A 50 years old female,came on 13th,march, with complaints of Fever since 6 days and Shortness of breath since 1 day..
She was asymptomatic 10 yrs ago and then developed giddiness for which she was taken to hospital and was diagnosed with diabetes and hypertension…
5 years ago,she was admitted in the hospital,for ?sepsis ,documentation not available..
1 week ago she developed fever ,high grade,continuous not relieved on meditation,and sudden onset SOB since morning for which she went to local hospital,and in that hospital Her saturation was ,48% on room air, and 96% on high flow oxygen ,and was brought here for further management,at 7pm on 13th march..
K/c/o Diabetes and hypertension on medication not known..
No addictions.
She lives with granddaughters,here in NKP,now the attenders who brought her here are son and daughter in law,who lives in hyd..
crepts present in ,Right mammary,right Infrascapular area..
And she is having intermittent moments of bilateral upperlimbs,each lasting for 5–10seconds,once every 10minutes..
In view of co2 narcosis and flapping tremors secondary to co2 narcosis,Patient was intubated and connected to ventilator..
On,ACMV mode patient has a Decreasing trends of co2,and as the patient is obeying commands,and as the CXR got cleared,we thought of extubating and on T-piece,yesterday night
And as the co2,is increasing reconnected to ventilator..
All other blood investigations are normal..
The oral cavity are thick from day of admission..
Type 2 respiratory failure secondary to ?diaphragmatic palsy/resp muscle weakness..
With viral pyrexia..
With k/c/o DM AND HYPERTENSION..
[3/16, 8:38 AM] Pushed Communicator 1N21: We are not coming to the conclusion of the cause of her type 2 respiratory failure sir..
Initially we thought pneumonia as a cause,but now her lung pathology also got resolved,but on trying to wean off from ventilator,her Co2 levels are increasing…
All her problems are from heart failure pulmonary edema from HFpEF was my conclusion.
Persistent hypoventilation is difficult to explain but is it due to neuroparalysis where the neuroparalytic agent given during initiation of ventilation is still not getting excreted due to her associated renal dysfunction?
[3/16, 8:44 AM] Rakesh Biswas: If we think this video is showing a seizure we'll need to get an EEG asap
[3/16, 8:46 AM] Pushed Communicator 1N21: But her renal parameters are normal sir even her input and output are also normal,
And the patient is not getting sedated and paralysed completely by our infusions sir..
[3/16, 8:47 AM] Rakesh Biswas: Share the serial daily renal parameters including input output in her fever Chart
[3/16, 8:49 AM] Pushed Communicator 1N21: After 2 hours of admission (after keeping her on NIV)
[3/16, 8:52 AM] Rakesh Biswas: Thanks! Looks like persistent hypoventilation even before being ventilated and after getting de escalated from ventilation
Will need to review the history keeping in mind any poisoning such as organophosphorus causing neuroparalysis
[3/16, 10:35 AM] Pushed Communicator 1N21:
Her serial ABGS sir @Rakesh Biswas
[3/17, 9:17 AM] Pushed Communicator 1N21: Mrng abg
[3/17, 9:36 AM] Unknown Medical Student: 17/3/24 Morning 6am abg
[3/17, 10:06 AM] Pushed Communicator 1N21: Add input/output also
[3/17, 11:57 AM] Pushed Communicator 1N21: @Unknown Medical Student
Post the conversation done about the pt with their grand daughters yesterday
[3/17, 12:07 PM] Unknown Medical Student: History from granddaughter Through phone call
Patient unemployed cooks and take care of their granddaughters
One granddaughter is studying 6th grade and other 3rd grade
She buys groceries from the pension she receives
She was apparently alright until last month and had productive cough first (don’t remember exactly how many days ago it started) before Shivaratri she had fever and her granddaughter insisted to go to hospital but she didn’t go and took paracetamol at home. On Sunday she went to hospital with complains of fever cough and sob and rest history they are not aware much after what happened in the hospital
Diet - non vegetarian
Doesn’t eat bottle guard
Drinks alcohol occasionally once a month or on festival only when her sons bring it for her
No history of any snake or Scorpion bites
[3/17, 12:07 PM] Unknown Medical Student: Electrolytes are here
[3/17, 4:24 PM] Rakesh Biswas: Also the WBC counts from Day 1
[3/17, 4:29 PM] Rakesh Biswas: Also the subjectivity from Day1 and essentially make it a soap column
[3/18, 9:58 AM] Unknown Medical Student: 18/3 8am ABG
[3/18, 11:31 AM] Rakesh Biswas: Ventilation settings?
[3/18, 11:32 AM] Unknown Medical Student: During abg
Mode: acmv vc
Tv: 420
Fio2: 40
Peep:5
Rr:14
[3/18, 11:42 AM] Rakesh Biswas: Any spontaneous respiration noted in the monitor?
[3/18, 11:42 AM] Rakesh Biswas: When do we plan to switch to weaning trial?
[3/18, 2:05 PM] Unknown Medical Student: Today sir
[3/23, 8:14 AM] Pushed Communicator 1N21: Todays CXR @Rakesh Biswas sir
[3/23, 8:57 AM] Rakesh Biswas: Reflects yesterday's worsening of her heart failure to account for her intermittent appearance and disappearance of this phantom in her chest X-ray since admission?
And heart failure is somehow influencing her hypoventilation?
[3/25, 7:50 AM] Pushed Communicator 1N21: Tracheostomy Done on 23rd sir
[3/25, 7:52 AM] Pushed Communicator 1N21: Today mrngs ABG on SIMV mode
[3/25, 7:55 AM] Rakesh Biswas: FiO2?
[3/25, 7:56 AM] Pushed Communicator 1N21: 30% sir
[3/25, 8:09 AM] Rakesh Biswas: Eagerly await the results of her first weaning trial
[3/25, 8:51 AM] Rakesh Biswas: Is that a cavity opening up or just the phantom tumor playing tricks!
[3/25, 12:15 PM] Pushed Communicator 1N21: On CPAP
[3/25, 6:09 PM] Pushed Communicator 1N21: On T piece 2L of oxygen sir
[3/25, 6:44 PM] Rakesh Biswas: After how many hours of T piece?
[3/25, 6:45 PM] Unknown Medical Student: 2:15pm tpiece sir
6pm abg
[3/26, 8:41 AM] Rakesh Biswas: Thanks! Wish we had the previous Echo video to compare and assess the recovery of her LV function
[3/26, 10:15 AM] Unknown Medical Student: 7am abg with 1ltr o2
[3/26, 10:23 AM] Unknown Medical Student: Sorry sir shared
[3/26, 10:23 AM] Unknown Medical Student: Wrong one
[3/26, 10:23 AM] Unknown Medical Student: This is the correct
[3/26, 10:23 AM] Rakesh Biswas: Are we giving her too much of oxygen!!??
Just went to the ICU and noticed the SpO2 at 100!!
That can take her ventilatory drive away?
[3/26, 10:24 AM] Unknown Medical Student: 7am abg with 1ltr o2
[3/26, 10:24 AM] Rakesh Biswas: I nearly had heart failure
Echo 1:
https://youtu.be/e5wDjyQB1EE?feature=shared
Echo 2:
https://youtu.be/pKUKv4KlStI?feature=shared
[3/26, 10:30 AM] Rakesh Biswas: Thanks
On eyeballing this and comparing it with yesterday's, there appears to be better movement of her interventricular septum now than previous
[3/26, 10:33 AM] Rakesh Biswas: Saw this again
The poor ventricular contractility persists even yesterday
[3/27, 8:58 AM] Pushed Communicator 1N21: Morning CXR sir
[3/27, 9:02 AM] Rakesh Biswas: The phantoms have climbed down for the first time!
[3/27, 9:05 AM] Rakesh Biswas: Similar phantoms in a past patient logged by our ex senior Resident Dr Zain here
[3/30, 8:59 AM] Pushed Communicator 1N21: Room air ABG sir
[3/30, 9:04 AM] Rakesh Biswas: Can we now reflect upon and explain all her post admission events in retrospect?
[3/31, 6:52 PM] Pushed Communicator 1N21:
No sir
I can’t
Can you help me sir
Am still unable to trace,the cause sir..
[3/31, 7:02 PM] Pushed Communicator 1N21: All credits to our SR @Vamsi K 2020 Kims PG Med sir ..
Sir😅
[3/31, 7:03 PM] Unknown Medical Student: Yes sir this success story is because of Vamsi sir purely
[3/31, 7:42 PM] Rakesh Biswas: Please share more about those "intervention" events.
That may also throw more light on how we may join the dots in her sequence of events
[3/31, 7:43 PM] Rakesh Biswas: Can you plot the major events post admission with date and time?
That would be the first step and would help me to help you.
[3/31, 7:55 PM] Vamsi K 2020 Kims PG Med: No it's not a single person's credit himaja
It's the people of general medicine dept. who were involved directly or indirectly by following up the patient regularly and managed her successfully to this extent
[3/31, 7:57 PM] Vamsi K 2020 Kims PG Med: One more major thing before us is decannulation and tracheostomy closure
[3/31, 8:00 PM] Unknown Medical Student:
Course :
Abg At Time Of Admission Showed Ph:7.29 Pco2: 98 Po2:69.2 Hco3:45.3.
In View Of Fall In Saturations And Increased Co2 Retention Patient Was Intubated And Connected To Mechanical Ventilator.
On Day 3 Patient Was connected To T Piece And Extubation Trial Was Done. But In View Of Increased Co2 Retention Patient Was Again Sedated And Connected To Mechanical Ventilator Acmv Vc Mode.
Serial Abgs Were Sent And Patient Condition Was Monitored.
Patient Had Grade 2 Bedsore On Left Gluteal Region Gradually Progressed To Right Gluteal Region. Surgery Referral Was Taken And Regular Bed Sore Dressings Wer Done.
Hrct Was Done And Hrot Showed Consolidation With Mild Bronchiectasis In Basal Segments Of Right Lower Lobe. Bilateral Mild Loculated Pleural Effusion/Right>Leftigradually
Planned For Extubation And On Day 9 Patient Was Extubated After Fulfilling Extubation Criteria After 30 Minutes Of Extubation Patient Had One Episode Of Gtcs And Fall In Saturations.
Rapid Sequence Intubation Was Done, Patient Had Cardiac Arrest.
One Cycle Of Cpr Was Done And Rosc Achieved. Patient Was Again Connected To Mechnical Ventilator.
On Day 11 Percutaneous Tracheostomy Was Done And Patient Was Gradually Tapered And Maintained On T Piece With One Litre Oxygen.
Us Chest Showed Bilateral Mild Pleural Effusion.
Consolidatory Changes In Right Lung.
Patient is Hemodynamically Stable And Maintaining Saturations At Room Air.
[3/31, 8:01 PM] Vamsi K 2020 Kims PG Med: Sir to be on point we just gave symptomatic & supportive care for her *known pathology (hypoventilation) with unknown etiology (???)* keeping some differentials in mind which were still remained as differentials?
[3/31, 8:02 PM] Pushed Communicator 1N21: Yea sir
@Rakesh Biswas to please help
[3/31, 8:32 PM] Rakesh Biswas: Thanks
Thr above sharing of the sequence of events is a big help and enables to tie up the causality by analyzing her event sequences. There are a lot of missing data here too but I can fill in for that :
Some medical cognition thumb rules or heuristics that may help :
Radiology largely shows us anatomy and to understand the physiological changes happening in the patient, radiology shadows need to be integrated with regular observational data and interpreted accordingly as attempted below
Missing data and hypothesis :
First event was a viral fever.
Comorbidities pre existent were trunkal obesity, metabolic syndrome and underlying coronary vasculopathy due to metabolic syndrome (bored of calling it atherosclerosis)
The hypothesis that the viral fever produced increased demands on her compromised myocardium is a recall bias from the covid era
Building on event data shared above by Haripriya:
By the time she came to us on the day of admission with acute pulmonary edema she was already fatigued and that explains her first ABG showing raised pCO2!
After being stable on the ventilator, her first weaning may have been early before her pulmonary edema subsided and hence she relapsed into fatigue and hypoventilation necessitating repeat acmv.
The second weaning trial was also premature and extubation stress made her pulmonary edema relapse and caused severe hypoxemia, seizures (?due to pre cardiac arrest cerebral hypoxia) followed by cardiac arrest, brilliant save and then to cut a long story short a more gradual weaning on tracheostomy!
Learning points :
1) How do we optimize our ventilator weaning strategies and decide when would be the best time to wean and extubate our patients depending on primary issues necessitating the ventilation in the first place?
2) Phantom shadows in chest X-rays may drive more over testing with 100 more X-rays (such as in one CT chest) especially when we may not be able to integrate patient's radiologic anatomy with their physiology due to lack of meticulous observations and documentation
3) Not every patient of cardiac arrest has a NDE (near death experience) story to tell! Factors driving NDE recall can be an interesting metapsych thesis @Patient Adv 59M CAD Metabolic
This patient is a participant for many of our ongoing PG projects by those working on trunkal obesity and cardiovascular outcomes, Heart failure comorbidities and outcomes, trunkal obesity and biopsychosocial outcomes, respiratory failure outcomes etc.
All the descriptive data and interpretations from this patient needs to be collected and archived for those who are working on the above projects
In the end my above interpretations could be wrong and I shall be grateful for counterviews and queries (triangulation) that can allow us to stand corrected on this patient participant.
Discharge summary from our official EMR written by the interns as part of their day job (Other than the traditional format, one can notice they use caps lock most of the times, not sure if that's a requirement of the official EMR) :
Pay Type
: Credit(AROGYA SREE)
Age/Gender
: 50 Years/Female
Address
Discharge Type: Relieved
Admission Date: 13/03/2024 06:33 PM
Name of Treating Faculty:
DR RAKESH BISWAS HOD
DR VAMSI KRISHNA SR
Diagnosis
TYPE 2 RESPIRATORY FAILURE
Acute pulmonary edema
(RESOLVED at discharge)
HEART FAILURE WITH PRESERVED EJECTION FRACTION
B/L GRADE II BEDSORES
KNOWN CASE OF HYPERTENSION SINCE 5 YEARS KNOWN CASE OF DIABETES SINCE 5 YEARS
Case History and Clinical Findings
50 YEAR woman from a nearby village WAS BROUGHT TO CASUALTY WITH COMPLAINTS OF
FEVER SINCE 5 DAYS COUGH SINCE 4 DAYS
DIFFICULTY BREATHING SINCE 1 DAY
PATIENT WAS APPARENTLY ASYMPTOMATIC UNTIL 5 DAYS AGO THEN HAD COMPLAINTS OF GENERALISED FEVER LOW GRADE NOT ASSOCIATED WITH CHILLS AND RIGOR NO DIURNAL VARIATIONS, INTERMITTENT, GRADUALLY PROGRESSIVE ASSOCIATED WITH COUGH- PRODUCTIVE WHITISH SPUTUM THICK CONSISTENCY, MUCOID, NON FOUL SMELLING, NON BLOOD STAINED, SHORTNESS OF BREATH GRADE 4 MMRC SINCE ONE DAY ,GENERALISED WEAKNESS.
NO COMPLAINS OF ORTHOPNEA,PALPITATIONS,PROFUSE SWEWATING
NO COMPLAINS OF BURNING MICTURITION, INCREASED OR DECREASED URINE OUTPUT, PEDAL EDEMA
NO COMPLAINS OF LOOSE STOOLS, NAUSEA, VOMITINGS NO HISTORY OF ANY MOSQUITO BITE, SCOPRION BITE
PAST HISTORY
HISTORY OF HOSPITALIZATION WITH?DENGUE ?SEPSIS 8 MONTHS AGO KNOWN CASE OF HYPERTENSION SINCE 5 YEARS ON UNKNOWN MEDICATION
KNOWN CASE OF DIABETES ON TAB METFORMIN 500MG AND TAB GLIMIPERIDE 1 MG OD NOT A KNOWN CASE OF TB,THYROID,ASTHMA,CAD,CVA
PERSONAL HISTORY
LOSS OF APPETITE SINCE THREE DAYS DIET-NON VEGETERIAN
BOWEL-CONSTIPATION SINCE THREE DAYS MICTURITION- NORMAL
NO KNOWN ALLERGIES OCCASIONAL ALCOHOLIC NON SMOKER
FAMILY HISTORY
NO SIGNIFICANT FAMILY HISTORY
MENSTRUAL HISTORY HYSTERECTOMY DONE 29YRS AGO
GENERAL EXAMINATION
NO PALLOR ICTERUS CYANOSIS CLUBBING AND LYMPHAEDENOPATHY VITALS AT TIME OF ADMISSION
TEMP-100F PR: 80BPM
BP:130/80MMHG RR: 20CPM
SPO2- 40% AT RA GRBS-221MG/DL
R/S: BILATERAL AIR ENTRY PRESENT CREPTS IN RIGHT MAMMARY, LEFT IAA,ISA CVS: S1S2 HEARD NO MURMURS
P/A: SOFT, NON TENDER CNS: NFND
COURSE IN THE HOSPITAL
THIS IS A CASE OF 50YR OLD FEMALE, CAME WITH COMPLAINTS OF FEVER, SHORTNESS OF BREATH SINCE 4DAYS AND FACIAL PUFFINESS SINCE 3DAYS, WAS EVALUATED INITIALLY AND NECESSARY INVETIGATIONS WERE DONE. AND AS ABG WAS DONE, WHICH SHOWED TYPE II RESPIRATORY FAILURE WITH FLAPPING TREMORS SEEN IN PATIENT SECONDARY ?CO2 NARCOSIS, PATIENT WAS INITIALLY KEPT ON NIV. BUT AS THERE IS NO IMPROVEMENT IN ABG AND AS STILL CO2 LEVELS ARE INCREASING ON NIV, PATIENT WAS INTUBATED I/V/O TYPE II RESPIRATORY FAILURE, AND ON FURTHER INVESTIGATIONS DONE AND HRCT SHOWED CONSOLIDATION WITH ,MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE WAS DIAGNOSED WITH COMMUNITY ACQUIRED PNEUMONIA OF RIGHT MIDDLE AND LOWER LOBE ,HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH A K/C/O T2DM &HYPERTENSION SO ANTIBIOTICS ,DIURETICS , IV FLUIDS AND OTHER SYMPTOMATIC AND SUPPORTIVE TREATMENT WAS GIVEN. DAY 3 PATIENT WAS STARTED WEANING TRIAL AS WEANING CRITERIA WAS MET,BUT COULDNT BE EXTUBATED BECAUSE OF RESPIRATORY DISTRESS AND HYPERCAPNIA WHEN PATIENT IS SHIFTED TO CPAP SO AGAIN SHIFTED BACK TO ACMV AND CONTINUED ON MV SUPPORT. PATIENT WAS EXTUBATED ON DAY 9 OF ADMISSION AS SHE IS COMPLETELY MAINTAINIG ON T PEICE WITHOUT ANY RESPIRATORY DISTRESS OR ANY ABG ABNORMALITIES AND COMPLETELY MET THE EXTUBATION CRITERIA WITH GCS OF E4VTM6. IMMEDIATELY AFTER 30MINS OF EXTUBATION, PATIENT HAD A SEIZURE EPISODE AND AFTER 1HR OF SEIZURE EPISODES, PATIENT DEVELOPED BRADYCARDIA AND WENT INTO CARDIAC ARREST FOLLOWED BY WHICH ROSC ACHIEVED AFTER 1 CYCLE OF CPR. POST REVIVAL AS PATIENT HAD AN EPISODE OF VENTRICULAR TACHYCARDIA, ANTI ARRHYTHMIC MEDICATION WERE GIVEN AND PATIENT WAS RE- INTUBATED. AS THERE IS A NEED A NEED FOR PROLONGED VENTILATOR SUPPORT, PERCUTANEOUS TRACHEOSTOMY WAS PLANNED AND DONE ON DAY 11 OF ADMISSION. THE PATIENT IS NOW ON TRACHEOSTOMY AND ON OTHER CONSERVATIVE MANAGEMENT WITH IV ANTIBIOTICS, ANTIPYRETICS, ANTIEPILEPTICS AND OTHER SUPPORTIVE
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
Investigation HEMOGRAM ON 13/3/24 ON 13/3/24
HB 14
TLC 14000
PLT 2.08
ON 15/3/24 HB 13.1
TLC 10 800
PLT 1.50
ON 16/3/24 HB 13.6
TLC 16000
PLT 1.5 ON 17/3/24 HB 11.9
TLC11 300
PLT 1.20
ON 18/3/24 HB 12.7 TLC12500 PLT1.20 ON 19/3/24 HB 12.0
TLC 9300
PLT 1.20 ON 20/3/24 HB 11.2
TLC 7400
PLT 1.35 ON 22/3/24 HB 11.3
TLC 8600
PLT 2.43 ON 23/3/24 HB 11.1
TLC 6300
PLT 3.14 ON 24/3/24 HB 11.3
TLC 7500
PLT 3.01 ON 27/3/24 HB 12.0
TLC 7200
PLT 3.02
RAPID HBSAG NEGATIVE HIV 1 AND 2 NEGATIVE
RAPID HCV ANTIBODIES NEGATIVE
RFT ON 13/3/24
UREA 42
CREAT 0.7
Na 142
K 4.0
CL 99
I CA 1.15
RFT ON 15/3/24 UREA 30
CREAT 0.9
Na 136
K 3.9
CL 101
RFT ON 15/3/24 UREA 44
CREAT 0.7
Na 143
K 3.6
CL 99
RFT ON 17/3/24 UREA 39
CREAT 0.8
Na 141
K 3.5
CL 96
RFT ON 20/3/24 UREA 18
CREAT 0.6
URIC ACID 2.0
Na 139
K 3.4
CL 96
RFT ON 29/3/24 UREA 29
CREAT 0.7
URIC ACID 3.7
CA 10.0
P 4.3
Na 139
K 3.8
CL 98
LFT ON 13/3/24 TB 1.33
DB 0.46
AST 30
ALT 64
ALP 205
TP 7.9
ALB 3.60
A/G 0.84
LFT ON 17/3/24 TB 2.86
DB 0.91
AST 94
ALT 55
ALP 186
TP 5.6
ALB 2.63
A/G 0.89
LFT ON 20/3/24 TB 1.62
DB 0.44
AST 99
ALT 78
ALP 202
TP 5.3
ALB 2.5
A/G 0.9
RBS 193
LIPID PROFILE
TOTAL CHOLESTEROL 219
TG 326
HDL 42
LDL 130
VLDL 65.2
RBS ON 14/3/24 122 HBA1C 7.0
THYROID PROFILE ON 20/3/24 T3 0.62
T4 11.26
TSH 3.98
ABG - 13/3/24 PH-7.295 PCO2-96 PO2-69.2 SO2-92.6
CHCO3 [PST]C 36.7
ABG - 14/3/24 POST INTUBATION PH-7.363
PCO2- 82.8
PO2-68 SO2-88.6
CHCO3 [PST]C 44.8 ABG - EXTUBATION PH-7.129
PCO2-65 PO2-84 SO2-92.6
CHCO3 [PST]C 20.7. ABG - REINTUBATION PH-7.431
PCO2-39.8 PO2-82.7 SO2-96.9
CHCO3 [PST]C 26
ABG - AFTER TRACHEOSTOMY PH-7.33
PCO2-47.9 PO2- 76.6 SO2-94.2
CHCO3 [PST]C 23.8
ABG - 26/3/24 ON T PIECE 1 L OF O2 PH-7.342
PCO2-44 PO2-64.8 SO2-92.9
CHCO3 [PST]C 23.2 ABG - 27/3/24
PH-7.472 PCO2-27.7 PO2-54.8 SO2-95
CHCO3 [PST]C 20 ABG - 28/3/24
PH-7.461 PCO2-42.7 PO2-57.2 SO2-90.9
CHCO3 [PST]C 30 ABG - 7/4/24
PH-7.445 PCO2-42.3 PO2-61.4 SO2-93.4
CHCO3 [PST]C 28.6
2DECHO VPC +
NO RWMA
MILD AR TRIVIAL TRTRIVIAL MR SCLEROTIC AV NO AS/MS
EF 64 RVSP 36MMHG
GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC FUNCTION IVC 0.8CM
MINIMAL PE
HRCT CHEST
CONSOLIDATION WITH MILD BRONCHIECTASIS IN BASAL SEGMENT OF RIGHT LOWER LOBE BILATERAL MILD LOCULATED PLEURAL EFFUSION [R.L] F/S/O INFECTIVE ETIOLOGY
ET CULTURE- NO GROWTH IS SEEN
BLOOD C/S - NO GROWTH IS SEEN AFTER 1 WEEK OF AEROBIC INTUBATION AND 48 HRS OF AEROBIC INTUBATION
WOUND SWAB C/S - NO GROWTH IS SEEN
USG CHEST - B/L MILD PLEURAL EFFUSION ,CONSOLIDATORY CHANGES IN RIGHT LUNG USG ABDOMEN AND PELVIS GB SLUDGE
MILD IHBRD
PROMINENT CBD
RAISED ECHOGENECITY OF B/L KIDNEYS POST CPR 2D ECHO (CPR DONE ON 21/3/24) NO RWMA
TRIVIAL TR,TRIVIAL AR,TRIVIAL MR MAC,SCLEROTIC AV,NO AS/MS EF= 64%,RVSP= 35MMHG
GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION IVC SIZE (0.9CMS) COLLAPSING
Treatment Given(Enter only Generic Name)
INJ.AUGMENTIN 1.2 GM IV/TID X 7 DAYS INJ. FENTANYL 2 AMP + 46 ML NS
INJ. ATRACURIUM 2 AMP + 45 ML NS INJ.LEVOFLOXACIB X 6 DAYS
INJ.HUMAN ACTRAPID INSULIN S/C TID PREMEALS ACC TO GRBS INJ.HYDROCORT 100MG IV OD
INJ.LASIX 20 MG IV TID IF SBP >100MMHG TAB.GLYCOPYROLATE 0.5 MG PO/TID TAB.HIFENAC SP PO/BD
TAB.FLUVIR 75MG X 6 DAYS TAB.AZITHROMYCIN X 7 DAYS TAB.MONOCEF X 8 DAYS TAB.PAN D 40MG PO/OD TAB.PCM 650 MG PO/BD TAB.PULMOCLEAR PO/BD TAB.MONTEK LC PO/HS TAB.BENFOMET PLUS PO/OD TAB .ULTRACET 1/2 TAB PO/BD TAB.TUS-MD PO/TID SYP.GRILINCTUS 15ML PO/TID SYP.MUCAINE GEL 15ML PO/TID
NEB WITH MUCOMIST 8 TH HRLY , DUOLIN-6TH HOURLY , BUDECORT- 8TH HRLY DICLOFENAC TD PATCH BD
OINT THROMBOPHEBE FOR L/A OINT ZYTEE GEL FOR L/A GRBS 7 POINT PROFILE
SPIROMETRY BREATHING EXERCISE CHEST PHYSIOTHERAPY
ET SUCTIONING POSITION CHANGE BED SORE DRESSING DVT STOCKING
AIR BED
Advice at Discharge
TAB AUGMENTIN 625MG PO BD 1-0-1 X 4 DAYS TAB.GLYCOPYROLATE 0.5 MG PO/TID X 3DAYS TAB LEVIPIL 500MG BD X 3 MONTHS
TAB METFORMIN 500MG PO/BD TO CONTINUE TAB.PAN D PO/OD X 5DAYS
TAB DYTOR PLUS 10/50 PO/OD 1-0-0 TO CONTINUE TAB DYTOR 10 MG PO/OD 0-0-1 TO CONTINUE
SYP CITAL UTI 20ML IN 1 GLASS OF WATER PO/TID 1-1-1 X 5 DAYS TAB DOLO 650MG PO/BD X 3 DAYS
TAB.PULMOCLEAR PO/BD X 7DAYS TAB.MONTEK LC PO/HS X 5DAYS TAB.BENFOMET PLUS PO/ODX 7 DAYS FOROCORT 200MCG 2 PUFFS BD
HOME OXYGEN @ 1-2LITS WHILE SLEEPING SPIROMETRY BREATHING EXERCISE
DAILY BEDSORE DRESSING WITH MEGAHEAL OINT AND CUTICELL SOFT DIET
AMBULATION
Follow Up
REVIEW TO GENERAL MEDICINE OPD 17/04/24 WEDNESDAY/SOS AND SURGEY OPD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In caseof Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 1/4/24 Ward: ICU
Unit:III
Home health care PaJR PHR journey :
The patient's advocate after her discharge sends a video of her bedsore dressing performed by a doctor in her thatched hut :
