Boudhayan sir we have a patient in 'intensive-care' who apparently seems to have been affected by P.falciparum though we havent been able to confirm it yet through the tests done . He is on antibiotics since Friday but his condition has not improved . What do you think we should do?
Boudhayan, Aadipta is looking after the 'intensive-care' patient and will share some ideas about how to further crack the puzzle of his 'pyrexia of unknown origin,' PUO as it persists relentlessly ( i wish Aadipta could have shared his fever chart after having put it in his online-record. Adwaya will tell us more about the patient who had torsades-de-pointes and is currently admitted again
Yes he is being given some water through the RT but we shall institute some RT feeds tomorrow. We have begun Artesunate in the evening rounds yesterday. His RR is 50 and fever spikes are persistent 101-102. His last USG was normal and we are repeating it today/tomorrow. Problem is i do not have any access to the file from here
Nothing on the CT brain (as far as i can remember but i do need to see the file). Unlikely to be due to RT or foleys but we could try changing the Foleys tomorrow and sending a urine C/s after 6 hours of removing the foley's and perhaps during re-insertion. The tip cultures are no longer recommended
Initially disease process later it seemed to have subsided and currently again begun since last 2 days so this one could be antibiotic induced but again its all based on sketchy history by brothers and there is no correlation between their version and the relatives
Thanks for continuing this discussion everyone. :-) I slept on the patient and when i woke up today morning i was thinking about the source of his PUO and suddenly remembered he had a pace maker and perhaps his infection could be related to the pacemaker leads that are supposed to be touching his myocardium? I quote from this gudeline from Cardiological society of India, "Device infection
can also occur months to years after the implantation, especially in thin built and elderly
patients, where the pacemaker gradually erodes through its subcutaneous pocket and
becomes adherent to the overlying skin with subsequently infection and extrusion.
Hence important pointers towards a device-related infection are if:
1. The patient presents with PUO weeks to months after device implantation.
2. The patient has recurrent unexplained episodes of pneumonitis.
3. There is evidence of local infection at the pacemaker site.
A trans-thoracic echocardiogram (and if needed a trans-esophageal echocardiogram as
well) should be done in all cases to rule out right heart endocarditis in cases with gross
pacemaker site infection and sepsis.
Vaibhav please add other interested students here. Or copy paste all the discussions above into a WhatsApp group frequented by other students. This way teachers and students who use different online platforms can still remain in touch and learn from each other better.
Hope you can share all the online activity that we share with you other interested batchmates through the WhatsApp platforms they frequent? Again i guess it would be best to blog all the separate online discussions we have been having in one place and then share that link? I guess i may have to do that when i find the time. :-)
Here's the blog link: http://userdrivenhealthcare.blogspot.in/2016/10/early-clinical-exposure-from-3rd.html to what we have discussed so far (along with some initial theory behind this activity. I have removed Aadipta's fever chart image as the paitent's identifier was visible there and i am looking forward to Aadipta's (or any of us) preparing this patient's report on an urgent basis today in a blog after removing the patient's identifiers and obtaining informed consent today.
You can share the above link along with all the other students in your WhatsApp group (as it hopefully contains a large amount of the necessary information in one place) although i shall be looking forward to getting all our current admitted (and some OPD patient's) into their individual online health records (blogs) so that we can learn more about how to help them online.
Wonderful ....... So happy to see such motivated students here ..... Sorry had slept off ..... few things..... I think we need to speak personally to one of the cardiologists for transoesophageal echo....... next we go for CT scan ...... if we think of Pacemaker induced infections do we need to for a Staph specific coverage......ur inputs Sir
But again depends on the mechanism ...... piptaz would have covered depending on the mechanism of production
So guys you are getting to learn abt antibiotic resistance ...... again an exam question but in a practical manner and something u will remember more .... I hope it helps and u realise the importance of practical utility
Aadipta if you are there in the campus can you once check out the procalcitonin values present in the patient's file. Boudhayan let us remember to get the password from the IT department to access all our patient investigations from the online database where it is stored. Yes the CT pancreas is suggestive of a pancreatitis in which case it would be a very atypical presentation of a pancreatitis without much of abdominal pain and near normal amylase. The mystery deepens but we may be coming closer to a diagnosis now. What is the cause of fever in a patient of pancreatitis? The CT doesn't reveal any pancreatic abscess.
I found this, " Serum amylase concentrations
were less than 100 mg. of glucose per 100 ml. of serum
on three occasions. " interesting in the gut article you shared. I wonder what it means. Perhaps some old school way of measuring amylase. Now i am getting interested in Biochemistry. Aadipta can we add your Biochem teachers here? Oh do you all have any other exam tomorrow?
Yes Boudhayan means those articles may appear hi fi but they are not that hi fi (so don't be scared). Just think of the patient and how these pieces of information (yes just think of them as pieces of information instead of hi-fi articles) matches your patients and what useful benefit you can derive to implement in your patient from these pieces of information.
26/10/16 Aadipta: 1) what should have been our line of treatment for that patient if we knew on the first day that he had acute pancreatitis?
Answer: This: http://www.cghjournal.org/article/S1542-3565(12)00520-4/fulltext. Simple isn't it. :-) Well but we reviewed the CT abdomen and it appears that the pancreas wasn't that bad after all. :-) Mild pancreatitis at best on CT scoring. In another institute ( i doubt if any such currently exists in India, PGI Chandigarh...maybe), this patient would have been autopsied and samples sent from his body to find any infection source through meticulous microbiological analysis and then perhaps we may have gotten a clue as to what killed him. :-( There is one thing that you may have noticed. His WBC counts were in the normal range throughout his illness. Not sure what to make of it though.