Ward notes
ICU
Patient 60 M with diabetes and hypertension admitted with fever, hyperglycemia, acute renal failure, metabolic acidosis, severe shortness of breath and oliguria and urine routine showing pus cells and RBCs. CT abdomen showed emphysematous pyelonephritis with areas of consolidation nodules in both upper lobes.
Incidental detection of left diaphragmatic palsy and mild mitral stenosis on echocardiography.
Intervention: broad antibiotics to also cover nosocomial, supportive inotropes, ventilation
Outcome: multiorgan failure and death
Intrigue: Admiited in corporate Hyderabad 2 months back with similar issues, recovered (with a hefty bill) and discharged on tablet linezolid 500 mg for 12 days. Son said he was in the habit of consuming the same tablet whenever he felt like it. Could this have led to the MDR organism that led to his death?
70 M with right sided pleural effusion and altered sensorium and hyponatremia 124-128 with reduced serum osmolality and increased urine sodium. Currently sensorium recovering although today's sodium was 122. Ecg shows Atrial fibrillation and rate controlled on metoprolol. Right upper limb soft signs of assymetric tone, CT head normal. Cranial MRI planned? Pleural fluid tapped twice suggestive of exudative with lymphocytic pleocytosis
Intervention: first Gen Antibiotics for Pneumonia (still continuing), hypertonic saline, heart rate control and amiodarone, planned for pulmonary opinion for bronchoscopy or empirical antitubercular
Outcome :
Continues to be slightly drowsy though better but bed ridden
Issues: diagnostic dilemma for the pleural effusion for TB vs malignancy
20M with dengue and 30,000 platelets and progressive rise of PCV/HCT
Intervention : Monitoring intake output and fluid support
Outcome : fever chart? Subjectively better
60F with hyperpyrexia and sterile pyuria with WBC 7000
Intervention : IV broad spectrum antibiotics and iv artesunate, temperature monitoring and fever reduction
Outcome? Evolving
FMW: 50F Diabetes with neuropathic pains for blood sugar monitoring and oral hypoglycemic dose titration
MMW 25M with acute ascending quadriparesis, myalgia with no apparent respiratory compromise
Intervention : monitoring single breath count, breath holding time and respiratory rate (chart?), NSAIDs for myalgia (?CPK)
Outcome: Power still grade 3+/5 in all four limbs
Conversational Learning
60M
Pedal edema for 1month orthopnea for 1 day with decreased urineoutput for 1 day
JVP raised cardiac apex down and out
Heart failure with reduced ejection fraction with prostatomegaly
Intervention propped up position
Fluid and salt restriction anti platelets statins
B blocker ace inhibitor
Outcome pedal edema subsided sob subsided
[1/28, 3:39 PM] Rakesh Biswas: Output is good 850ml with input 1lit sir
[1/28, 3:39 PM] Rakesh Biswas: Good. What about his decreased urine output? What was and is the current intervention for that?
[1/28, 3:39 PM] Rakesh Biswas: We are giving tamsulosin as advised by urologist
[1/28, 3:39 PM] Rakesh Biswas: Advised to remove Foley's and want to observe today sir....tamsulosin is aplha blocker..so it relaxes the smooth muscles in prostate and bladder neck
[1/28, 3:39 PM] Rakesh Biswas: So reduced urine output was due to urinary retention? Was he and is he still on a Foley's catheter? In which case how is Tamsulosin helping him?
[1/28, 3:39 PM] Rakesh Biswas: I removed it sir today
[1/28, 3:42 PM] Rakesh Biswas: 17F fever for 1 month
Pedal edema for 10 days
Petechae present in lower limbs
Infective endocarditis
Interventions
Antibiotics
Lasix
Pcm
Temp and vital monitoring
Outcome
Fever subsided
Pedal edema subsided
Petechiae vanishing
[1/28, 3:42 PM] Rakesh Biswas: What supports your diagnosis of infective endocarditis? Can you share her fever chart? It appears that she became afebrile even from Day 1 of her hospital stay?
[1/28, 3:44 PM] Rakesh Biswas: 59M with pedal edema
With hypoglycemic attacks in morning
CKD with dm2 with htn with ?TIA
Intervention fluid and salt restriction
CCB
Lasix
Antiplatelet
Outcome
GRBs 116
No hypoglycemic attacks
[1/28, 3:44 PM] Rakesh Biswas: It appeared to be recurrent hypoglycemia from the history rather than TIA. You didn't mention a very important intervention. You had withheld his oral hypoglycemic which was responsible for his hypoglycemia. Even withholding a prior intervention can be very important intervention in its own right.
[1/28, 3:46 PM] Rakesh Biswas: 65M
Fever for 1 wk sob for 3 days
No fresh complain fever subsided sob subsided
Pneumonia with malaria with dengue with ?oral candidiasis
Intervention broad spectrum antibiotic
Ivfluids
Nebulization
Potassium syrup o2 inhalation
Temp charting
Monitoring vitals
Outcome fever subsided
Sob subsided
[1/28, 3:46 PM] Rakesh Biswas: So which one did this patient actually have although we appeared to have treated him for all possible causes such as malaria, typhoid etc?
[1/28, 3:46 PM] Rakesh Biswas: Pneumonia sir
[1/28, 3:46 PM] Rakesh Biswas: What about the smear taken yesterday from his tongue? Does it show candidal hyphae?
[1/28, 3:46 PM] Rakesh Biswas: Malaria and dengue sir
[1/28, 3:46 PM] Rakesh Biswas: What evidence do we have for pneumonia in him?
[1/28, 3:46 PM] Rakesh Biswas: Which one did he have?
[1/28, 3:46 PM] Rakesh Biswas: I will find out sir
[1/28, 3:46 PM] Rakesh Biswas: First xray showed consolidation sir
[1/28, 3:46 PM] Rakesh Biswas: Both sir...we gave artesunate
[1/28, 3:46 PM] Rakesh Biswas: Can you share that chest X-ray?
[1/28, 3:46 PM] Rakesh Biswas: No treatment for dengue
[1/28, 3:46 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: Doesn't look like either pneumonia or malaria? What about dengue? Any seropositivity there although again not reliable sensitivity, specificity.
[1/28, 3:50 PM] Rakesh Biswas: Lb nagar report is positive
[1/28, 3:50 PM] Rakesh Biswas: Our side no sir
[1/28, 3:50 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: Doesn't it look more like dengue?
[1/28, 3:50 PM] Rakesh Biswas: 10000
15000
30000
60000
75000
1.5 lakh
[1/28, 3:50 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: What was the trend of his platelet counts?
[1/28, 3:53 PM] Rakesh Biswas: Please share his CT head
[1/28, 3:53 PM] Rakesh Biswas: 55M with hemiplegia on rt side due to bleed
Intervention
Anti epileptic
Anti platelet
Statins
Glycerol
DVT stockings
Physiotherapy
Outcome fever present today temp 101 antipyretics given
Power improved in rt upper limb 1/5
Rt lower limb 3/5
[1/28, 3:53 PM] Rakesh Biswas: What is the evidence for glycerol? Why antiepileptics? Did he have a seizure?
[1/28, 3:53 PM] Rakesh Biswas: He did not have seizure sir....
[1/28, 3:53 PM] Rakesh Biswas: Since when is he having the fever? Fever chart?
[1/28, 3:53 PM] Rakesh Biswas: Yday night
[1/28, 3:53 PM] Rakesh Biswas: Then why antiepileptics? Is there any role of prophylactic antiepileptic drugs in intracerebral hemorrhage?
[1/28, 3:53 PM] Rakesh Biswas: Charting was not done properly sir....asked sisters to do it
[1/28, 3:53 PM] Rakesh Biswas: Please share chart. Is it present in the charts that you already shared. Would be nice if you could have cropped the identifiers
[1/28, 3:53 PM] Rakesh Biswas: Can antiplatelets be given in intracerebral hemorrhage?
[1/28, 3:53 PM] Rakesh Biswas: Is the power 1/5 after improvement?
[1/28, 3:53 PM] Rakesh Biswas: Yes sir
[1/28, 3:53 PM] Rakesh Biswas: Power was initially 0/5 in lower limb... Prophylactically I advised sir
[1/28, 3:53 PM] Rakesh Biswas: Why DVT stockings?
[1/28, 3:53 PM] Rakesh Biswas: https://googleweblight.com/i?u=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215779/&hl=en-IN&grqid=mq3cOK46
[1/28, 3:53 PM] Rakesh Biswas: So is was the stocking necessary. Didn't we unnecessarily add to his cost? Also please let me have your answers to the antiplatelets and antiepileptic query
[1/28, 3:53 PM] Rakesh Biswas: When does a patient get DVT? After how many days of immobilization? Did you notice what we did on yesterday's rounds to prevent DVT and improve functionality? We made him sit up, I stand and walk. How's that for a logically more effective DVT prophylaxis?
[1/28, 3:53 PM] Rakesh Biswas: Yes sir we did that and today he is moving his lower limb sitting
[1/28, 3:53 PM] Rakesh Biswas: Also please let me have your answers to the antiplatelets and antiepileptic query
[1/28, 3:53 PM] Rakesh Biswas: Anti epileptics I shared an article sir
[1/28, 3:53 PM] Rakesh Biswas: So what is your interpretation of this study after critical appraisal?
[1/28, 3:53 PM] Rakesh Biswas: We should give sir
[1/28, 3:53 PM] Rakesh Biswas: Why?
[1/28, 3:53 PM] Rakesh Biswas: " 11% of patients placed on a PAED had an early seizure versus 6.3% who not placed on a PAED."
[1/28, 3:53 PM] Rakesh Biswas: What is the type of study?
[1/28, 3:53 PM] Rakesh Biswas: Only reason to give is to reduce mortality
[1/28, 3:53 PM]: How many did not die in the antiepileptic group vs the group that did not get the antiepileptic?
[1/28, 3:53 PM] Otherwise all results were not significant
[1/28, 3:53 PM] : "Death or hospice discharge was less common in patients prescribed a PAED (24% versus 46%, p = 0.02), but this difference was no longer significant after adjustment for multiple comparisons."
[1/28, 3:53 PM]: So any other better evidence that you can search for?
ICU
Patient 60 M with diabetes and hypertension admitted with fever, hyperglycemia, acute renal failure, metabolic acidosis, severe shortness of breath and oliguria and urine routine showing pus cells and RBCs. CT abdomen showed emphysematous pyelonephritis with areas of consolidation nodules in both upper lobes.
Incidental detection of left diaphragmatic palsy and mild mitral stenosis on echocardiography.
Intervention: broad antibiotics to also cover nosocomial, supportive inotropes, ventilation
Outcome: multiorgan failure and death
Intrigue: Admiited in corporate Hyderabad 2 months back with similar issues, recovered (with a hefty bill) and discharged on tablet linezolid 500 mg for 12 days. Son said he was in the habit of consuming the same tablet whenever he felt like it. Could this have led to the MDR organism that led to his death?
70 M with right sided pleural effusion and altered sensorium and hyponatremia 124-128 with reduced serum osmolality and increased urine sodium. Currently sensorium recovering although today's sodium was 122. Ecg shows Atrial fibrillation and rate controlled on metoprolol. Right upper limb soft signs of assymetric tone, CT head normal. Cranial MRI planned? Pleural fluid tapped twice suggestive of exudative with lymphocytic pleocytosis
Intervention: first Gen Antibiotics for Pneumonia (still continuing), hypertonic saline, heart rate control and amiodarone, planned for pulmonary opinion for bronchoscopy or empirical antitubercular
Outcome :
Continues to be slightly drowsy though better but bed ridden
Issues: diagnostic dilemma for the pleural effusion for TB vs malignancy
20M with dengue and 30,000 platelets and progressive rise of PCV/HCT
Intervention : Monitoring intake output and fluid support
Outcome : fever chart? Subjectively better
60F with hyperpyrexia and sterile pyuria with WBC 7000
Intervention : IV broad spectrum antibiotics and iv artesunate, temperature monitoring and fever reduction
Outcome? Evolving
FMW: 50F Diabetes with neuropathic pains for blood sugar monitoring and oral hypoglycemic dose titration
MMW 25M with acute ascending quadriparesis, myalgia with no apparent respiratory compromise
Intervention : monitoring single breath count, breath holding time and respiratory rate (chart?), NSAIDs for myalgia (?CPK)
Outcome: Power still grade 3+/5 in all four limbs
Conversational Learning
60M
Pedal edema for 1month orthopnea for 1 day with decreased urineoutput for 1 day
JVP raised cardiac apex down and out
Heart failure with reduced ejection fraction with prostatomegaly
Intervention propped up position
Fluid and salt restriction anti platelets statins
B blocker ace inhibitor
Outcome pedal edema subsided sob subsided
[1/28, 3:39 PM] Rakesh Biswas: Output is good 850ml with input 1lit sir
[1/28, 3:39 PM] Rakesh Biswas: Good. What about his decreased urine output? What was and is the current intervention for that?
[1/28, 3:39 PM] Rakesh Biswas: We are giving tamsulosin as advised by urologist
[1/28, 3:39 PM] Rakesh Biswas: Advised to remove Foley's and want to observe today sir....tamsulosin is aplha blocker..so it relaxes the smooth muscles in prostate and bladder neck
[1/28, 3:39 PM] Rakesh Biswas: So reduced urine output was due to urinary retention? Was he and is he still on a Foley's catheter? In which case how is Tamsulosin helping him?
[1/28, 3:39 PM] Rakesh Biswas: I removed it sir today
[1/28, 3:42 PM] Rakesh Biswas: 17F fever for 1 month
Pedal edema for 10 days
Petechae present in lower limbs
Infective endocarditis
Interventions
Antibiotics
Lasix
Pcm
Temp and vital monitoring
Outcome
Fever subsided
Pedal edema subsided
Petechiae vanishing
[1/28, 3:42 PM] Rakesh Biswas: What supports your diagnosis of infective endocarditis? Can you share her fever chart? It appears that she became afebrile even from Day 1 of her hospital stay?
[1/28, 3:44 PM] Rakesh Biswas: 59M with pedal edema
With hypoglycemic attacks in morning
CKD with dm2 with htn with ?TIA
Intervention fluid and salt restriction
CCB
Lasix
Antiplatelet
Outcome
GRBs 116
No hypoglycemic attacks
[1/28, 3:44 PM] Rakesh Biswas: It appeared to be recurrent hypoglycemia from the history rather than TIA. You didn't mention a very important intervention. You had withheld his oral hypoglycemic which was responsible for his hypoglycemia. Even withholding a prior intervention can be very important intervention in its own right.
[1/28, 3:46 PM] Rakesh Biswas: 65M
Fever for 1 wk sob for 3 days
No fresh complain fever subsided sob subsided
Pneumonia with malaria with dengue with ?oral candidiasis
Intervention broad spectrum antibiotic
Ivfluids
Nebulization
Potassium syrup o2 inhalation
Temp charting
Monitoring vitals
Outcome fever subsided
Sob subsided
[1/28, 3:46 PM] Rakesh Biswas: So which one did this patient actually have although we appeared to have treated him for all possible causes such as malaria, typhoid etc?
[1/28, 3:46 PM] Rakesh Biswas: Pneumonia sir
[1/28, 3:46 PM] Rakesh Biswas: What about the smear taken yesterday from his tongue? Does it show candidal hyphae?
[1/28, 3:46 PM] Rakesh Biswas: Malaria and dengue sir
[1/28, 3:46 PM] Rakesh Biswas: What evidence do we have for pneumonia in him?
[1/28, 3:46 PM] Rakesh Biswas: Which one did he have?
[1/28, 3:46 PM] Rakesh Biswas: I will find out sir
[1/28, 3:46 PM] Rakesh Biswas: First xray showed consolidation sir
[1/28, 3:46 PM] Rakesh Biswas: Both sir...we gave artesunate
[1/28, 3:46 PM] Rakesh Biswas: Can you share that chest X-ray?
[1/28, 3:46 PM] Rakesh Biswas: No treatment for dengue
[1/28, 3:46 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: Doesn't look like either pneumonia or malaria? What about dengue? Any seropositivity there although again not reliable sensitivity, specificity.
[1/28, 3:50 PM] Rakesh Biswas: Lb nagar report is positive
[1/28, 3:50 PM] Rakesh Biswas: Our side no sir
[1/28, 3:50 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: Doesn't it look more like dengue?
[1/28, 3:50 PM] Rakesh Biswas: 10000
15000
30000
60000
75000
1.5 lakh
[1/28, 3:50 PM] Rakesh Biswas: Yes sir
[1/28, 3:50 PM] Rakesh Biswas: What was the trend of his platelet counts?
[1/28, 3:53 PM] Rakesh Biswas: Please share his CT head
[1/28, 3:53 PM] Rakesh Biswas: 55M with hemiplegia on rt side due to bleed
Intervention
Anti epileptic
Anti platelet
Statins
Glycerol
DVT stockings
Physiotherapy
Outcome fever present today temp 101 antipyretics given
Power improved in rt upper limb 1/5
Rt lower limb 3/5
[1/28, 3:53 PM] Rakesh Biswas: What is the evidence for glycerol? Why antiepileptics? Did he have a seizure?
[1/28, 3:53 PM] Rakesh Biswas: He did not have seizure sir....
[1/28, 3:53 PM] Rakesh Biswas: Since when is he having the fever? Fever chart?
[1/28, 3:53 PM] Rakesh Biswas: Yday night
[1/28, 3:53 PM] Rakesh Biswas: Then why antiepileptics? Is there any role of prophylactic antiepileptic drugs in intracerebral hemorrhage?
[1/28, 3:53 PM] Rakesh Biswas: Charting was not done properly sir....asked sisters to do it
[1/28, 3:53 PM] Rakesh Biswas: Please share chart. Is it present in the charts that you already shared. Would be nice if you could have cropped the identifiers
[1/28, 3:53 PM] Rakesh Biswas: Can antiplatelets be given in intracerebral hemorrhage?
[1/28, 3:53 PM] Rakesh Biswas: Is the power 1/5 after improvement?
[1/28, 3:53 PM] Rakesh Biswas: Yes sir
[1/28, 3:53 PM] Rakesh Biswas: Power was initially 0/5 in lower limb... Prophylactically I advised sir
[1/28, 3:53 PM] Rakesh Biswas: Why DVT stockings?
[1/28, 3:53 PM] Rakesh Biswas: https://googleweblight.com/i?u=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215779/&hl=en-IN&grqid=mq3cOK46
[1/28, 3:53 PM] Rakesh Biswas: So is was the stocking necessary. Didn't we unnecessarily add to his cost? Also please let me have your answers to the antiplatelets and antiepileptic query
[1/28, 3:53 PM] Rakesh Biswas: When does a patient get DVT? After how many days of immobilization? Did you notice what we did on yesterday's rounds to prevent DVT and improve functionality? We made him sit up, I stand and walk. How's that for a logically more effective DVT prophylaxis?
[1/28, 3:53 PM] Rakesh Biswas: Yes sir we did that and today he is moving his lower limb sitting
[1/28, 3:53 PM] Rakesh Biswas: Also please let me have your answers to the antiplatelets and antiepileptic query
[1/28, 3:53 PM] Rakesh Biswas: Anti epileptics I shared an article sir
[1/28, 3:53 PM] Rakesh Biswas: So what is your interpretation of this study after critical appraisal?
[1/28, 3:53 PM] Rakesh Biswas: We should give sir
[1/28, 3:53 PM] Rakesh Biswas: Why?
[1/28, 3:53 PM] Rakesh Biswas: " 11% of patients placed on a PAED had an early seizure versus 6.3% who not placed on a PAED."
[1/28, 3:53 PM] Rakesh Biswas: What is the type of study?
[1/28, 3:53 PM] Rakesh Biswas: Only reason to give is to reduce mortality
[1/28, 3:53 PM]: How many did not die in the antiepileptic group vs the group that did not get the antiepileptic?
[1/28, 3:53 PM] Otherwise all results were not significant
[1/28, 3:53 PM] : "Death or hospice discharge was less common in patients prescribed a PAED (24% versus 46%, p = 0.02), but this difference was no longer significant after adjustment for multiple comparisons."
[1/28, 3:53 PM]: So any other better evidence that you can search for?
