2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links
Case 1
https://chat.whatsapp.com/LeUjoFdD9rnGmrmTBrAr8c
[31/08/23, 10:33:04 AM] Cherish Kandru: soap notes
31:8:23
ICU Bed 3
Dr.ZainSR)
Dr.Haripriya(PGY2)
DR.Govardhini(PGY1)
S: No Fever Spikes
O: Pt is Sedated and Intubated
GCS- E1V1M1
PR-80bpm
RR-15cpm
BP-60/40 mmhg
@20ml/hr NORAD
@14ml/hr DOBU
ACMV Mode
FiO2 @70
SPO2 98%
RS: BLAE +
NVBS
CVS: S1S2 +, No murmurs
CNS:
Tone :Normal B/L both UL&LL
Power : Unable to elicit
Reflexes: Absent B/L in both UL & LL
I/O 1900/200ml
GRBS 327mg/DK
A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done) 2 years back
P:
1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr
2. INJ DOBUTAMINE 1AMP (5ml) + 45ml NS @ 10 ml /hr
3. INS 3% NACL @ 50 ml/hr I.V /stat
4. INJ PIPTAZ 2.25 gm IV/TID
5. TAB AZITHROMYCIN 500 mg RT/OD
6. NEB WITH BUDECORT + IPRAVANT 6 Th hourly
7. RT FEEDS 100 ml water 2 nd hourly
200 ml milk 4 Th hourly
8. MONITOR VITALS TEMP; PR; RR ; spo2
9. POSITION CHANGE EVERY HOURLY
10. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr
11. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr
12. INJ HAI ACC to GRBS
[31/08/23, 3:44:59 PM] Rakesh Biswas Sir: Please share the post admission transfer events of yesterday in detail as to how and why the patient had to undergo CPR @919676979003 @919573087708
[31/08/23, 3:52:38 PM] Rakesh Biswas Sir: Did he have any recent trauma @919676979003 ?
That's not clear! In the description it's mentioned years and here it's mentioned weeks. Please clarify
[31/08/23, 6:04:12 PM] Cherish Kandru: Yes Sir H/0 trauma (slip and fall from steps) 3 weeks back and also
H/o Rt proximal femur fracture Intramedullary Interlocking nailing done 10 years back
[31/08/23, 6:28:04 PM] Cherish Kandru: Sir the Patient t was shifted from Ortho ward at around 11:30 am in an altered state but the patient was responding when called by his name and obeying commands. At that time the Vitals were
PR-134bpm
BP-60/40mmhg
RR-10cpm
Then Patient was shifted to ICU immediately and ABG and S.Electrolytes were sent.Ionotropic support was started with INJ. DOBUTAMINE and INJ. NORAD. On reporting Sod was found to be 122mEq/L and diagnosis was Altered Sensorium secondary to hyponatraemia. Further Sodium correction was given. After giving correction of 3%Nacl, Sodium was found to be 124mEq/L and patient’s condition didn’t improve. Again Sodium Correction was kept with 3%Nacl @ 30ml/hr. On auscultation grunting was observed and saturations decreased to below 90% with O2 support and also Neb with Budecort and Ipravent was done. Inspite of all these efforts patient’s saturations didn’t improve and continuously decreased to around 78% to 80% and decision to intubate was taken. During intubation Patient went to cardiac arrest and 3 cycles of CPR was done, ROSC was achieved and patient was kept on ventilator ACMV VC mode with FiO2 100%.
[01/09/23, 9:37:14 AM] Cherish Kandru: soap notes
1:9:23
ICU Bed 3
Dr.ZainSR)
Dr.Nishita(PGY2)
DR.Govardhini(PGY1)
S: No Fever Spikes
O: Pt is on Mechanical Ventilator
GCS- E1V1M1
PR-130bpm
RR-14cpm
BP-100/60 mmhg
@10ml/hr NORAD
@10ml/hr DOBU
ACMV Mode
FiO2 @30
SPO2 99%
RS: BLAE +
Decreased BS in IAA with crepts present in Lt IMA; Rt MA, IMA, IAA
CVS: S1S2 +, No murmurs
CNS:
Tone :Normal B/L both UL&LL
Power : Unable to elicit
Reflexes: Absent B/L in both UL & LL
Brain stem reflexes:
Pupillary reflex- absent
Corneal reflex- absent
Conjunctival reflex- absent
Gag reflex- Present
Occulocephalic reflex- Present
P/A- Soft, NT
I/O 1900/200ml
GRBS 327mg/DK
A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago
S/P Post CPR status with chronic calcific Pancreatitis
P:
1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr
2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr
3. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr
4. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr
5.TAB AZITHROMYCIN 500 mg RT/OD
6.NEB WITH BUDECORT + IPRAVANT 6 Th hourly
7.INJ THIAMINE 1 Amp In 100 ml NS IV/BD
8.RT FEEDS 200 ml water 2 nd hourly
200 ml milk 4 Th hourly
9.MONITOR VITALS TEMP; PR; RR ; spo2
10.POSITION CHANGE EVERY HOURLY
11.INJ HAI ACC to GRBS
12.INJ.MEROPENEM 500mg IV/BD
13.INJ HEPARIN 500 IU S.c/ QID
15.INJ LEVIPIL 1gm IV/BD
[01/09/23, 9:45:27 AM] Rakesh Biswas Sir: 👆The EF is much more than 44% in this video taken yesterday @919676979003 where it appears to be 60% and the only other prominent finding is the LVH that appears absent in his Ecg (but that just reflects the 30% sensitivity of Ecg to pick up LVH)
Possible that he may have developed cardiogenic shock pre arrest which is when the 44% Echo was done? Can you share that video if possible?
[01/09/23, 9:46:13 AM] Cherish Kandru: Yes sir
[01/09/23, 10:06:09 AM] Cherish Kandru: Sir the video wasn’t taken sir I’ll try to find the report
[01/09/23, 10:07:07 AM] Cherish Kandru: Update @9am Sir
Temp is 101
[02/09/23, 4:10:15 PM] Rakesh Biswas Sir: Please share all the events that happened around him from falling 3 weeks back to presenting at our hospital
[03/09/23, 10:04:28 AM] Cherish Kandru: Sir the patient fell from staircase 1 month back. Then he had severe pain of lower back radiating to his lower limbs. So he was taken to a nearby hospital in Nalgonda where X-rays and they were told that no fracture was found, he was also taken to another hospital and the same happened again. Then CT scan was done wherein they found the L5 unstable burst fracture with PLC injury and a belt was given to contain the fracture along with some analgesics for the pain. As the patient wasn’t compliant to the treatment given and the pain was severe he was brought to our hospital and he was advised L4 L5 S1 posterior stabilisation.
[03/09/23, 10:16:36 AM] Cherish Kandru: Sir the whole 3 weeks span of him coming to our hospital he was having good appetite, he was compliant with his OHAs, he had no other complaints except for his pain
[03/09/23, 10:17:02 AM] Cherish Kandru: Should I ask the attenders anything in particular sir?
[03/09/23, 10:21:40 AM] Rakesh Biswas Sir: Ask them what was he doing hourly in the past three weeks and was it any different from before he fell down
[03/09/23, 10:22:25 AM] Cherish Kandru: After coming to our hospital he had three episodes of vomiting, non bilious, non foul smelling ,food particles as content. The morning before he was shifted to ICU
[03/09/23, 10:47:00 AM] Cherish Kandru: He used to just lie down on bed the entire day sir and there were no irregularities observed by the attenders sir
[03/09/23, 11:20:49 AM] Rakesh Biswas Sir: Was he bedridden before the fall three weeks ago?
[03/09/23, 11:23:15 AM] Cherish Kandru: No sir
[03/09/23, 11:24:07 AM] Cherish Kandru: He wasn’t bedridden, he used to do his daily activities sir
[03/09/23, 11:44:02 AM] Rakesh Biswas Sir: What were his hourly daily activities?
[03/09/23, 12:01:43 PM] Cherish Kandru: Sir He used to wake up at 6 Am
Does his daily activities by 7:30 Am
Breakfast around 9:00 Am
Has lunch by 1:00 Pm
And then takes a nap
Evening he chats with neighbours and has his dinner around 8:30pm
And sleeps by 9:30 pm
[03/09/23, 12:35:43 PM] Rakesh Biswas Sir: These were same even after the fall since last three weeks?
[03/09/23, 6:46:36 PM] Cherish Kandru: Yea sir but he used to not do his daily activities and he used to just lie down on bed the whole day
[03/09/23, 7:49:34 PM] Rakesh Biswas Sir: That means he was bed ridden after the fall
Case 2:
[31/08/23, 7:00:29 AM] Rakesh Biswas Sir: 58 is a strange pulse rate for a person in pain @919676979003 ?
[31/08/23, 7:00:59 AM] Rakesh Biswas Sir: Clinical images, blood sugars, CBC?
[31/08/23, 7:48:09 AM] Cherish Kandru: Sir will update the fever chart and all the investigations now sir
[31/08/23, 7:50:08 AM] Rakesh Biswas Sir: A standing image of lateral abdomen and biceps
[31/08/23, 7:51:05 AM] Cherish Kandru: Yes sir
[31/08/23, 7:52:39 AM] Cherish Kandru: Yes sir for someone in pain ,they are generally tachy
[31/08/23, 7:53:06 AM] Cherish Kandru: Even the ECG showed Brady sir
[31/08/23, 7:53:35 AM] Cherish Kandru: I’ll upload everything by 9 sir
[31/08/23, 9:34:50 AM] Cherish Kandru: GRBS
12 pm - 200
8pm-208
10pm-125
31/8
2AM-220
7AM-220
[31/08/23, 12:25:58 PM] Cherish Kandru: 31/08/2023
Ward : ward
Unit : 2
DOA : 30/08/2023
S :
C/o abdominal pain decreased
(Dull aching in lower abdomen)
Nausea+
Stools not passed
Flatus passes +
O:
Patient is conscious, coherent
No Pallor, icterus,clubbing, cyanosis, lymphadenopathy, oedema.
Vitals :
Temp Afebrile
BP- 130/90mmHg
PR -86bpm
RR-16 cpm
CNS: NFND
CVS: S1,S2 heard , no murmurs.
RS: BAE, NVBS, no added sounds.
P/A: Rigid,NT
Pain in lower abdomen
Bowel sound 3/min
Sluggish
A: Acute Pancreatitis with alcoholic ketosis with k/c/o DM ll since 6 months with indirect hyperbilirubinemia
P:
IV fluids @75 ml/hr
Inj. Neomol 1Amp in 500 ml NS/IV/BD
Inj pantop 40 mg IV/OD/BBF
Inj Zofer 4 mg IV/BD
[31/08/23, 5:03:45 PM] Rakesh Biswas Sir: Is he really having lumbar lordosis or the image has been taken in that manner to match his suspected type 2 diabetes? Or is it type 3?
[01/09/23, 12:25:40 PM] Cherish Kandru: Image has been taken like that sir
Case 3
[23/08/23, 2:28:52 PM] Hari Priya Mam GM: Update her FBS,PPBS And HBA1C @918639058489 @919676979003
[23/08/23, 2:47:50 PM] Rakesh Biswas Sir: What is the difference between ionized and serum and how are both done separately?
[23/08/23, 2:51:09 PM] Cherish Kandru: Sir S.Calcium is the total calcium in the blood whereas Ionised calcium is the active form of calcium or the free calcium
[25/08/23, 11:24:44 AM] Cherish Kandru: soap notes
25:8:23
Female medical ward-8
Dr.Nikitha(SR)
Dr.Haripriya(PGY2)
DR.Govardhini(PGY1)
S:
Neck pain decreased compared to yesterday.
Headache decreased compared.
1 Episode of Vomiting- Yesterday night
No Fever spikes
Stools passed
O:
pt is C/C/C
No signs of pallor, Icterus, clubbing, cyanosis,lymphedenopathy, pedal edema
BP: 120/80mmhg
PR: 78bpm
RR: 18cpm
Temp: 96.2 F
Cvs: S1,S2 heard, No murmurs
RS:BAE+
P/A: distended and non tender
CNS: No FND
Neck Examination
Restriction of movements decreased
Able to flex and extend
Neck stiffness -
kernig’s sign -
Brudzinki sign -
A:
NECK PAIN-CERVICAL RADICULOPATHY (C5-C6) with Paraspinal Spasm
K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO secondary to Vertebro basilar insufficiency
WITH DENOVO THYROID DISEASE (HYPOTHYRODISM) WITH Left CERVICAL LYMPHEDENOPATHY WITH DENOVO DMII
P:
1.INJ. Diclofenac Im/sos
2.T.Dolo 650 mg po/sos
3.T. Nicardia 10 mg po/sos
4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg
5.T. vertin 8 mg po/bd
6.T. Thyronorm 75 mcg po/od
7.T. Metformin 500 mg po/be
8.T. Cinod 10 mg po/od
9.T. Myoril 2ml IM/BD
10.INJ. Zofer 4mg IV/SOS
11.INJ.PAN 40mg/IV/OD
12.T.PREGABA 75MG/PO/HS
[25/08/23, 2:57:10 PM] Rakesh Biswas Sir: Peripheral vertigo everyday since 4 years!!?
[25/08/23, 2:57:51 PM] Rakesh Biswas Sir: You have updated just one patient today?
You have only work responsibility for just one patient throughout the day?
[25/08/23, 3:03:43 PM] Cherish Kandru: Sir as there are only 2 interns in each Unit we’ve been called to help The interns in OP sir.
[25/08/23, 3:10:49 PM] Cherish Kandru: Vertigo only since the past 10 days Sir
[25/08/23, 4:38:18 PM] Rakesh Biswas Sir: If there is two interns and one patient in the ward it's logical to have one intern go and help in opd
[25/08/23, 4:38:58 PM] Cherish Kandru: Yes Sir we are helping Unit 5 on their OP days
[25/08/23, 4:40:31 PM] Rakesh Biswas Sir: Not we. Only one of the two interns who doesn't have a patient in the ward
[25/08/23, 4:41:07 PM] Cherish Kandru: Yes Sir
[28/08/23, 9:03:06 AM] Cherish Kandru: soap notes
28:8:23
Female medical ward-8
Dr.Nikitha(SR)
Dr.Haripriya(PGY2)
DR.Govardhini(PGY1)
S:
Neck pain decreased .
No Episodes of Vomiting since yesterday and Na
No Fever
sleep adequate
Stools not passed
O:
pt is C/C/C
No signs of pallor, Icterus, clubbing, cyanosis,lymphedenopathy, pedal edema
BP: 120/80mmhg
PR: 82bpm
RR: 16cpm
Temp: Afebrile
Cvs: S1,S2 heard, No murmurs
RS:BAE+
P/A: soft and non tender
CNS: No FND
Neck Examination
Restriction of movements decreased
Neck stiffness -
kernig’s sign -
Brudzinki sign -
Finger finger incoordination absent
Finger nose incoordination absent
Spine tenderness absent
Nystagmus absent
EOM movements absent
Diplopia absent
No Increased ICT features
Cervical LN palpable in Lt occipital triangle
No palpable axillary LN
A:
NECK PAIN-CERVICAL RADICULOPATHY (C5-C6) with Paraspinal Spasm
K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO secondary to Vertebro basilar insufficiency
WITH DENOVO THYROID DISEASE (HYPOTHYRODISM) WITH Left CERVICAL LYMPHEDENOPATHY WITH DENOVO DMII with Migraine
P:
1.INJ. Diclofenac Im/sos
2.T.Dolo 650 mg po/sos
3.T. Nicardia 10 mg po/sos
4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg
5.T. vertin 8 mg po/bd
6.T. Thyronorm 75 mcg po/od
7.T. Metformin 500 mg po/be
8.T. Myoril 2ml IM/BD
9.INJ. Zofer 4mg IV/SOS
10.INJ.PAN 40mg/PO/OD
11.T.PREGABA 75MG/PO/HS
12.T.Clonazepam 0.25mg PO/HS
Case 4
[26/08/23, 2:40:35 PM] Cherish Kandru: Soap notes
S:
Yellowish discolouration of eyes same as yesterday
Abdominal Distension with SOB decreased compared to yesterday
Pedal Edema same as yesterday
No fever Spikes
Stools Passed
O:
pt is C/C/C
BP: 100/80 mmhg
PR: 92bpm
RR: 19cpm
Temp Afebrile
CVS: S1S2 Heard
P/A: Distended Abdomen
Shifting dullness present
Fluid thrill absent
CNS: NFND
A: Chronic Liver Disease
P:
Tab. Furosemide + Aldactone 40/50 PO/OD
Tab. Riifaximin 550 mg PO/OD
Tab. Ursodepxycholic acid 300 mg PO/BD
Syp. Lactulose 15 ml PO/OD
Syp. L-Ornithine L-Aspartate PO/OD
[26/08/23, 2:54:07 PM] Rakesh Biswas Sir: Why Rifaxamin, udca, LOLA!?
What is the evidence of their efficacy?
[27/08/23, 1:21:37 PM] Cherish Kandru: The 23 randomized trials were published between 1984 and 2013. Outcomes were diverse, and patient cohorts highly heterogeneous. Seven randomized trials reported no clinical outcomes or evaluated rifaximin administered for less than 7 days.17,22–28 The remaining trials evaluated long-term treatment or prevention of HE with rifaximin. Twelve randomized trials assessed the effect of rifaximin on overt HE.16,18,19,29–37 Two trials assessed the effect of rifaximin on minimal HE,14,38 and one trial (described in two records) assessed the prophylactic effect of rifaximin on recurrent HE.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964161/
[27/08/23, 1:38:22 PM] Cherish Kandru: Beneficial effects of LOLA have been reported in over 20 randomized controlled clinical trials (RCTs), the findings of the majority of which have been published in peer-reviewed biomedical journals. The present review focuses on patients with cirrhosis and summarizes the results obtained regarding the efficacy of LOLA as indicated in improvement of mental state and lowering of blood ammonia when compared to placebo or no intervention.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6416237/
[27/08/23, 8:07:54 PM] Rakesh Biswas Sir: Just select one randomized controlled trial and discuss that in a PICO format as done by the 2019 batch student in the other group yesterday. Others here can guide
[27/08/23, 8:08:24 PM] Rakesh Biswas Sir: Same as above
[28/08/23, 8:44:28 AM] Cherish Kandru: Population: Patients with previous episodes of overt hepatic encephalopathy (HE) who were nonresponders to lactulose
Intervention: Treatment with rifaximin
Comparison: Placebo or lactulose
Outcome: Reduction in risk of new HE episodes, decrease in hospitalizations due to HE
Duration: Mean treatment duration of 130 days
Results: Number needed to treat of 4 patients to prevent one episode of overt HE; long-term treatment also reduced hospitalizations and HE episodes; reduced portal hypertension and complications in cirrhosis patients; superior to lactulose in reducing HE-related hospitalizations; reduced hospitalization rates and recurrence of HE in maintenance therapy patients
[28/08/23, 8:45:05 AM] Cherish Kandru: Population: Patients with cirrhosis
Intervention: L-Ornithine L-Aspartate (LOLA)
Comparison: Placebo, no intervention, lactulose, rifaximin, probiotics, branched-chain amino acids (BCAAs)
Outcome: Improvement in mental state, reduction of blood ammonia levels
Results: Multiple randomized controlled clinical trials (RCTs) show LOLA's beneficial effects; LOLA superior to placebo in improving mental state and reducing post-prandial ammonia; LOLA effective in patients with overt hepatic encephalopathy (OHE) grades 1 or 2; mixed results for minimal HE (MHE); LOLA beneficial for acute episodes or chronic HE but not MHE in a specific subgroup.
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