PaJR CBBLE collective group shares:
Figure 1: Paper based post admission timeline with prominent fever and sodium event trends
[08/10, 10:57] CBBLE moderator: After 35M who was a patient of clinical complexity around seizures where the diagnostic uncertainty was around hypertensive encephalopathy vs alcohol withdrawal and with time here we have put more weight on hypertension as the key driving force for his seizures (more here: https://medicinedepartment.blogspot.com/2024/10/project-pajr-paper-emr-integration.html?m=1),
while in the next bed this 64F with metabolic syn has a suspicion for stroke as well as overt hyponatremia for her presentation with seizures, @thesis PG 2023 (PI for this project) to note.
Figure 2: reminiscent of the offline bedside discussion on right upper lobe shadow on chest X-ray
[14/10, 15:49] CBBLE moderator: 👆 Getting discharged today?@ 2022 PG Medicine Please pm her IP number with me so that I can collect her EMR summary from S.
@ 2023 please pm me her Hrct images that we discussed today
[14/10, 15:50] CBBLE moderator: 👆 Please share the updated chart @ 2022 PG Medicine @ 2023
[14/10, 15:51] 2022 PG Medicine: She is not getting discharged today sir
We have planned bronchoscopy tomorrow.
[14/10, 15:52] CBBLE moderator: Please pm me her IP number and clinical and radiology images
[14/10, 15:53] CBBLE moderator: I found @2023 had pmed me the Hrct earlier
[15/10, 10:23] CBBLE moderator: One of the previous seizures with clinical complexity archived from PaJR, paper, EMR data here 👇
[16/10, 10:22] CBBLE: Hope to prepare her case report today
[16/10, 10:24] CBBLE: Getting discharged today. Bronchoscopy didn't alleviate the persistent diagnostic uncertainty
Figure 4: paper based file note
Paper:
EMR summary
Age/Gender : 67 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 05/10/2024 08:35 PM
Diagnosis
GENERALISED TONIC CLONIC Seizures SECONDARY TO HYPONATREMIA SECONDARY TO SIADH ?SECONDARY TO PARANEOPLASTIC SYNDROME and COMMUNITY ACQUIRED PNEUMONIA{ RESOLVED }
BEDSORE
K/C/O HYPERTENSION SINCE 8 YRS
Case History and Clinical Findings
PATIENT WAS BROUGHT TO CASUALITY WITH HISTORY OF INVOLUNTARY MOVEMENTS OF BOTH UPPER AND LOWER LIMBS 10 MIN , BACK , WHICH LASTED FOR AROUND 2- 3MIN, ASSOCIATED WITH FROTHING FROM MOUTH PRESENT , BLADDER INCONTINENCE ( URINARY INCONTINENCE +) NOT Associated WITH UPROLLING OF EYES .
NOT Associated WITH TONGUE BITE , POST ICTAL CONFUSION (+) NO H/O OF Similar COMPLAINTS IN THE PAST
H/O BURNING MICTURITION SINCE 4-5 DAYS NOT ASSOCIATED WITH URGENCY OR FREQUENCY
NOT ASSOCIATED WITH ANY FEVER . NO C/O COLD , COUGH
H/O HYPOGLYCAEMIA EPISODES 2-3 DAYS PAST HISTORY
K/C/O HTN SINCE 8-9 AND IS ON REGULAR MEDICATIONS N/K/C/O DM , CAD ,CVA , Epilepsy , TB , ASTHMA . PERSONAL HISTORY:
DIET: VEGITARIAN APPETITE: NORMAL SLEEP: ADEQUATE
BOWEL AND BLADDER :REGULAR ADDICTIONS: NIL
ALLERGIES: NIL GENERAL EXAMINATION:
NO PALLOR,ICTERUS,CYANOSIS,
PR:78BPM RR:22CPM SPO2:95 @ RA GRBS:159
SYSTEMIC EXAMINATION: CVS:S1 S2 HEARD ,NO MURMURS RS:BAE PRESENT
CNS: NFND P/A:SOFT,NT
COURSE IN HOSPITAL: PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE . SERUM OSMOLALITY:216, SERUM SODIUM WAS 108 MEQ/L AND WAS DIAGNOSED AS EUVOLEMIC HYPONATREMIA AND STARTED ON 3% NS@15ML/HR AND SERIAL SODIUM LEVELS MONITORING WAS DONE 6/10/24@8AM:108, @1PM:110 @7PM:114 AS THE PATIENT SENSORIUM WAS NOT IMPROVING TAB TOLVAPTAN WAS ADDED AND SODIUM LEVELS ON 7/10/24 @ 8AM:120, @1PM: 126, @ 8PM:131. ON 8/10/24 @8AM :133. AND SENSORIUM IMPROVED. MRI BRAIN WAS DONE AND SHOWED CHRONIC Microvascular WHITE MATTER ISCHEMIA AND RIGHT MASTOID EFFUSION. HRCT WAS DONE I/V/O OLD PULMONARY KOCHS AND XRAY SHOWED CONSOLIDATORY CHANGES AND SHOWED REACTIVATION OR REINFECTION OF TB. PULMONOLOGIST OPINION WAS TAKEN AND I/V/O HRCT REPORT AND ADVICED TREATMENT. ENT OPINION WAS TAKEN I/V/O RIGHT MASTOID EFFUSION FOR WHICH CT TEMPORAL BONE WAS DONE AND SHOWED RIGHT OTOMASTOIDITIS FOR WHICH CONSERVATIVE TREATMENT WAS GIVEN. PATIENT BECAME DROWSY AND ABG SHOWED PH:7.3, PCO2: 49, PO2:66 AND HCO3: 22 AND WAS STARTED ON NIV SUPPORT. PATIENT IMPROVED AND HEMODYNAMICALLY STABLE HENCE BEING DISCHARGED WITH FOLLOWING ADVICE.
Investigation
RFT 05-10-2024 09:35:PM
Discharge Type: Relieved
Admission Date: 05/10/2024 08:35 PM
Diagnosis
GENERALISED TONIC CLONIC Seizures SECONDARY TO HYPONATREMIA SECONDARY TO SIADH ?SECONDARY TO PARANEOPLASTIC SYNDROME and COMMUNITY ACQUIRED PNEUMONIA{ RESOLVED }
BEDSORE
K/C/O HYPERTENSION SINCE 8 YRS
Case History and Clinical Findings
PATIENT WAS BROUGHT TO CASUALITY WITH HISTORY OF INVOLUNTARY MOVEMENTS OF BOTH UPPER AND LOWER LIMBS 10 MIN , BACK , WHICH LASTED FOR AROUND 2- 3MIN, ASSOCIATED WITH FROTHING FROM MOUTH PRESENT , BLADDER INCONTINENCE ( URINARY INCONTINENCE +) NOT Associated WITH UPROLLING OF EYES .
NOT Associated WITH TONGUE BITE , POST ICTAL CONFUSION (+) NO H/O OF Similar COMPLAINTS IN THE PAST
H/O BURNING MICTURITION SINCE 4-5 DAYS NOT ASSOCIATED WITH URGENCY OR FREQUENCY
NOT ASSOCIATED WITH ANY FEVER . NO C/O COLD , COUGH
H/O HYPOGLYCAEMIA EPISODES 2-3 DAYS PAST HISTORY
K/C/O HTN SINCE 8-9 AND IS ON REGULAR MEDICATIONS N/K/C/O DM , CAD ,CVA , Epilepsy , TB , ASTHMA . PERSONAL HISTORY:
DIET: VEGITARIAN APPETITE: NORMAL SLEEP: ADEQUATE
BOWEL AND BLADDER :REGULAR ADDICTIONS: NIL
ALLERGIES: NIL GENERAL EXAMINATION:
NO PALLOR,ICTERUS,CYANOSIS,
PR:78BPM RR:22CPM SPO2:95 @ RA GRBS:159
SYSTEMIC EXAMINATION: CVS:S1 S2 HEARD ,NO MURMURS RS:BAE PRESENT
CNS: NFND P/A:SOFT,NT
COURSE IN HOSPITAL: PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS AND NECESSARY INVESTIGATIONS WERE DONE . SERUM OSMOLALITY:216, SERUM SODIUM WAS 108 MEQ/L AND WAS DIAGNOSED AS EUVOLEMIC HYPONATREMIA AND STARTED ON 3% NS@15ML/HR AND SERIAL SODIUM LEVELS MONITORING WAS DONE 6/10/24@8AM:108, @1PM:110 @7PM:114 AS THE PATIENT SENSORIUM WAS NOT IMPROVING TAB TOLVAPTAN WAS ADDED AND SODIUM LEVELS ON 7/10/24 @ 8AM:120, @1PM: 126, @ 8PM:131. ON 8/10/24 @8AM :133. AND SENSORIUM IMPROVED. MRI BRAIN WAS DONE AND SHOWED CHRONIC Microvascular WHITE MATTER ISCHEMIA AND RIGHT MASTOID EFFUSION. HRCT WAS DONE I/V/O OLD PULMONARY KOCHS AND XRAY SHOWED CONSOLIDATORY CHANGES AND SHOWED REACTIVATION OR REINFECTION OF TB. PULMONOLOGIST OPINION WAS TAKEN AND I/V/O HRCT REPORT AND ADVICED TREATMENT. ENT OPINION WAS TAKEN I/V/O RIGHT MASTOID EFFUSION FOR WHICH CT TEMPORAL BONE WAS DONE AND SHOWED RIGHT OTOMASTOIDITIS FOR WHICH CONSERVATIVE TREATMENT WAS GIVEN. PATIENT BECAME DROWSY AND ABG SHOWED PH:7.3, PCO2: 49, PO2:66 AND HCO3: 22 AND WAS STARTED ON NIV SUPPORT. PATIENT IMPROVED AND HEMODYNAMICALLY STABLE HENCE BEING DISCHARGED WITH FOLLOWING ADVICE.
Investigation
RFT 05-10-2024 09:35:PM
UREA 20 mg/dl
CREATININE 0.9 mg/dl URIC ACID 2.0 mmol/L
CALCIUM
9.4 mg/dl PHOSPHOROUS 2.0 mg/dl
9.4 mg/dl PHOSPHOROUS 2.0 mg/dl
SODIUM 110 mmol/L POTASSIUM 4.6 mmol/L.CHLORIDE 87 mmol/L
LIVER FUNCTION TEST (LFT) 05-10-2024 09:35:PM
Total Bilurubin 0.25 mg/dl Direct Bilurubin 0.19 mg/dl SGOT(AST) 33 IU/L SGPT(ALT) 20 IU/L ALKALINE PHOSPHATASE 215 IU/L TOTAL
PROTEINS 5.9 gm/dl
ALBUMIN 3.0 gm/dlA/G RATIO 1.02HBsAg-RAPID Negative Anti HCV Antibodies - RAPID 05-10-2024 09:35:PM Non Reactive
COMPLETE URINE
EXAMINATION (CUE) 05-10-2024 09:35:PM
COLOUR Pale yellow
APPEARANCE Clear
REACTION
Acidic
Acidic
SP.GRAVITY 1.010ALBUMIN +SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 2- 4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS
DEPOSITS AbsentOTHERS Nil
SERUM ELECTROLYTES (Na, K, C l) 06-10-2024 05:37:AMSODIUM 108 mmol/L POTASSIUM 4.6 mmol/LRFT 06-10-2024 09:27:AMUREA 25 mg/dlCREATININE 1.1 mg/dlURIC ACID 2.4
mmol/LCALCIUM 8.9 mg/dlPHOSPHOROUS 1.8 mg/dl SODIUM 107 mmol/L POTASSIUM 4.3
mmol/L. CHLORIDE 80 mmol/L
T3, T4, TSH 06-10-2024 12:02:PMT3 0.36 ng/ml T4 13.62 micro g/dllTSH 0.55 micro Iu/mSERUM ELECTROLYTES (Na, K, C l) 06-10-2024 12:02:PMSODIUM 110 mmol/L POTASSIUM 4.1 mmol/L ABG 06-10-2024 12:03:PMPH 7.41PCO2 28.9PO2 44.9HCO3 18.3St.HCO3 19.9BEB -5.1BEecf -
5.4TCO2 39.0O2 Sat 78.8O2 Count 8.8SERUM ELECTROLYTES (Na, K, C l) 06-10-2024
07:00:PMSODIUM 114 mmol/L POTASSIUM 4.4 mmol/L CHLORIDE 84 mmol/L
SERUM ELECTROLYTES (Na, K, C l) 07-10-2024 01:10:PMSODIUM 126 mmol/L 145-136
mmol/LPOTASSIUM 4.1 mmol/L 5.1-3.5 mmol/LCHLORIDE 91 mmol/L 98-107 mmol/LTreatment Given(Enter only Generic Name)
SERUM ELECTROLYTES (Na, K, C l) 06-10-2024 09:19:PMSODIUM 120 mmol/L 145-136
mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 88 mmol/L 98-107 mmol/L
SERUM ELECTROLYTES (Na, K, C l) 06-10-2024 05:37:AMSODIUM 108 mmol/L POTASSIUM 4.6 mmol/LRFT 06-10-2024 09:27:AMUREA 25 mg/dlCREATININE 1.1 mg/dlURIC ACID 2.4
mmol/LCALCIUM 8.9 mg/dlPHOSPHOROUS 1.8 mg/dl SODIUM 107 mmol/L POTASSIUM 4.3
mmol/L. CHLORIDE 80 mmol/L
T3, T4, TSH 06-10-2024 12:02:PMT3 0.36 ng/ml T4 13.62 micro g/dllTSH 0.55 micro Iu/mSERUM ELECTROLYTES (Na, K, C l) 06-10-2024 12:02:PMSODIUM 110 mmol/L POTASSIUM 4.1 mmol/L ABG 06-10-2024 12:03:PMPH 7.41PCO2 28.9PO2 44.9HCO3 18.3St.HCO3 19.9BEB -5.1BEecf -
5.4TCO2 39.0O2 Sat 78.8O2 Count 8.8SERUM ELECTROLYTES (Na, K, C l) 06-10-2024
07:00:PMSODIUM 114 mmol/L POTASSIUM 4.4 mmol/L CHLORIDE 84 mmol/L
SERUM ELECTROLYTES (Na, K, C l) 07-10-2024 01:10:PMSODIUM 126 mmol/L 145-136
mmol/LPOTASSIUM 4.1 mmol/L 5.1-3.5 mmol/LCHLORIDE 91 mmol/L 98-107 mmol/LTreatment Given(Enter only Generic Name)
SERUM ELECTROLYTES (Na, K, C l) 06-10-2024 09:19:PMSODIUM 120 mmol/L 145-136
mmol/LPOTASSIUM 3.9 mmol/L 5.1-3.5 mmol/LCHLORIDE 88 mmol/L 98-107 mmol/L
MRI BRAIN PLAIN ON 6/ 10/24
IMPRESSION : FEW TINY TO SMALL FLAIR HYPERINTENSE AREAS ARE SEEN IN BILATERAL FRONTAL DEEP WHITE MATTER WITHOUT DIFFUSION RESTRICTION LIKELY S/O CHRONIC MICROVASCULAR WHITE MATTER ISCHAEMIA .
RIGHT MASTOID EFFUSION .
2D ECHO DONE ON 7/10/24
IMPRESSION :
POOR ECHO WINDOW NO RWMA MILD LVH+
MILD TR+ , NO PAH { RVSP = 36+ 05 = 41 MMHG} MILD AR+ { AR-PHT -508 M/SEC}
NO MR, NO AS/MS SCLEROTIC AV ZAS-INTACT / ANEURISAMS
EF=65% GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION + MINIMAL PE +/ PLURAL EFFUSION +
IVC SIZE { 0.3 CMS } COLLAPSING
HRCT CHEST DONE ON 7/10/24
1. FIBROBRONCHIECTATIC AND FIBROCALCIFIC ARCHITECTURAL DESTRUCTION OF PART OF RIGHT UPPER LOBE WITH MODERATE PLURAL THICKENING CAUSING MODERATE IPSILATERAL Mediastinal SHIFT AND TRACHEAL DEVIATION, MODERATE RIGHT HILAR UPWARD DEVIATION ,CROWDING OF RIBS ON THE RIGHT SIDE WITH MILD VOLUME LOSS OF RIGHT HEMITHORAX. MULTIPLE SUBCENTRIMETRIC CALCIFIED GRANULOMAS IN RIGHT LUNG . FEW OF THEM ARE ALSO SEEN IN LEFT UPPER LOBE - SUGGESTIVE OF DESTRUCTIVE SEQALE OF OLD INFECTION
DIFFUSE MOSAIC ATTENUATION PATTERN IN LEFT LUNG - COULD BE SMALL AIR WAY DISEASE OR MILD PARENCHYMAL INFRCTION
MILD RIGHT LOWER LOBE BRONCHIAL WALL THICKENTING WITH MILD BROCHIAL DILATATION . MULTPILE CENTRILOBULAR NODULES IN RIGHT LOWER LOBE - S/O REACTIVATION /REINFECTION
FEW SUBCENTRIMETRIC PREVASCULAR AND RIGHT HILAR LYMPHNODES MILD CARDIOMEGALY
TRACHEA , RIGHT MAIN BRONCHUS AND LEFT MAIN BRONCHUS APPEAR NORMAL THE RIBCAGE, CHGEST WALL AND DORSAL SPINE
DORSAL SPINE SHOWS MILD SPONDYLOSIS
MILD TO MODERATE SCOLIOSIS OF UPPER LUMBER SPINE WITH CONVEXCITY TO LEFT SIDE
PULMONOLOGY REFFERAL DONE ON 8/10/24 I/V/O ? REACTIVATION , ? REINFECTION OF PULMONARY KOCHS
CLINICALLY AND RADIOLOGICALLY -NO ACTIVE LESIONS ARE OBVIUOSLY EVIDENT ADVICE : PATIENT CAN BE PLANNED FOR BRONCHOSCOPY AFTER NEUROLOGICAL STABILIZATION
IMPRESSION : FEW TINY TO SMALL FLAIR HYPERINTENSE AREAS ARE SEEN IN BILATERAL FRONTAL DEEP WHITE MATTER WITHOUT DIFFUSION RESTRICTION LIKELY S/O CHRONIC MICROVASCULAR WHITE MATTER ISCHAEMIA .
RIGHT MASTOID EFFUSION .
2D ECHO DONE ON 7/10/24
IMPRESSION :
POOR ECHO WINDOW NO RWMA MILD LVH+
MILD TR+ , NO PAH { RVSP = 36+ 05 = 41 MMHG} MILD AR+ { AR-PHT -508 M/SEC}
NO MR, NO AS/MS SCLEROTIC AV ZAS-INTACT / ANEURISAMS
EF=65% GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION + MINIMAL PE +/ PLURAL EFFUSION +
IVC SIZE { 0.3 CMS } COLLAPSING
HRCT CHEST DONE ON 7/10/24
1. FIBROBRONCHIECTATIC AND FIBROCALCIFIC ARCHITECTURAL DESTRUCTION OF PART OF RIGHT UPPER LOBE WITH MODERATE PLURAL THICKENING CAUSING MODERATE IPSILATERAL Mediastinal SHIFT AND TRACHEAL DEVIATION, MODERATE RIGHT HILAR UPWARD DEVIATION ,CROWDING OF RIBS ON THE RIGHT SIDE WITH MILD VOLUME LOSS OF RIGHT HEMITHORAX. MULTIPLE SUBCENTRIMETRIC CALCIFIED GRANULOMAS IN RIGHT LUNG . FEW OF THEM ARE ALSO SEEN IN LEFT UPPER LOBE - SUGGESTIVE OF DESTRUCTIVE SEQALE OF OLD INFECTION
DIFFUSE MOSAIC ATTENUATION PATTERN IN LEFT LUNG - COULD BE SMALL AIR WAY DISEASE OR MILD PARENCHYMAL INFRCTION
MILD RIGHT LOWER LOBE BRONCHIAL WALL THICKENTING WITH MILD BROCHIAL DILATATION . MULTPILE CENTRILOBULAR NODULES IN RIGHT LOWER LOBE - S/O REACTIVATION /REINFECTION
FEW SUBCENTRIMETRIC PREVASCULAR AND RIGHT HILAR LYMPHNODES MILD CARDIOMEGALY
TRACHEA , RIGHT MAIN BRONCHUS AND LEFT MAIN BRONCHUS APPEAR NORMAL THE RIBCAGE, CHGEST WALL AND DORSAL SPINE
DORSAL SPINE SHOWS MILD SPONDYLOSIS
MILD TO MODERATE SCOLIOSIS OF UPPER LUMBER SPINE WITH CONVEXCITY TO LEFT SIDE
PULMONOLOGY REFFERAL DONE ON 8/10/24 I/V/O ? REACTIVATION , ? REINFECTION OF PULMONARY KOCHS
CLINICALLY AND RADIOLOGICALLY -NO ACTIVE LESIONS ARE OBVIUOSLY EVIDENT ADVICE : PATIENT CAN BE PLANNED FOR BRONCHOSCOPY AFTER NEUROLOGICAL STABILIZATION
BRONCHOSCOPY WAS DONE ON 15/10/24
RIGHT MAIN BRONCHUS UPPER LOBE NARROWING PRESENT LEFT MAIN BRONCHUS NORMAL
BAL ASPIRATED FROM RIGHT UPPER LOBE AND LOWER LOBE SEGMENTS . BAL SENT FOR TRUENAT, WHICH IS NEGATIVE.
SERUM ELECTROLYTES 16/10/24
SODIUM 136 mmol/LPOTASSIUM 4.0 mmol/LCHLORIDE 99mmol/LCALCIUM IONIZED 1.06 mmol
/L
ENT REFFERAL DONE ON 8/10/24 I/V/O RIGHT MASTIOD EFFUSION
BLOOD FOR CULTURE AND SENSITIVITY :
REPORT : NO GROWTH AFTER 48HRS OF AEROBIC INTUBATION
URINE FOR CULTURE AND SENSITIVITY :
REPORT : NO BACTERIAL GROWTH
HRCT - TEMPORAL BONE DONE ON 8/ 10/ 24 IMPRESSION : OTOMASTOIDITIS ON THE RIGHT .
COMPLETE OPACIFICATION OF RIGHT MASTOID AIR CELLS , MASTOID ANTRUM , ADITUS AND ANTRUM , EPITYMPANIC RECESS .
FLUID IS ALSO SEEN SURROUNDING THE HEAD OF MALLEOULUS AND BODY OF INCUS ON THE RIGHT .
RFT ON 9/10/24
UREA 36 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.1 mmol/LCALCIUM 9.0 mg/dlPHOSPHOROUS
2.91 mg/dlSODIUM 134 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 104 mmol/L ELECTROLYTES ON 10/10/24
SODIUM 138 mmol/LPOTASSIUM 4.5 mmol/LCHLORIDE 104 mmol/LCALCIUM IONIZED 1.25
mmol/L
RFT ON 11/10/24UREA 37 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.1 mmol/LCALCIUM 9.9
mg/dlPHOSPHOROUS 3.5 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 103
mmol/L
SERUM ELECTROLYTES (Na, K, C l) ON 12/10/24SODIUM 135 mmol/LPOTASSIUM 4.4
mmol/LCHLORIDE 98 mmol/LCALCIUM IONIZED 1.03 mmol/L
ABG ON 12/10/24PH 7.40PCO2 45.9 mmHgPO2 75.5 mmHgHCO3 28.4 mmol/LSt.HCO3 27.8
mmol/LBEB 3.8 mmol/LBEecf 4.0 mmol/LTCO2 60.3 VOLO2 Sat 93.7 %O2 Count 11.1 vol % HEMOGRAM ON 13/10/24HAEMOGLOBIN 9.0 gm/dlTOTAL COUNT 11,000 cells/cumm
RIGHT MAIN BRONCHUS UPPER LOBE NARROWING PRESENT LEFT MAIN BRONCHUS NORMAL
BAL ASPIRATED FROM RIGHT UPPER LOBE AND LOWER LOBE SEGMENTS . BAL SENT FOR TRUENAT, WHICH IS NEGATIVE.
SERUM ELECTROLYTES 16/10/24
SODIUM 136 mmol/LPOTASSIUM 4.0 mmol/LCHLORIDE 99mmol/LCALCIUM IONIZED 1.06 mmol
/L
ENT REFFERAL DONE ON 8/10/24 I/V/O RIGHT MASTIOD EFFUSION
BLOOD FOR CULTURE AND SENSITIVITY :
REPORT : NO GROWTH AFTER 48HRS OF AEROBIC INTUBATION
URINE FOR CULTURE AND SENSITIVITY :
REPORT : NO BACTERIAL GROWTH
HRCT - TEMPORAL BONE DONE ON 8/ 10/ 24 IMPRESSION : OTOMASTOIDITIS ON THE RIGHT .
COMPLETE OPACIFICATION OF RIGHT MASTOID AIR CELLS , MASTOID ANTRUM , ADITUS AND ANTRUM , EPITYMPANIC RECESS .
FLUID IS ALSO SEEN SURROUNDING THE HEAD OF MALLEOULUS AND BODY OF INCUS ON THE RIGHT .
RFT ON 9/10/24
UREA 36 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.1 mmol/LCALCIUM 9.0 mg/dlPHOSPHOROUS
2.91 mg/dlSODIUM 134 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 104 mmol/L ELECTROLYTES ON 10/10/24
SODIUM 138 mmol/LPOTASSIUM 4.5 mmol/LCHLORIDE 104 mmol/LCALCIUM IONIZED 1.25
mmol/L
RFT ON 11/10/24UREA 37 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.1 mmol/LCALCIUM 9.9
mg/dlPHOSPHOROUS 3.5 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 103
mmol/L
SERUM ELECTROLYTES (Na, K, C l) ON 12/10/24SODIUM 135 mmol/LPOTASSIUM 4.4
mmol/LCHLORIDE 98 mmol/LCALCIUM IONIZED 1.03 mmol/L
ABG ON 12/10/24PH 7.40PCO2 45.9 mmHgPO2 75.5 mmHgHCO3 28.4 mmol/LSt.HCO3 27.8
mmol/LBEB 3.8 mmol/LBEecf 4.0 mmol/LTCO2 60.3 VOLO2 Sat 93.7 %O2 Count 11.1 vol % HEMOGRAM ON 13/10/24HAEMOGLOBIN 9.0 gm/dlTOTAL COUNT 11,000 cells/cumm
NEUTROPHILS 80 %LYMPHOCYTES 14 %EOSINOPHILS 01 %MONOCYTES 05
%BASOPHILS 00 %PCV 26.1 vol %M C V 86.1 flM C H 29.5 pgM C H C 34.3 %
%BASOPHILS 00 %PCV 26.1 vol %M C V 86.1 flM C H 29.5 pgM C H C 34.3 %
COURSE IN HOSPITAL :
PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS , MRI BRAIN PLAIN DONE IT SHOWED CHRONIC MICROVASCULAR WHITE MATTER ISCHEMIA AND RIGHT MASTOID EFFUSION. AND OTHER NECESSARY INVESTIGATIONS WERE DONE AND SODIUM 108 MEQ/L, URINARY SODIUM WAS 208 MEQ/L AND SERUM OSMOLALITY WAS 216 AND DIAGNOSED AS TRUE HYPONATERMIA AND WAS STARED ON 3% NS @ 15 ML/HR. AND SERIAL SODIUM LEVEL MONITORING WAS DONE
Treatment Given(Enter only Generic Name)
COURSE IN HOSPITAL:
1. RYLES FEED 200 ML MILK WITH PROTEIN POWDER 200 ML WATER EVERY 2 HRS
2. IV FULID NS @ 50 ML PER HR
3. INJ MONOCEF 1 GM IV BD8AM--X--8PM
4. INJ PAN 40 MG IV OD
5. INJ LEVIPILL 500 MG IV BD
6. INJ NEOMOL 1 GM IV SOS IF TEMP IS GREATER THAN 101F
7. TAB AZITHROMYCIN 5OO MG RT OD
8. TAB DOLO 650 MG RT OD
9. TAB TOLVAPTAN 15 MG RT OD
10. FREQUENT POSITION CHANGE EVERY 2 HRLY
11. SYP LACTULOSE 45 MG / RT/STAT 12.NEOSPRIN POWDER OVER BEDSORE L/A
13. INJ PIPTAZ 3.375GM IV QID
Advice at Discharge
1. INJ PIPTAZ 3.375GM IV QID FOR 2 DAYS
1 .TAB. LEVIPILL 500MG PO / BD 1--0--1 X 3 MONTHS TAB TOLVAPTAN 15 MG PO/OD 1--0--0
TAB NEUROBION FORTE PO/OD O--1--O X 15 DAYS
3. TAB. DOLO 650 MG PO / TID X 3DAYS
4. TAB . PAN PO / OD X2 DAYS
5. NEOSPRIN POWDER LOCAL APPLICATION OVER THE BED SORE OINTMENT HYROHEAL FOR L/A
6. FREQUENT POSITION CHANGING
Follow Up
REVIEW TO GM OPD AFTER 1 WEEK
REVIEW TO PULMONOLOGY OPD AFTER 1 WEEK REVIEW TO ENT OPD AFTER 1 WEEK
REVIEW TO SURGERY OPD AFTER 1 WEEK
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 case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 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:10/10/24 Ward:ICU
Unit:VI
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