2019
Conference title: Patient centred clinical problem solving 2019Workshop Title: Altered sensorium in presence of comorbiditiesGuest faculty: Dr Ambarish Bhattacharya sharing his patientActive participants:Ambarish Bhattacharya -Consultant at Nightingale Hospital,Kolkata, Consultant (medicine) at Spandan Hospital and Consultant at The Apollo Clinic, SaltlakeArvindran Alaga
Fellow, Respiratory Medicine
Dr. Sushma Sapkota Pandey, an Internal Medicine Specialist in Boonville, New York.
Harinder Singh, Professor Otorhinolaryngology, IQ City hospital, Durgapur.
Anupam Halder, AIIMs Bhopal
Nitin Garg, Neurosurgeon, Bhopal
Gaurav Sharma, Orthopedic surgeon, Lucknow
Rakesh Biswas , Prof Medicine, KIMs, NarketpallyPassive participants: 1800 asynchronous online global participants consisting of MBBS and MD students, question senior residents, independent researchers and faculty Professors in global locations but maximum represented from Indian subcontinent as well as Europe, US, AustraliaConversational learning outcomes:Dr Ambarish Bhattacharya presents the patient data:"65yrs male known DM, HTN, COPD, Parkinson's.H/o fall followed by # neck femur. Hemiarthroplasty done. Patient discharged after 4 days on Amoxyclav but found drowsy on discharge so brought to another center and admitted under me. On examination 103F temperature and GCS 12/15, Mild generalized rigidity, anemia, few crepts bilaterally, tenderness in operation site and large bed sore.Gave Paracetamol, fever came down and patient became 15/15 GCS.Thinking of Hospital acquired infection gave him Meropenem + Doxy + Clindamycin for 1 week. But fever recurs as soon as PCM/NSAIDS is stopped.Hb 8, TLC 13500, PLC 200000, ESR 125, CRP 200. Malaria, Dengue, Blood cs, Urine cs all negative. CXR, USG abdomen NAD. Renal and LFT normal.Did CT chest small effusion and small consolation left lower zone. Did CT of operated hip. Small collection near femur. Too little fluid for diagnostic tap.CRP is progressively increasing (now 320) with normal Procal (1) and high Ferritin (5300). TLC was 10500. Albumin 2.4, Sugar well controlled. Now on Colistin + Tigecycline + Linezolid.Orthopedic surgeons say no intervention from their part. Bone marrow planned.Would be grateful for ideas in further management."
Active participants inputs:
Rakesh Biswas, Professor Medicine
How is the patient now? A fever pattern data on regular monitoring would have been useful
Rakesh Biswas Patient has expired
Ultimately got: Arthroplasty associated infection, Aspirated pneumoniae leading to severe sepsis and MODS
Input 2 from Anupam Halder, AIIMs Bhopal
Sir did we find the pathogen a/w sepsis?
Input 3 from Arvindran Alaga
Fellow, Respiratory Medicine
Any Echocardiography was done?
Input 4 from Dr. Sushma Sapkota Pandey, an Internal Medicine Specialist in Boonville, New York.
Did we rule out Stills disease?
Input 5 from Harinder Singh
USG abdomen?
Tarun Chakrabarti
Did you ask for CPK? NMS could be superimposed on sepsis.
Input from Nitin Garg, Neurosurgeon, Bhopal
Ambarish Bhattacharya sorry to hear that the patient expired. Any CSF analysis done as these procedures are done under spinal anaesthesia to rule out meningitis?
Input from Anupam Halder, AIIMS, Bhopal
Sir do we rule out meningitis in absence of any localizing history of meningitis?
Input 7 from Gaurav Sharma, Orthopedic surgeon, Lucknow
Sorry to hear the patient expired...read this message only today...I have been associated with a cardiac centre where I routinely manage ortho cases with such morbidities.
If the duration between the occurance of fracture and admission to hospital is prolonged...such cases very commonly come to hospital with bedsores and a bad chest. Optimization of such patients to near normal..no matter how long it takes to do so...is the key to prevent SIRS n MODS. Also in such cases one has to keep the duration of surgery short.
I wished to throw some light on the prevention part rather than the treatment hence this post
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