- Aadipta Ghosh
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? 
10/24, 9:13pm
Rakesh Biswas
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
10/24, 9:15pm
10/24, 9:16pm
Boudhayan Dm
I am not being able to scroll through the msgs...dont know why
Not being able to go through the chart in details....can u all pls tell abt the fever tracings over last 24 hrs He was on Piperacillin Tazobactum if I am not incorrect
Rakesh Biswas Sir.......Is he still on NPO with the Ryle's tube...What was discussed during rounds today ??- 10/24, 9:24pm
- 10/24, 9:25pm
Rakesh Biswas
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 - 10/24, 9:25pm
- 10/24, 9:26pm
Rakesh Biswas
negative on both counts but again none of the reports are coming in time and just hand collected so again no communication with the lab here - 10/24, 9:26pm
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Rakesh Biswas
No scrolling function at my end too. :-(
Yes and currently we are repeating it to look for any occult abscesses - 10/24, 9:27pm
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Boudhayan Dm
In PUO when we are unable to get anything I suggest we go for a CT Scan of Abdomen and may be Thorax ....I dont think USG will be of any help
Sir did u come yesterday??
besides how has the response been to artesunate
Is the Ryle s tube and Catheter acting as a source of Infection...........Need to change them and may send their tips for Culture
Pls clarify my doubts
What happened to the CT Brain
Has it picked up anything - 10/24, 9:35pm
Rakesh Biswas
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 - 10/24, 9:36pm
Rakesh Biswas
Had asked for a repeat CXR pa today. He was also passing watery stools so asked for a stool C/S - 10/24, 9:36pm
Boudhayan Dm
I know it is not recommended..But sometimes we can get clues in things we discard
Why watery stools? Antibiotic induced?? Had coverage with Metronidazole
Sir u need to discuss protocols at the hospital infection control committee meeting whenever it is next
An urone sample sent usually used to undergo gram's stain, wet mount followed by culture
uncentrifuged sample
I dont think that s the scenario here - 10/24, 9:44pm
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Boudhayan Dm
what happened to peripheral blood smear
plus what is the temp profile after starting artesunate - 10/24, 9:52pm
Rakesh Biswas
Yes Aadipta discussed the peripheral smear with his pathology teacher today (name Aadipta?) and it appeared to be normal
Will have to check in the file tomorrow. Wish we have online access to it. :-( - 10/24, 9:52pm
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Rakesh Biswas
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 - 10/24, 9:55pm
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Rakesh Biswas
Now i am able to scroll up and yes we came yesterday and picked up Adwaya from SEPCO with our ambulance. :-) - 10/24, 9:55pm
- 10/24, 9:56pm
Rakesh Biswas
Alright we go for a CECT of his abdomen tomorrow. Adwaya did you see the CECT of the pancreatitis patient?
Began Doxy today
Although again not sure of its role when we have already given the broadest coverage possible with Piptaz. Aadipta could you take a look at what organizms are covered by piptaz? - 10/24, 9:57pm
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Boudhayan Dm
Again are we dealing with an infectious process or a non infectious process
Se procalcitonin was WNL as far as i remember - 10/24, 10:04pm
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Boudhayan Dm
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Boudhayan Dm
Be there with Nidhi Madam and ask her all ur doubts during the procedure if u can...That would be a gr8 way of learning
I do that even now - 10/24, 10:53pm
- 10/24, 10:54pm
Boudhayan Dm
whats the fever chart or temperature trend for today guys
So how many of u attended class today
i hope the references are useful - 10/24, 10:55pm
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Boudhayan Dm
Now read up the chapter on Penicillins and cephalosporins.............U will get more insight into Ceftriaxone and Tazobatum
also read up Metronidazole - 10/24, 10:58pm
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Boudhayan Dm
Also read up Sepsis from Robbins and Urinary tract infection
that covers ur pathology
read up benign prostatic hyperplasia from Patho - 10/24, 10:59pm
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Boudhayan Dm
Now u will understand better
Also read abt the drugs used so far in this patient like metoclopromide
pantoprazole - 10/24, 11:06pm
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Adwaya Das
Sir the 52 yr lady with a past history of cardiac arrest,pleural effusion,atrophic kidney, indigestion and vomiting is reporting of fever today
I m referring to the patient with Torsades de pointes. - 10/24, 11:23pm
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Boudhayan Dm
Plus she has been in and out of the hsopital over the last two weeks
when was she diagnosed as SLE
SLE cannot be past - 10/24, 11:25pm
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- Tuesday
- 10/25, 7:37am
Rakesh Biswas
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. - 10/25, 7:38am
Rakesh Biswas
I think we need a cardiac consultation today and ask them to do a transesophageal echocardiography. - 10/25, 7:43am
Rakesh Biswas
Also Vaibhav, can you and Novoneel paste your patient's history (that you took in word and Novoneel in ppt) into a blog so that they can be shared more widely? Please remove the patient identifiers as per these http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528047/figure/fig1/ HIPAA guidelines on how to remove 19 potential patient identifiers before sharing online. Also even more important is to take a signed informed consent from the patient and here's :http://www.udhc.co.in/STATICS/docs/udhc-bengali.pdf, http://www.udhc.co.in/STATICS/docs/udhc-hindi.pdf, http://www.udhc.co.in/STATICS/docs/udhc-english.pdf the link to the consent form in Bengali, Hindi, English. - 10/25, 7:45am
Rakesh Biswas
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. 
10/25, 7:46am
Vaibhav Kapoor
Sure, Sir. I dont think that the signed consent will be possible because the patient has already been discharged .- 10/25, 7:46am
Rakesh Biswas
Off course the history that you took cannot be blogged till you manage to get the patient's informed signed consent but Nobhoneel's patient is still in the ward and his consent can be takeh. - 10/25, 7:46am
Rakesh Biswas
This is one reason you need to take the address, mobile number of the patient so that you can complete some of the earlier missed details later. :-) - 10/25, 7:47am
Vaibhav Kapoor
Yes sir, will look into that. Sure sir, wasn't aware of the necessary details to be taken before, will do that in the upcoming histories. - 10/25, 7:48am
Rakesh Biswas
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. :-) - 10/25, 7:49am
10/25, 7:50am
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Rakesh Biswas
Yes please do and let me summarize what has been discussed in the last few days with all of you in a blog and i shall share that link too - 10/25, 7:50am
- 10/25, 7:50am
Rakesh Biswas
Yes Navoneel it should be fairly easy for you to copy paste the excellent history (minus the patient identifiers) that you took yesterday into a blog (after taking the patient's consent). - 10/25, 7:51am
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Rakesh Biswas
Let me see if i can do it in the next 5 minutes before i set off for the hospital. :-) - 10/25, 7:52am
TueVaibhav changed the chat colors
TueVaibhav changed the chat colors
- 10/25, 8:04am
Rakesh Biswas
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. - 10/25, 8:06am
Rakesh Biswas
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. - 10/25, 8:08am
Boudhayan Dm
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 - 10/25, 8:15am
Aadipta Ghosh
We have been using broad spec antibiotics . why havent they worked and if we have pacemaker induced staph infections response should have been started against staph - 10/25, 8:17am
Boudhayan Dm
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 - Tuesday
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Boudhayan Dm
Well 3rd semester team members let us discuss the role of lab parameters ....raised lipase with minimally raised Amylase with normal TLC but raised CPK - but with normal Procalcitonin
So can someone come up with the physiology and biochemistry of Lipase and Amylase - 10/25, 6:13pm
Aadipta Ghosh
Procalcitonin values would give an understanding about the prognosis of antibiotics in sepsis - 10/25, 6:55pm
Boudhayan Dm
We are dealing with a necrotic pancreas I believe...... though I am not an expert in Radiology.......Will wait for Sir s comments
Patient is presently on Piperacillin Tazobactum
I am more used to using meropenem or imipenem cilastin in such cases - 10/25, 7:07pm
- 10/25, 7:19pm
Rakesh Biswas
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. - 10/25, 7:42pm
Boudhayan Dm
As far as I remember patient had tenderness bit no pain
but
during my initial examination
last Tuesday
minimally raised Amylase with elevated Lipase is more a feature of Chronic Pancreatitis
Did we check his lipid profile
is there anything to Suggest the cause of pancreatitis
article ta access hochche na..Could u pls send the full article - 10/25, 7:57pm
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Rakesh Biswas
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? - 10/25, 8:04pm
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Rakesh Biswas
Did our patient have an "abdominal compartment syndrome (ACS)." This is from the article Boudhayan shared here: http://www.cghjournal.org/article/S1542-3565(12)00520-4/fulltext - 10/25, 8:19pm
Boudhayan Dm
if we go through the PIPTAZ article then probabaly we hastened a bit in changing to a Carbapenem
probably
neglect typos pls - 10/25, 8:22pm
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Boudhayan Dm
Guys I know the articles are a bit hi fi for u all at this level
So we can come to the issues one by one
Let us start by what we have actually seen
It would be nice if I could have taken u to the console room and shown u the CT findings....will do that tomorrow - 10/25, 8:33pm
Rakesh Biswas
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. - 10/25, 10:47pm
10/25, 10:59pm
- 10/25, 11:29pm
Boudhayan Dm
Would Invite our faculty from IQCT to discuss the reasons for normal Amylase in abt 1/5 th of the patients as per ACG guidelines in acute pancreatitis
For a clinician the time we order the tests is of utmost importance
the time in relation to the disease process - 10/25, 11:39pm
Boudhayan Dm
to help the third term students to complete their third term subjects....Here s the chapter from Robbins textbook of pathology - 10/25, 11:42pm
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Boudhayan Dm
just like Arindam Sir bollen u all can read up the chapter on Shock from Robbins ...attaching the file for ur online learning
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.
1 comment:
Long thread.. I may have missed some things but sounds like a case of PUO that has CT scan suggestion of pancreatitis but not clinical features. Wonder if there was pancreatic mass (if no other etiology identified.. I cannot see the images). Also, a non-infectious cause of fever to consider would be VTE in patients with pancreatitis/mass.
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