CBBLE case report open EMR with integrated PaJR PHR data : A 60 year old woman covid like viral with severe heart failure due to trunkal obesity comorbidities and her subsequent outcomes

Summary : A 60 year old woman, living alone in a straw hut in a remote village, at a distance from our hospital is admitted with a covid like viral illness but has multiple comorbidities from her trunkal obesity because of which she has a stormy course in the hospital with mechanical ventilation, nosocomial sepsis, cardiac arrest, recovery after CPR followed by tracheostomy and more ventilation and eventual discharge followed by some informational continuity in her PHR where the family shared her local doctor doing the bed sore dressing. 

The PHR, patient journey record PaJR transcripts below reflect the diagnostic and therapeutic uncertainties around the patient and their resolution through team based learning. 

Keywords : http://userdrivenhealthcare.blogspot.com/2023/11/glossary-of-user-driven-healthcare.html?m=1

Introduction :

We are introduced to this patient inside her PaJR by one of our post graduate residents who has been anonymized with a different name :

[3/16, 8:35 AM] Pushed Communicator 1N21:

Good morning sir

ICU BED 1

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..

On presentation:

Phenotype :

Vitals

Bp:130/80mmHg

PR:96bpm

RR:26cpm

Temp:100F

Spo2:56%on Room air

96%On high flow oxygen 

RS: NVBS

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..

Ecg:showed NSR

ABG AT PRESENTATION:

PH:7.295

Pco2:96

Po2:68.2

S02:92.6

Hco3:36.7

Kept on NIV(CPAP-VC)

PH:7.267

Pco2:101

Po2:72.2

Spo2:90.4

Hco3:35.4

In view of co2 narcosis and flapping tremors secondary to co2 narcosis,Patient was intubated and connected to ventilator..

Post intubation ABG:

PH:7.57

Pco2:44

Po2:67.3

So2:95.5

Hco3:39.7

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

ABG:

PH:7.338

PCo2:72.1

Po2:74.5

So2:93.6

HCO3:32.3

And as the co2,is increasing reconnected to ventilator..

All other blood investigations are normal..

Secretions from

The oral cavity are thick from day of admission..

Diagnosis:

Type 2 respiratory failure secondary to ?diaphragmatic palsy/resp muscle weakness..

With viral pyrexia..

With k/c/o DM AND HYPERTENSION..

[3/16, 8:35 AM] Pushed Communicator 1N21: X ray on the day of presentation

[3/16, 8:36 AM] Pushed Communicator 1N21: Yesterday’s CXR

[3/16, 8:36 AM] Pushed Communicator 1N21: Today’s CXR

[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…

[3/16, 8:43 AM] Rakesh Biswas: I evaluated this patient yesterday. 

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, 8:44 AM] Rakesh Biswas: Share her serial ABGs

[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, 8:47 AM] Rakesh Biswas: 👆this too in her fever Chart

[3/16, 8:49 AM] Pushed Communicator 1N21: Day 1 ABG ,On the Day of admission

[3/16, 8:49 AM] Pushed Communicator 1N21: After 2 hours of admission (after keeping her on NIV)

[3/16, 8:50 AM] Pushed Communicator 1N21: After 12hrs of Post intubation

[3/16, 8:50 AM] Pushed Communicator 1N21: Abg On T piece

[3/16, 8:50 AM] Pushed Communicator 1N21: On NIV-VC

[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, 8:54 AM] Pushed Communicator 1N21: Yes sir

Asked the Granddaughters to come today sir…

[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

 https://userdrivenhealthcare.blogspot.com/2022/02/a-young-man-with-severe-hypertension.html?m=1

[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 MANAGEMENT.AS PATIENT IS IMPROVING WEAN 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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: 0123456 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  :

https://youtube.com/shorts/ScsfM1ISm9w?feature=shared

Last and final PaJR update on 21 May, 2024 :

Till now her younger son was taking care of her and yesterday she went to her elder son’s home ,where she was alone as they went to some other place and suddenly early in the morning at 3am, she collapsed in the bathroom and passed away.

No one was  there to help her at that time.