj moxifloxacin 400mg IV/OD -DAY 7

22.Inj hydrocortisone 100mg IV/ prior to dialysis

23.Inj HAI s/c 8u-8u-6u

24.T.Amlong 5mg PO OD

25.Tab.ecosprin 75mg od

26.Tab clopidogerl 75mg stat

Blog-https://mvineelarollno90.blogspot.com/2023/11/65-y-female-with-co-fever-since-4-days.html

Case 2**

[09/11, 15:48] Rakesh Biswas Sir: Share the standing lateral view of biceps and abdomen

[10/11, 13:06] Vineela: 10/11/23

AMC

Unit -3

Date of admission-8/11/23

Vitals 

Patient is c/c/c

PR-72bpm

BP-110/70mm hg

RR-16cpm

Temp-96.8

GRBS-163mg/dl

Systemic examination 

RS-BLAE,NVBS

CVS-S1 S2 heard no murmurs 

CNS-NFND

P/A-Soft,tenderness present at left Iliac region 

Input/output -2150/750 ml 

GRBS 

9/11/23

8am -250mg/dl -12units HAI,8 units nph 

10am -248 mg /dl 

2pm-115 -6 units HAI 

8pm-177 no food taken 

10pm -139

2am -134

8am -163 -6units HAI ,4units  nph 

Diagnosis-K/C/O Type 2 DM with left pyelonephritis with dyselectrolemia 

1:Inj Neomol 1g IV sos if temp >101F

2:IV fluids NS at 100ml /hr

3:Inj HAI According to GRBS SC/TID(pre meal)

4:Inj -NPH according to GRBS SC/BD

5:Monitor vitals 

6:GRBS monitoring 

7:TAB dolo 650 mg PO/SOS 

8:Inj Kcl 20meq in 500ml NS over 4 to 6 hours ×2 infusions

[11/11, 15:31] Vineela: 10/11/23

AMC

Unit -3

Date of admission-8/11/23

Vitals 

Patient is c/c/c

PR-72bpm

BP-110/70mm hg

RR-17cpm

GRBS-147mg/dl

Systemic examination 

RS-BLAE,NVBS

CVS-S1 S2 heard no murmurs 

CNS-NFND

P/A-Soft,tenderness present at left Iliac region

GRBS 

10/11/23

8am -163mg/dl -6units HAI,4 units nph 

10am -360 mg /dl 

4pm-133

8pm-103-6units hai,4units hai given 

2am -115

Diagnosis-K/C/O Type 2 DM with left pyelonephritis with dyselectrolemia 

1:Inj PCM  1g IV sos if temp >101F

2:IV fluids 3  NS at 100ml /hr

3:Inj HAI According to GRBS SC/TID(pre meal)

4:Inj -NPH according to GRBS SC/BD

5:Monitor vitals 

6:GRBS monitoring 

7:TAB dolo 650 mg PO/SOS 

8:Inj Piptaz 4.5gm IV TID 8 th hourly 

9.Inj Pan iv od BBF

[11/11, 15:44] Vineela: Sodium-135mEq /L

Potassium-3.9meq/l

Chloride-109meq/l

[11/11, 16:58] Rakesh Biswas Sir: Fever chart?

[11/11, 16:59] Rakesh Biswas Sir: Evidence of pyelonephritis?

[11/11, 17:03] Rakesh Biswas Sir: The chart has tilted like the tower of pisa because the dots have not been joined in the proper time sequence

[11/11, 17:03] Rakesh Biswas Sir: 👆

[11/11, 18:47] Rakesh Biswas Sir: Urine cue and culture?

[11/11, 18:48] Rakesh Biswas Sir: Share the proper images

[11/11, 18:48] Vineela: Yes sir

[11/11, 18:55] Vineela: Sir urine c/s no pus cells seen and no growth sir

[11/11, 18:56] Vineela: Cue sir

[11/11, 18:58] Rakesh Biswas Sir: So our impression is based only on imaging? 

What about symptoms of pyelonephritis?

[11/11, 19:07] Vineela: She has Pain at left loin region since 10 days sir 

H/O Increased urination since 3 to 4 days associated with increased frequency and increased urgency 

Burning micturition is also present sir since 10 days 

Fever is also present sir

[13/11, 10:56] Vineela: 13/11/23

Unit -3

Date of admission-8/11/23

Vitals 

Patient is c/c/c

PR-80bpm

BP-120/80mm hg

RR-16cpm

GRBS-146mg/dl

Systemic examination 

RS-BLAE,NVBS

CVS-S1 S2 heard no murmurs 

CNS-NFND

P/A-Soft,Non tender 

GRBS 

12/11/23

8am -107mg/dl -6units HAI,4 units nph 

10am -161 mg /dl 

2pm-225 -6units HAI 

4pm-310

8pm-296-6units hai,4units nph given 

10pm-183

13/11/23

12am-155

8am -146 6units HAI

   4units nph 

Diagnosis-K/C/O Type 2 DM with left pyelonephritis with dyselectrolemia (resolved)

1:Inj PCM  1g IV sos if temp >101F

2:Inj HAI According to GRBS SC/TID(6u-6u-6u)

3:Inj -NPH according to GRBS SC/BD(6u-0-4u)

4:Monitor vitals 

6:GRBS monitoring 

6:TAB dolo 650 mg PO/SOS 

7:Inj Piptaz 4.5gm IV TID 8 th hourly 

8.Tab Pantop -d  po/od BBF

[13/11, 15:05] Rakesh Biswas Sir: Chart update?

[13/11, 17:09] Vineela: Yes sir

[13/11, 18:32] Rakesh Biswas Sir: Share the updated chart

[13/11, 21:35] Rakesh Biswas Sir: Thanks 

Please prepare a case report for this patient 

See a sample case report prepared here 👇

https://vaishnavimaguluri.blogspot.com/2023/07/general-medicine-case-report-osce.html?m=1

[13/11, 21:39] Vineela: Okay sir

[23/11, 23:30] Vineela: https://mvineelarollno90.blogspot.com/2023/11/60-year-old-female-with-complaints-of.html

OSCE

[24/11, 06:39] Rakesh Biswas Sir: You are not supposed to share eye images as that may reveal identity!

[24/11, 06:39] Rakesh Biswas Sir: Remove the eye and face image

[24/11, 11:14] Vineela: Yes sir I removed

Blog-https://mvineelarollno90.blogspot.com/2023/11/60-year-old-female-with-complaints-of.html