20F severe headache, neckpains and vomitings.
First admission discharge summary
Age/Gender : 21 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 27/09/2022 04:57 PM
Date of Operation MLC No
DR.ADITYA [SR] DR.CHARAN[PGY3] DR.DEEPIKA[PGY1]
Diagnosis
SYSTEMIC LUPUS ERYTHEMATOSUS WITH GLOMERULONEPHRITIC FLARE UP OF LUPUS NEPHRITIS ?CATASTROPHIC APLA SECONDARY TO SLE [LIBMAN SACKS ENDOCARDITIS
,CNS THROMBO EMBOLISM, AND RENAL FAILURE]
Case History and Clinical Findings
20 YR OLD FEMALE CAME ITH C/O B/L PEDAL EDEMA SINCE 15 DAYS HYPERPIGMENTED MACULES SINCE 15 DAYS
FEVER SINCE 15 DAYS
ABDOMINAL DISTENSION SINCE 8 DAYS DRY COUGH SINCE 7 DAYS
SORE THROAT SINCE 7 DAYS DECREASED APPETITE SINCE 7 DAYS SOB SINCE 5 DAYS
DECREASED URINE OUTPUT SINCE 3 DAYS CONSTIPATION SINCE 3 DAYS
HOPI -20 YEAR OLD FEMALE CAME WITH C/O OF B/L PEDAL EDEMA EXTENDING TILL THE KNEES PITTING TYPE SINCE 15DAYS
FOR WHICH SHE GOT MEDICAL HEALTH CHECKUP AND PRESCRIBED SOME MEDICATION [UNKNOWN] THEN HER PEDAL EDEMA GOT RESOLVED ALNG WITH FEVER SHE DEVELOPED HYPER PIGMENTED MACULES ON FACE LATER THEY STOPPED MEDICATIONS AFTER 2 DAYS SHE AGAIN HAD A COMPLAINT OF B/L PEDAL EDEMA AND FEVER ABDOMINAL DISTENSION ASSOCIATED WITH DRY COUGH AND DECREASED APPETITE SHE ALSO HAS COMPLAINTS OF DECREASED URINE OUTPUT AND CONSTIPATION SINCE 3 DAYS
PASSING STOOLS ONCE IN 3-4 DAYS N/K/C/O HTN DM THYROID CAD EPILEPSY TB
PERSONAL HISTORY DIET MIXED APPETITE LOST
BOWEL AND BLADDER MOVEMENTS DECREASED
FAMILY HISTORY NOT SIGNIFICNT
O/E-
PT WAS C/C/C
ON ADMISSION VITALS BP 110/70 MMHG
PR-79 BPM RR-19 CPM TEMP -98.8 F
CVS- APEX BEAT DISPLACED LATERALLY PALPABLE THRILL IN MITRAL AREA
LOUD S2 HEARD IN ALL AREAS NO S3 HEARD
PAN SYSTOLIC MURMUR AT MITRAL AREA
RS-
BAE DECREASED
RT INFRA SCAPULAR CREPTS PRESENT P/A-
SOFT NON TENDER WITH EMBILICUS NORMAL SHAPE AND INVERTED XIPHI UMBILICAL LENGTH 15 CM
UMBILICO PUBIC LENGTH 12 CM
ON PALPATION NO ORGANOMEGALY
CNS -B/L UPPER LIMB AND LOWER LIMB
HYPER TONIA WITH EXAGERATED DTR ,ABSENT ANKLE REFLEX PATELLAR CLONUS-
RT SIDE 4+
LT SIDE 3+
MOTOR POWER- 4/5 4/5
4/5 4/5
1/10/22
MMSE - DONE ON 1/10/22 ORIENTATION -
ORIENTED TO DAY,MONTH ,SEASON ,DATE -2 FLOOR ,HOSPITAL,DISTRICT,STATE ,COUNTRY-4 RECALL-2/3
ATTENTION AND CALCULATION-3/4 LANGUAGE -2 OBJECTS-2 SENTENCE-1
3 STAGE COMMAND -3 READING CLOSE YOUR EYES WRITING A SENTENCE -0
MODERATE COGNITIVE IMPAIRMENT COURSE IN HOSPITAL
28/09/22-
NEPHRO REFERAL I/V/O ELEVATED RENAL PARAMETERS AND ANASARCA
REFERAL NOTES-LVTS-,OBSTRUCTION -,HEMATURIA-,PYURIA-,YELLOWIS DISCOLORATION-
,NSAID ABUSE -,NATIVE MEDICATION - ADVICED TO CONTINUE THE SAME TREATMENT 28/09/22-
PULMO REFERAL I/V/O WHEEZE ,XRAY CHANGES [BL PLEURAL EFFUSION] ADVICED -INJ AUGMENTIN 1.2 GM IV/TID
INJ.LASIX 40 MG IV/BD NED DUOLIN
BUDECORT 6TH HOURLY IMJ NEOMOL 1GM IV/SOS BETADINE GARGLING TAB AZITHROMYCIN
GENERAL SURGERY REFERAL I/V/O BED SORE [1/10/22]
LE- TWO SMALL ULCERS NOTED EITHER SIDE OF INTERGLUTEAL CLEFT MEASURING 1X1 CM EACH
NO ACTIVE DISCHARGE
FLOOR -GRANULATION TISSUE,NO SLOUGH
EDGE SLOPING EDGES NO SURROUNDING INDURATION MARGINS -BLACKISH
ADVICED -TO MAINTAIN HYGEINE AND KEEP THE AREA DRY OINT T BACT FOR LA
NEOSPORIN POWDER FOR LA FREQUENT POSITION CHANGE AIR BED
29/09/22-
ENT REFERRAL WAS TAKEN I/V/O DYSPHONIA REFRAL NOTES-
O/E OF ORAL CAVITY- MUCOSA PALE TONGUE IS COATED
OROPHARYNX-BL GRADE 2 TONSILLAR HYPERTROPHY ,NO CONGESTION NECK-TRACHEA CENTRAL
LARYNGEAL FRAMEWORK NORMAL LARYNGEAL CREPITUS+
NOSE-
EXTERNAL FRAMEWORK NORMAL CAUDAL DISLOCATION-LEFT ANTERIOS MILD DNS -RIGHT
B/L NASAL MUCOSA -PALE TURBINATES AND FLOOR -NORMAL ROOMY NASAL CAVITIES
OE EAR-
B/L TYMPANIC MEMBRANE INTACT .,COL+ DIAGNOSIS-DYSPHAGIA UNDER EVALUATION NO ACTIVE ENT INTERVENTION
30/09/22-
REVIEW NEPHRO REFERAL-
USG KUB SHOWING BULKY LT KIDNEY WITH ALTERED ECHOTEXTURE ADVICED TAB AUGMENTIN
TAB PAN 40 MG OD TAB DOLO 650 MG TID 4/10/22-
DVL REFERAL I/V/O HYPERPIGMENTED MACULES NOTED OVER CHEEKS AND FOREHEAD
,NOSE ,CHIN EAR LOBULE ,RETROAURICULAR REGION [CONCHA SPARED], BOTH FOREARMS,BACK,UPPER CHEST
ORAL CAVITY- N
MULTIPLE HYPERPIGMENTED MACULES NOTED OVER BOTH THE PALMS DIAGNOSIS -POST INFLAMMATORY HYPERPIGMENTATION
ADVICED -CEBHYDRA LOTION LA/BD
REVIEW ENT REFERAL I/V/O DYSPHONIA [13/10/22]
ADVICED TO CONTINUE MEDICATION AS ADVICED BY PHYSICIAN WAIT AND WATCH
FOLLOWED BY SPEECH THERAPY
01/10/2022-
20 F WITH ANASRCA BL PEDAL EDEMA ,PLEURAL EFFUSION ,AND PERICARDIAL EFFUSION - RESOLVING
+RASH HEALED +FEVER
SKIN- HEALED RASHES +PAINLESS EMBOLI LIKE LESIONS [JANEWAY LESIONS] PT APPEARS COMFORTABLE
FEVER SPIKES PERSIST -FEVER CHART ANALYSIS-SEPTIC PTTERN ACTION TREMOR+B/L
REDUCTION IN TACHYCARDIA[HR 148->112] LIDLAG
HEALING BEDSORE ON BACK [BUTTOCK AREA]
ON 02/10/22-
ANA PROFILE -ANTI dsDNA +++
ANTI HISTONE ,ANTINUCLEOSOME,ANTI KU AG++
MRI BRAIN- MULTIPLE HYPERINTENSITIES IN BRAIN PARENCHYMA F/S/O-VASCULITIS? USG ABDOMEN -MODERATE ASCITES
SLE DAI SCORE-30 POINTS S/O ACTIVE DISEASE
ON 3/10/22-
TACHYPNEA AND TACHYCARDIA SUBSIDED ACTION TREMOR DECREASED
0N 4/10/22
INJ UNFRACTIONATED HEPARIN 5000IU /IV/STAT
FOLLOWED BY INJ UNFRACTIONATED HEPARIN 5000 IU /SC/QID FOR 3 DAYS[GIVEN FOR 3 DAYS [TILL 6//10/22]]
TAB WARFARIN 5MG /PO/OD IS STARTED
TAB LASIX 40MG PO/BD STARTED ON 12/10/22
BLOOD TRANSFUSION WAS DONE ON 13/10/22
ONE PINT OF A+VE BLOOD WAS TRANSFUSED AFTER DOING THE BLOOD GROUPING AND TYPING AND CROSS MATCHING
TRANSFUSION STARTED AT 7;30 PM AND WAS COMPLETED BY 11;20 PM
HALF AND HOURLY MONITORING OF VITALS WAS DONE DURING THE PROCESS OF TRANSFUSION
PRE TRANSFUSION VITALS AND POST TRANSFUSION VITALS WERE MONITORED,PT WAS STABLE AND NO CHILLS,RIGORS,FEVER,MYALGIA DURING THE TRANSFUSION
Investigation
USG IMPRESSION[28/09/2022] MODERATE PERICARDIAL EFFUSION BILATERAL PLEURAL EFFUSION GROSS ASCITES
MRI BRAIN PLAIN WITH CSPINE SCREENING[ON 3/10/22] IMPRESSION-
DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY
MULTIPLE SMALL ACUTE INFARCTS IN BOTH CEREBRAL HEMISPHERES-EMBOLIC SCREENING OF CERVICAL AND DORSAL SPINE APPEARS NORMAL
Treatment Given(Enter only Generic Name)
1] INJ AUGUMENTIN 1.2 GM IV/BD FOR 2 DAYS
2] INJ LASIX 40 MG IV/BD FOR 9 DAYS
3] NEB WITH DUOLIN BUDECORT
4] INJ NEOMOL 1GM IV/SOS
5] TAB AZITHROMYCIN 500 MG PO/OD FOR 2 DAYS
6] BETADINE GARGLES /TID
7] INJ DERIPHYLLINE 100 MG IV /BD FOR 7 DAYS
8] TAB PREDNISOLONE 50 MG PO/BD FOR 3 DAYS[STARTED ON 29/9/22 TO 1/10/22] TAB PREDNISOLONE 30 MG PO/BD FOR 1 DAY[STARTED ON 2/10/22 ]
TAB PREDNISOLONE 20 MG PO/BD FOR 11 DAYS[STARTED ON 3/10/22 ] 9]INJ PAN 40 MG IV/OD
10] INJ CEFTRIOXONE 1 GM IV/BD FOR 7 DAYS
11] INJ TRAMADOL 1 AMP IN 100 ML NA/IV/BD
12] INJ METHYL PREDNISOLONE 750 MG IN 100 ML NS/IV /OD FOR 3 DAYS[2/10/22 TO 4/10/22]
13] TAB HCQ 200 MG PO/OD[STARTED ON 2/10/22]
14] TAB DOLO 650 MG PO/TID
15] OINT T BACT FOR LA /BD
16] NEOSPORIN POWDER FOR LA
17] TAB AZORAN 50 MG PO/BD
18] SYP DULPHALAC 15 ML PO/TID
19] INJ UNFRATIONATED HEPARIN 5000 IU/SC/QID FOR 3 DAYS
20] TAB WARFARIN 5MG /PO/OD
21] CEBHYDRA LOTION LA /BD
Advice at Discharge
1] TAB HCQ 200 MG PER ORAL ONCE DAILY
2] TAB PREDNISOLONE 20 MG PER ORAL TWICE DAILY
3] TAB AZORAN 50 MG PER ORAL TWICE DAILY
4] TAB LASIX 40 MG PER ORAL TWICE DAILY
5] SYP SUCRALFATE 10 MLTHRICE DAILY
6] SYP DULPHLAC 15 ML PER ORAL THRICE DAILY
7] OINT TBACT LOCAL APPLICATION TWICE DAILY
8] CEBHYDRA LOTION LOCAL APPLICATION TWICE DAILY
9] NEOSPORIN LOCAL APPLICATION
SECOND ADMISSION :
Patient presented with flare up of SLE with Libmann Sachs endocarditis and vasculitic stroke discharged with Tab. Prednisolone 20mg BD, Tab. Azathioprine 50mg BD, Tab. HCQ 200mg OD, Tab. Warfarin 5 mg BD.
On 01/12/22 patient presented to OPD with complaints of Headache, vomitings and neck pains since 2-3 days.
Patient was apparently improved after discharge ( oct 2022 ) and was alright till 3 days back, Then she developed Headache diffuse associated with neck pains which worsened next day following which she developed, vomiting of 3-4 episodes, non bilious and food particles as contents, she told it was not associated with pain abdomen or abdominal discomfort.
No fever, no altered sensorium, No blurring of vision, No diplopia, No photophobia or phonophobia.
No history of trauma.
Vitals at admission :
Bp 170/110mmhg
Pr : 84
Spo2 : 99 on RA
RR : 18 cpm
Temp : Afebrile to touch.
On examination :
Facial puffiness present with stary look. Previous rashes subsided.
Echymotic patch noticed on Rt knee.
Neck stiffness present associated with Pain.
CVS : no raised JVP, Heart sounds unremarkable, previous MR murmur subsided.
Rs : Bilateral air entry presents, clear.
P/A : soft, nontender bowel sounds present.
CNS :
MMSE : 30/30
HMF : intact
Cranial nerves : normal
Motor: detailed examination will be shared shortly.
Exaggerated deep tendon reflexes.
With I'll sustained patellar clonus.
Persistent nausea and vomiting. After low dose opinoid ( Tramadol ) + antiemetic
Persistent neck pain with stiffness.
Crcl = 60ml/min
For acute headache and neck pain reduction she was given Naproxen 125mg stat.
Clinically - ?meningitis 2to Warfarin induced Intra cranial bleed ( SLE ) > infective.
MRI brain was done
3/12/22
Patient developed Diplopia today. Transient Rt. LR palsy. Started in inj. 3%NACL to decrease ICP. For 6hrs.
Patient attenders councelled regarding this and advised for neurosurgical opinion but due to personal problems they continued treatment here with high risk.
4/12/22
Reviewed patient today.
Diplopia subsided and no fever spikes
Neck pain and vomitings subsided.
[2/1, 8:39 AM] saicharankulkarni: Spoke to this patient and her father today, she has no complaints except swelling of face ( ? iatrogenic Cushings ). She was on Oral prednisone 20 - x - 10mg, tappered to 10mg twice daily using since 3 days. They are in a plan to visit our OPD in 2-3 days sir.
[2/1, 8:51 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Did you try to find out more about her possible neurodegenerative disorder that you brought out in the conference?
[2/7, 11:47 PM] saicharankulkarni: Came for review today
Complaints of difficulty in sitting on floor, difficulty in getting up from chair since 1 month,
O/e
Facial swelling+
Hump behind the neck +
B/L lower limb Proximal muscle weakness +
Hyperreflexia of all DTR + since 4 months
Abdominal striae + on lateral aspect of abdomen and knee
B/L fine tremors +
Amenorrhea since 4 months ( LMP in october )
Bp - 110/70mmhg
Pr - 78bpm
[2/8, 8:16 AM] Dr Rakesh Biswas Sir Hod Gm Kam: So is her current proximal myopathy due to Cushing's or Polymyositis?
How would you decide?
[2/27, 9:02 AM] saicharankulkarni: Reviews case through teleconsultation
C/o facial puffiness decrease ( not completely subsided ),
hair loss present
Difficulty in standing from sitting position decreased.
Decreased wysolone dose from 10mg - X - 5mg to 5mg twice daily. She is on HCQ, AZA
Advised to review general medicine OPD.
Telemedical follow up :
[28/09/22, 3:15:33 PM] 20F Lupus Nephritis relapse 2 weeks, Seizures and nephritis recovered, Telangana PaJR: Messages and calls are end-to-end encrypted. No one outside of this chat, not even WhatsApp, can read or listen to them.
[28/09/22, 3:15:33 PM] 20F Lupus Nephritis relapse 2 weeks, Seizures and nephritis recovered,
[22/05/24, 6:09:02 PM] Sai Charam Kulkarni: @919398587059 can you please archive all the chat in this group from day one and share me in DM.
[22/05/24, 6:40:18 PM] Dr Bharath Jnr Gm Kam: OK sir
[04/06/24, 11:48:43 AM] Dr. Deepika Jnr Gm Kam: She presented today with complaints of
Pain and swelling at both ankles and finger joint swelling ( right middle finger)
Associated With fever since yesterday night
Pain and fever subsided with medication( paracetamol)
Swelling over ankles increased from yesterday
No h/o trauma
Examination-
Erythematous rash over lt ankle
Pitting type pedal edema grade 1
Local rise of temperature + at medial malleolus
Joint -Non tender
No restriction of movement
[04/06/24, 11:50:51 AM] Dr. Deepika Jnr Gm Kam:
[04/06/24, 3:31:09 PM] Sai Charam Kulkarni: What is your assessment..?
[04/06/24, 5:14:58 PM] ~ Gouthami: ~ Gouthami joined using this group's invite link
[04/06/24, 6:25:41 PM] Dr. Deepika Jnr Gm Kam: Sir
Looks like inflammatory arthritis with ? Enthesitis
Or
Could be flare up of sle too
Pedal edema --can be attributed to either - nephritis leading to proteinuria causing this
Or inflammatory too sir
After discussion with HOD sir
We've sent few investigations -
24h upcr
Hemogram
S albumin /total protein
S Uric acid
S creatinine and urea
[04/06/24, 6:33:01 PM] Sai Charam Kulkarni: Early or late pitting.??
[04/06/24, 6:33:16 PM] Sai Charam Kulkarni: Points in favour of flare up ..?
[04/06/24, 8:43:29 PM] Dr. Deepika Jnr Gm Kam: Sir do u mean in time of recovery
Patient is having pitting edema recovered with in 5-6 sec ( approx 2mm)
Points in favour of flare up -SLEDAI -2k
Systemic symptoms -
Arthritis - 4
Rash -2
Fever-1
Adding up to a score of 7
Increase in SLEDAI to 7 made me think of flare up
[04/06/24, 9:00:01 PM] Sai Charam Kulkarni: Which rash..? What was her last SLEDAI..?
[04/06/24, 9:36:40 PM] ~ Aneef: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045928/table/T1/?report=objectonly
Flares defined
: Table 1.
Definitions of SLE flares according to existing validated indices2,5,10
Index Definition(s)
PGA1
Mild/moderate: increase by ≥1.0 compared with the previous visit
Severe: increase by ≥1.0 to ≥2.5
SLEDAI
Mild/moderate: increase by >3
Severe: increase by >10
SFI
Mild/moderate: 1) increase of SLEDAI by ≥3 points; and/or 2) new/worse skin, stomatitis, serositis, arthritis, fever; and/or 3) increase in PGA by ≥1.0; and/or 4) treatment intensification: increase in prednisone <0.5 mg/kg or added NSAIDs or hydroxychloroquine
Severe: 1) increase of SLEDAI by >12; and/or 2) new/worse CNS involvement, vasculitis, glomerulonephritis, myositis, platelet counts <60,000/mm3, hemolytic anemia (hemoglobin <70 g/L), requiring doubling of prednisone dose or dose >0.5 mg/kg; and/or 3) need for hospitalization due to SLE; and/or 4) any manifestation requiring prednisone >0.5 mg/kg or new immunosuppressive therapy; and/or 4) increase in PGA to >2.5
BILAG
Moderate: increase from C, D or E to B score in any system
Severe: increase to A score in any system
SLAM
Increase by ≥3
LAI
Increase by >0.26
1PGA, Physician Global Assessment; SLEDAI, SLE Disease Activity Index; SFI, SELENA-SLEDAI Flare Index; NSAID, non-steroidal anti-inflammatory drugs; CNS, central nervous system; BILAG=British Isles Lupus Assessment Group; SLAM, SLE Activity Measure; LAI, Lupus Activity Index
[04/06/24, 9:44:44 PM] Dr. Deepika Jnr Gm Kam: 👆rash over left ankle sir
Before this episode excluding the labs clinically score is 0 sir
[04/06/24, 9:56:34 PM] Sai Charam Kulkarni: Can’t it be chikun or Deng..?
What was her previous SLEDAI..?
What made us to think autoimmune only and not infective..?
[04/06/24, 10:32:45 PM] Dr. Deepika Jnr Gm Kam: Given the background history of autoimmune disease
Inflammatory was more thought of but infective is still a differential sir.
History of low grade fever only 1 spike yesterday
No bleeding manifestations
Rash didn't appear as maculopapular
( erythema +)
During her prior visit she had no complaints so clinically her score is 0 sir
[06/06/24, 3:55:47 PM] Dr. Deepika Jnr Gm Kam:
Should we consider adding steroid along with azathioprine/MMF sir ?
[06/06/24, 5:00:36 PM] Sai Charam Kulkarni: Why don’t we get her kidney biopsy done.. I failed to convince her father when I was in pg. by the time he convinced I was preparing for practical’s.
Please plan for biopsy @919121046928
[06/06/24, 5:01:27 PM] Dr. Dinesh Datta Jr Kam: Risk versus benefit analysis?
How would management change based on purported biopsy findings?
[06/06/24, 5:01:48 PM] Sai Charam Kulkarni: However given her socioeconomic status I think MMF would add more burden.
Better to start with steroids and AZA
[06/06/24, 5:02:54 PM] Dr. Dinesh Datta Jr Kam: If not about socioeconomic status and if patient is millionaire,what would you rather advise at this juncture?
[06/06/24, 5:03:54 PM] Dr. Dinesh Datta Jr Kam: Let's do some deductive reasoning/analysis.
Aka science
[06/06/24, 5:04:09 PM] Dr. Dinesh Datta Jr Kam: Aka medical cognition project
[06/06/24, 5:04:45 PM] Dr. Dinesh Datta Jr Kam: Let's ask the rheumie hotshot professor/guide and mentor.
[06/06/24, 5:05:58 PM] Dr Adithya Sir Gm Kam: I disagree with this zero sum thinking here. MMF would add human capital to her life and society. She will become productive, have a normal life and pursue a career and make money?
[06/06/24, 5:06:56 PM] Dr. Dinesh Datta Jr Kam: And what are the factors suggesting her productivity and normal life and career in future?
[06/06/24, 5:06:56 PM] Sai Charam Kulkarni: Nothing change in management.
As ours is globally avarage institute at least PGs like me you and @919121046928 could help them to assess stage of lupus nephritis and chances of she landing up in ESRD.
Also can plan for pulse to resync her immune system.
[06/06/24, 5:07:57 PM] Dr. Dinesh Datta Jr Kam: Let's call it globally below average institute with globally above average and leading doctors and professors like yourselves,RB @919652955915 etc
[06/06/24, 5:08:56 PM] Sai Charam Kulkarni: Do agree for health care systems like where you currently work. But her parents earns on daily base where they could get an avarage of 500 bucks a day. Would run there house and spend on her education.
[06/06/24, 5:08:58 PM] Dr. Dinesh Datta Jr Kam: Any other ways we can assess the chances of landing in ESRD?
Any simple biochemical/clinical markers?
[06/06/24, 5:09:38 PM] Dr. Dinesh Datta Jr Kam: That looks like a factor to be addressed regarding ESRD in biopsychosocial healthcare model.
In PNI terms?
[06/06/24, 5:10:02 PM] Dr Adithya Sir Gm Kam: "People are brains not stomachs". See it in a human capital context not just saving her kidneys.
What is she currently doing?
[06/06/24, 5:10:40 PM] Dr. Dinesh Datta Jr Kam: Check her status.
And work on what best she could be.
Regardless of diagnosis etc
[06/06/24, 5:10:48 PM] Sai Charam Kulkarni: Doing her degree I guess
[06/06/24, 5:10:53 PM] Dr. Dinesh Datta Jr Kam: And how we may facilitate it
[06/06/24, 5:11:08 PM] Dr. Dinesh Datta Jr Kam: And why is that?
[06/06/24, 5:11:15 PM] Dr Adithya Sir Gm Kam: From the western shores - Dr. Biswas' department globally well above average.
[06/06/24, 5:11:42 PM] Dr. Dinesh Datta Jr Kam: Yes.
Very well agree.
Doesn't mean institute is above average
[06/06/24, 5:11:53 PM] Dr Adithya Sir Gm Kam: So much capital!! She must pursue it and be able to have a career for herself.
[06/06/24, 5:12:30 PM] Dr. Dinesh Datta Jr Kam: So any other tech or AI tools etc we can facilitate her to earn money?
To have career without degree and stuff?
[06/06/24, 5:12:38 PM] Dr. Dinesh Datta Jr Kam: What's her abilities?
[06/06/24, 5:13:41 PM] Dr. Dinesh Datta Jr Kam: Let's apply first principles thinking.
Why must she?
Is it mandatory to pursue career?
[06/06/24, 5:13:55 PM] Dr Adithya Sir Gm Kam: Do we have the right to breach these boundaries and suggest these to her? Pretty sure she did not consult us for this? Micromanagement perhaps? A classic Indian attribute
[06/06/24, 5:13:56 PM] Sai Charam Kulkarni:
i remember you made me to show the evidenceof AZA VS MMF in APLA. Finally we started her on AZA.
[06/06/24, 5:14:21 PM] Dr Adithya Sir Gm Kam: None of my business. It's her autonomy
[06/06/24, 5:14:25 PM] Dr. Dinesh Datta Jr Kam: It's not micro/macro management.
It's all healthcare.
She's our patient
[06/06/24, 5:14:37 PM] Dr. Dinesh Datta Jr Kam: Agree..
Let's facilitate
[06/06/24, 5:14:37 PM] Dr Adithya Sir Gm Kam: Yes not our person. Patient. That's where it ends.
[06/06/24, 5:14:52 PM] Dr. Dinesh Datta Jr Kam: Relatable
[06/06/24, 5:15:22 PM] Dr. Dinesh Datta Jr Kam: And thats where satisfaction by benefitting or uplifting a life through medicine ends too?
[06/06/24, 5:15:32 PM] Dr. Dinesh Datta Jr Kam: By passing the buck?
[06/06/24, 5:16:14 PM] Dr Adithya Sir Gm Kam: That's her privacy and autonomy. There's no buck to be passed. She's not a puppet is she?
[06/06/24, 5:16:14 PM] Dr. Dinesh Datta Jr Kam: Full article
[06/06/24, 5:17:34 PM] Sai Charam Kulkarni: Digressed from point 😂
[06/06/24, 5:17:34 PM] Dr. Dinesh Datta Jr Kam: Think deeper.
She came for healthcare complaints.
And we evaluate the complaints in biopsychosocial model and PNI..
If not,why do we even have pajr?
Why not just prescribe some tabs and ask to come for next review 3 months later?
[06/06/24, 5:20:00 PM] Dr. Dinesh Datta Jr Kam: And how does your purported management plan helps/benefits the patient in her life?
Or is it just your placebo and self defeating stuff?
[06/06/24, 5:20:17 PM] Dr. Dinesh Datta Jr Kam: It's an asymptote
[06/06/24, 5:21:19 PM] Dr Adithya Sir Gm Kam: Let me have a look.
[06/06/24, 5:21:37 PM] Dr Adithya Sir Gm Kam: And it has improved her life hasn't it?
[06/06/24, 5:22:10 PM] Dr. Dinesh Datta Jr Kam: Perhaps..
Any blogspot/published?
[06/06/24, 5:22:14 PM] Dr. Dinesh Datta Jr Kam: Would love to learn more
[06/06/24, 5:22:15 PM] Dr Adithya Sir Gm Kam: Zero sum again. What do you think the MMF can help her with?
[06/06/24, 5:22:47 PM] Dr. Dinesh Datta Jr Kam: Yes..that's my question
[06/06/24, 5:23:05 PM] Dr. Dinesh Datta Jr Kam: How's she doing now?
[06/06/24, 5:28:18 PM] Sai Charam Kulkarni: Yes with AZA
[06/06/24, 5:36:14 PM] Sai Charam Kulkarni:
THURSDAY 20 0CT.pptx • 49 slides <attached: 00000086-THURSDAY 20 0CT.pptx>
[06/06/24, 6:44:11 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Description box
[06/06/24, 6:50:26 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Agree @919154575937
We can start her on her previous treatment
I don't think biopsy helps in changing the management. Regardless of the biopsy result be it DPGN class IV or any other histopathological stage.
Yes I feel biopsy simply tells stage of the disease (some equate that to prognosis) rather than diagnosis and perhaps future non invasive cellular monitoring tech will be able to prove my contention better (currently it's just my hypothesis that most primary glomerulopathies, classified according to histopathological patterns and thought to be separate disease entities are simply stages in pathophysiologic progression and some may simply remain minimal change or membranous and resolve while some would become fsgs and accelerate)
[06/06/24, 7:58:06 PM] Dr. Deepika Jnr Gm Kam: 36-month, randomized, double-blind, double-dummy, phase 3 study
P-227 patients were randomly assigned to maintenance treatment
116 to mycophenolate mofetil
111 to azathioprine
I &C -
oral mycophenolate mofetil (2 g per day) and oral azathioprine (2 mg per kilogram of body weight per day), plus placebo in each group
O-
rates of treatment failure were 16.4% (19 of 116 patients) in the mycophenolate mofetil group and 32.4% (36 of 111) in the azathioprine group
Serious adverse events occurred in 33.3% of patients in the azathioprine group and in 23.5% of those in the mycophenolate mofetil group
Cons??
Notes-
Supported by Vifor Pharma (formerly Aspreva Pharmaceuticals) as part of the Roche–Aspreva rare diseases collaboration.
[06/06/24, 8:02:41 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Well done 👏👏
[06/06/24, 8:03:10 PM] Dr. Deepika Jnr Gm Kam: total remission rate 84% (82% with MMF and 87% with AZA), complete remission rate of 59.3% (58% with MMF and 60% with AZA), and a partial remission rate of 25% (22% with MMF and 27% with AZA) over 41.5 + 7 months
Relapse-free survival was higher with MMF (78%) and AZA (58%) compared to i.v. CYC (43%).
Cons:
creatinine levels are higher in the MMF group at the start, and proteinuria is higher after treatment in the MMF group
[06/06/24, 8:25:40 PM] Dr Rakesh Biswas Sir Hod Gm Kam: If possible share absolute values such as x number of patients out of y had...
rather than relative values (as above in percentage)
[06/06/24, 8:33:37 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Look how insignificant the differences in the absolute values are!
[06/06/24, 8:34:06 PM] Dr. Deepika Jnr Gm Kam: My question here is 2 different studies showed different answers
One showed MMF superior to AZA
Other showed AZA slightly better than MMF ( though smaller study)
Both studies had their cons
So how do we go about it sir?
As already thought of should we give Azathioprine bcoz she responded prior to it sir?
[06/06/24, 8:34:55 PM] Dr. Deepika Jnr Gm Kam: Sir could it be because the n in each group were not equal ?
[06/06/24, 8:38:19 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Looks like a coin toss as far as therapeutic uncertainty between choosing either of them lies. Best give our current patient what she has already responded to
[06/06/24, 8:51:48 PM] Sai Charam Kulkarni: Received call from patients father today. Updated on patient condition.
She discontinued her education and not working anywhere. Her father aspire her to be alive in front of her with good health.
I asked him why she discontinued from her education..?
He replied in low voice that he has no extra money for her education apart for her medical bills.
Told @919121046928 @918367363668 has helped them with initial assessment and in hope of getting her better soon. Thank you 🙏🏻
[06/06/24, 9:24:00 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @918106178236 She can be trained to become a fantastic PaJR coordinator
[06/06/24, 9:31:12 PM] ~ Stay Hungry Stay Foolish✌: Ok sir I will talk to her
[06/06/24, 9:31:15 PM] ~ Stay Hungry Stay Foolish✌: 🙏
[06/06/24, 9:34:45 PM] ~ Stay Hungry Stay Foolish✌: May I know who is patient advocate
[06/06/24, 9:36:19 PM] Dr. Deepika Jnr Gm Kam: I can pm the details of patient advocate (father)as he is not on WhatsApp
[06/06/24, 9:37:38 PM] ~ Stay Hungry Stay Foolish✌: Thank you
[07/06/24, 8:36:24 AM] Sai Charam Kulkarni: Given her body weight of 40-45 kgs. Better to Start with wysolone 20mg BD and AZA 50mg OD.
@918367363668
Look for any contraindications for the drugs..
[11/06/24, 8:34:27 AM] Sai Charam Kulkarni: Patient called and reported Pedal edema has decreased and started facial puffiness.
I don’t think any diuretic was given for her anasarca..?
@Dr. Deepika Jnr Gm Kam can you share what she is currently using ..?
[11/06/24, 8:36:09 AM] Sai Charam Kulkarni: Advised dytor plus once daily for 3 days.
[11/06/24, 9:35:17 AM] Dr. Deepika Jnr Gm Kam: Azathioprine once
Wysolone 20 twice sir
[11/06/24, 9:38:04 AM] Dr. Dinesh Datta Jr Kam: Duration?
[11/06/24, 10:00:14 AM] Dr Rakesh Biswas Sir Hod Gm Kam: In the mornings she will notice that and in evenings she will notice pedal edema
[11/06/24, 10:06:27 AM] Sai Charam Kulkarni: She reported after started this medication only she developed facial puffiness..
I remember what u say..
“Corelation is not causation”
[11/06/24, 10:07:33 AM] Sai Charam Kulkarni: However duretic for 3 days would resolve her volume overload symptomatically and above 2 medicines will take care of this relapse
[11/06/24, 10:16:24 AM] Dr Rakesh Biswas Sir Hod Gm Kam: We can only hope it will just because it did once but then we are dealing with a dynamic adaptible immune system and we also don't have any idea of her PNI drivers? @918519976747
[11/06/24, 10:31:21 AM] Sai Charam Kulkarni: Added @919133006151 patients advocate to the group now we can have answers to the patients health related issues and PNI factors
[11/06/24, 10:52:19 AM] Dr Rakesh Biswas Sir Hod Gm Kam: This will be tricky as it's traditionally a dyadic process and converting it to team based learning can be an intriguing experiment
[11/06/24, 10:58:14 AM] Sai Charam Kulkarni: Now she is part of the team where she can provide her inputs and triggers related to PNI
[11/06/24, 11:00:09 AM] Sai Charam Kulkarni: @919133006151 చెప్పండి ఇప్పుడు మీ పేషెంట్ కి ఎలా ఉంది..? ఏమైనా ఆరోగ్య సమస్యలు ఉన్నాయా..?
[11/06/24, 11:11:48 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Hope she can keep the patient well deidentified to protect the patient's privacy and confidentiality in the team?
[11/06/24, 11:17:53 AM] Sai Charam Kulkarni: I explained patient advocate to deidentify patient and related data for the matter of privacy sir
[11/06/24, 9:04:41 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Your security code with Rakesh Biswas Sir Hod changed.
[12/06/24, 11:34:03 AM] Pt SLE: Gd mrng sir nd madam moham vapu thagadam ldu kalla vapulu thaginae
[12/06/24, 11:35:02 AM] Pt SLE: Maa frnd ki sir
[12/06/24, 11:38:14 AM] Sai Charam Kulkarni: Let me introduce her she is the advocate of current patient
[12/06/24, 11:38:24 AM] Sai Charam Kulkarni: @918367363668
[12/06/24, 12:49:58 PM] Dr. Deepika Jnr Gm Kam: Sir spoke with her on call
She's giving history of facial puffiness since 2 days
This started 2 days after her initiation of medications
No other history
Fever, Pedal edema subsided <This message was edited>
[12/06/24, 12:50:59 PM] Dr. Deepika Jnr Gm Kam: With previous history of cushings should we consider and taper steroid slowly to lower dose sir
Like 20 mng and 10 at night?
Or consider other differentials sir?
[12/06/24, 12:54:34 PM] Dr Rakesh Biswas Sir Hod Gm Kam: We need to see her facial swelling to determine it's clinical significance by admitting her here if necessary for a few days
[12/06/24, 12:57:46 PM] Sai Charam Kulkarni: Thank you. Please encourage patient to text in group than talking in person so that she will be habituated to share her physical and emotional illness here.
[12/06/24, 12:58:19 PM] Dr Rakesh Biswas Sir Hod Gm Kam: You mean patient advocate right
[12/06/24, 1:05:58 PM] Sai Charam Kulkarni: Yes sir
[12/06/24, 1:26:49 PM] Dr. Deepika Jnr Gm Kam: @917731951004 okasari me ammayini teskuni hospital ki vastara vaapu ekkuva unda leda hospital lo unchi chustamu
Dani batti mek icche mandulu chptaru .
Okasari hospital ki admit avvadaniki ragaltara?
[14/06/24, 9:05:09 AM] Pt SLE: Gd mrng sir nd madam sir moham thagadam ledu maa frnd ki hospital ki rammannaru kani money adjust katldu anta sir nxt time vastha antunnaru sir epudu m aena dose thagisthara sir
[14/06/24, 9:12:05 AM] Dr Rakesh Biswas Sir Hod Gm Kam: @919154575937 @918106178236 Can you translate?
[14/06/24, 9:13:33 AM] Dr. Deepika Jnr Gm Kam: Advocate is telling that pt facial puffiness didn't subside and they are trying to arrange money to visit the hospital but they couldn't right now Can we suggest the patient any thing sir
[14/06/24, 9:19:22 AM] Dr Rakesh Biswas Sir Hod Gm Kam: How much money do they require to visit? How far are they?
[14/06/24, 9:20:52 AM] Dr Rakesh Biswas Sir Hod Gm Kam: @918106178236 a homehealth network would again be more effective here? All we need to do is to get their local doctors into this PaJR group network?
[14/06/24, 9:41:51 AM] Dr. Deepika Jnr Gm Kam: They live near choutuppal sir
[14/06/24, 9:44:43 AM] Sai Charam Kulkarni: What about IP free ..?? Is this scheme not available now..?
Didn’t they have KAP..?
@918367363668
@919121046928
[14/06/24, 9:48:11 AM] Dr Rakesh Biswas Sir Hod Gm Kam: It's been upgraded to free with 500/- worth of free tests
However the reluctance in getting admitted could be because time is money and every day in hospital is loss of pay.
@918106178236 all the more reasons to push for a networked based approach detailed above?
[14/06/24, 9:58:28 AM] Sai Charam Kulkarni: Yes sir. But when patient feels that his/her illness hampering activities of daily living then they will be forced to admit.
[14/06/24, 10:00:02 AM] Dr Rakesh Biswas Sir Hod Gm Kam: And our idea of the home health network is to not let it wait and fester that long but deliver Amazon healthcare at home
[17/06/24, 12:40:44 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Reviewed her now in the OPD
On examination has mild facial puffiness
Mild pedal edema
On 40mg of prednisolone and 50 mg of azathioprine
Edema likely due to nephrotic syndrome which will need to be reevaluated with a repeat 24 hour protein and creatinine after one month.
Last time from OPD someone ordered serum total protein not albumin!
[17/06/24, 12:43:20 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Dr Rakesh Biswas Sir Hod Gm Kam changed the group name to “20F Lupus Nephritis relapse 2 weeks, Seizures and nephritis recovered, Telangana PaJR”
Reviewed her in the OPD today as she's complaining of right hypochondrium pain her fingers in the image pointing towards the site of pain
[16/07/24, 8:57:05 AM] Sai Charam Kulkarni: patient rushed to hospital in morning hours to our hospital with complaints of severe pain abdomen and SOB.
Patient is redirected to surgery OPD by someone.
Don’t know why..?
Can duty pg quickly look into this..?
[16/07/24, 8:58:34 AM] Sai Charam Kulkarni: Is there any indication for surgery..?
What made us to refer her to surgery department ..?
They are waiting for surgerons (46 no OPD )
[16/07/24, 8:59:47 AM] Sai Charam Kulkarni: @918897799393 @919491489659 @919505766290
[16/07/24, 9:15:43 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Who are the duty PG's?
[16/07/24, 9:16:14 AM] Dr Rakesh Biswas Sir Hod Gm Kam: I'll go to the surgery OPD and check
[16/07/24, 9:19:22 AM] Sai Charam Kulkarni: Thank you sir 🙏🏻
[16/07/24, 9:21:01 AM] Dr Rakesh Biswas Sir Hod Gm Kam: They sent her to casualty from surgery OPD. I'm going there
[16/07/24, 9:32:11 AM] ~ Lajrupa Bhadra: Dr Rakesh Biswas Sir Hod Gm Kam added ~ Lajrupa Bhadra
[16/07/24, 9:34:05 AM] Dr Rakesh Biswas Sir Hod Gm Kam: 👆Very similar pain with increased intensity.
On examination, apparently a pleural rub heard
Impression is pleuritic pain
Plan:
Ask surgeons to document their impression @919398587059
Shift to AMC ICU
Add NSAIDs for pain relief
Can start with oral Ultracet 1/2 qds with pcm 500 qds
Inj NSAIDs sos
Ultrasound bedside to evaluate any tappable fluid to rule out kochs
[16/07/24, 9:39:29 AM] Sai Charam Kulkarni: On Teleconsultation yesterday night patient attender told me that she is having SOB and cough with no fever.
Advised Tab Montek LC BD
Syp ascoril LS
[16/07/24, 9:50:18 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes she still has cough along with what appears to be pleuritic pain
It's likely mycobacterial colonies knocking at her pleural doors encouraged by our once daily prednisolone 40mg and azathioprine 50mg?
[16/07/24, 11:23:38 AM] Dr Bharath Jnr Gm Kam:
[16/07/24, 11:27:54 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Multiple lung abscesses
Without fever due to our immunosuppressives!
[16/07/24, 11:29:06 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Let's do the ultrasound guided pleural tap asap and include CBNAAT too in the tests other than WBC cell type cell count and protein LDH along with serum protein LDH ASAP
[16/07/24, 11:36:21 AM] Dr Himaja Jnr Gm Kam: Dr Himaja Jnr Gm Kam joined using this group's invite link
[16/07/24, 11:44:36 AM] Prachethan Gm Jnr Kam:
[16/07/24, 11:47:01 AM] +91 90009 62944: +91 90009 62944 joined using this group's invite link
[16/07/24, 11:58:43 AM] +91 99634 18233: +91 99634 18233 joined using this group's invite link
[16/07/24, 12:03:45 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Subdiaphragmatic collection!?
Please ask them what could be the reason for that!!
Or did they mean subpulmonic?
[16/07/24, 12:09:17 PM] Harika Gm Jnr Kam: Harika Gm Jnr Kam joined using this group's invite link
[16/07/24, 12:22:12 PM] Sai Charam Kulkarni: Can some one share lung Ultrasound video @919491489659 @918074920633 @917989589761
Multiple air fluid levels in lungs
[16/07/24, 12:42:19 PM] Dr Pradeep Gm Kam: Dr Pradeep Gm Kam joined using this group's invite link
[16/07/24, 12:59:36 PM] Prachethan Gm Jnr Kam: Subdiaphragmatic sir
[16/07/24, 1:06:37 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Share the video
[16/07/24, 3:51:44 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Dr Rakesh Biswas Sir Hod Gm Kam changed the group description
[16/07/24, 3:52:24 PM] ~ Raghavendra: Dr Rakesh Biswas Sir Hod Gm Kam added ~ Raghavendra
[16/07/24, 4:05:02 PM] ~ Dr RAVI KUMAR: Dr Rakesh Biswas Sir Hod Gm Kam added ~ Dr RAVI KUMAR
[16/07/24, 3:52:09 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Previous echo on September 2022
[16/07/24, 4:10:25 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Even in September 2022 we had started her on IV augmentin for poorly localised sepsis👇
Even today in July 2024 we started on augmentin metrogyl @916309964666 for right sided multiple lung abscesses possibly a result of opportunistic bacterial infection due to her one month of immunosuppressives
We shall get the urine for 24 hours protein and creatinine tomorrow
[16/07/24, 4:11:23 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @918500225142 will share the YouTube link to the chest ultrasound and echo video we took today afternoon
[16/07/24, 5:14:50 PM] ~ SavanthReddy: ~ SavanthReddy joined using this group's invite link
[16/07/24, 5:10:38 PM] ~ Raghavendra:
[16/07/24, 6:58:19 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Thanks
[16/07/24, 7:35:44 PM] Dr Chandana Gm Kam:
She has a hydropneumothorax sir
[16/07/24, 8:05:46 PM] Sai Charam Kulkarni: Thanks . Only hydropneumo or ruptured abscess..?
Any needle was placed to get diagnosis..?
Patient advocated called me in fear to seek some emotional support.
Any spiking fever..? Any plan for ICD..?
@917989589761
[16/07/24, 8:11:01 PM] Prachethan Gm Jnr Kam: Fever spike was present at the time of admission sir
Subsided now
She is having breathlessness and cough predominantly sir
RR ranging from 26-28cpm
Case have been discussed with pulmo team sir
Still Plan for ICD not yet confirmed
Will update sir
[16/07/24, 8:14:46 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes likely due to ruptured abscesses which will be clear if you can share the Hrct films. The one shared here is the mediastinal cut where the lung isn't visible
[16/07/24, 8:15:37 PM] Dr Chandana Gm Kam: Yes sir i will post the video
[16/07/24, 8:19:24 PM] Dr Chandana Gm Kam: @917989589761 please post the other videos if available
[16/07/24, 8:20:00 PM] Dr Rakesh Biswas Sir Hod Gm Kam: This video doesn't show the Hrct lung windows
[16/07/24, 8:20:35 PM] Dr Chandana Gm Kam: Yes sir @917989589761 is sending
[16/07/24, 8:52:18 PM] Prachethan Gm Jnr Kam:
[16/07/24, 10:20:12 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Amazing!
This looks like a loculated hydropneumothorax!
[16/07/24, 10:21:10 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Let's ask pulmonology to go ahead with a chest tube drain
[16/07/24, 10:21:23 PM] Prachethan Gm Jnr Kam: Yes sir
They r doing it now
[16/07/24, 10:40:45 PM] Dr Adithya Sir Gm Kam: Any bearing with the recent right hypochondrial pain you think.
[16/07/24, 10:40:46 PM] Dr Adithya Sir Gm Kam: ?
[17/07/24, 11:58:49 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Absolutely yes
We did think of a pleuritic pain and she also had a pleural rub
[17/07/24, 2:13:48 PM] Prachethan Gm Jnr Kam:
ICD placed yesterday night
[17/07/24, 2:14:34 PM] Prachethan Gm Jnr Kam: Can we taper the steroids for now sir ?
[17/07/24, 2:21:40 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes
What about her urine for 24 hour protein and creatinine? Have we started collecting it since today morning?
[17/07/24, 2:25:01 PM] Prachethan Gm Jnr Kam: Started today sir
[17/07/24, 3:15:10 PM] Dr Rakesh Biswas Sir Hod Gm Kam: icd functioning well
24h proteinuria much less than before, although still significant proteinuria persist and glomerular inflammatory activities dont appear to be in remission.
persistent lung abcess fluid levels perhaps as the pleural hydropneumothorax appears to have been dealt with fairly well by the ICD
[18/07/24, 4:27:01 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @919154575937 @918500225142 would you like to update the above information about her current issues into the case report that you have already made for her years ago?
[18/07/24, 6:44:13 PM] Sai Charam Kulkarni: Will share soon sir
[18/07/24, 6:45:40 PM] Sai Charam Kulkarni: @patient happy birthday 🎂🎂💐💐
[19/07/24, 8:54:21 AM] Prachethan Gm Jnr Kam:
[19/07/24, 9:30:38 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Let's not repeat chest X-rays daily unless absolutely indicated?
[19/07/24, 10:01:45 AM] Prachethan Gm Jnr Kam: Okay sir
[19/07/24, 6:58:52 PM] ~ Vyshnavi: Pulmonology people advised for bronchscopy with the ICD insitu. Shall we go ahead @919121046928 sir? <This message was edited>
[19/07/24, 7:06:00 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Ask what do they hope to gain from this test
[19/07/24, 7:38:30 PM] ~ Vyshnavi: Okay sir
[20/07/24, 9:36:40 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Dr Rakesh Biswas Sir Hod Gm Kam changed the group description
[20/07/24, 9:37:08 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Dr Rakesh Biswas Sir Hod Gm Kam changed the group description
[22/07/24, 9:53:18 PM] Prachethan Gm Jnr Kam:
[22/07/24, 9:57:44 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Ask the patient's to give a signed informed consent where they request the pulmonologist to remove the ICTD with a caveat that it's a trial removal and if necessary it would need to be reinserted.
Tell the pulmonologist that it's better to reinsert it if necessary onto another locule instead of needlessly keeping it in a locule which is already drained
[22/07/24, 10:05:16 PM] Prachethan Gm Jnr Kam: Okay sir
[23/07/24, 10:12:00 PM] Sai Charam Kulkarni: Is there any intra luminal pathology..?
What they are expecting in bronchoscopy..?
Why everyone want to refer her for further evaluation..?
Is her present condition is more life threatening than when she was admitted with IVH where have ‘death consent’ to continue treatment in KIMS in NKP ..?
Patient advocated called me and told ‘ everyone here is trying to refer us to higher center for further management except rakesh sir and other mam may be unit SR..
His emotions exploded with this statement..!!
My elder daughter was expired in gandhi so I denied going there.. tell me where you want to go am ready to take my patient there..!!
He also told I feel KIMS is more safer than Gandhi ( actually true ) but don’t know why am being referred.
@919121046928 is she need any intervention currently..?
What to be done next..?
ICD removal followed by OP follow up or any other suggestions from your side..?
[23/07/24, 10:14:20 PM] Prachethan Gm Jnr Kam: Sir plan from our side as advised by @919121046928 sir is to remove the Current icd after taking the informed consent from attenders regarding risk of insertion
[23/07/24, 10:17:30 PM] Prachethan Gm Jnr Kam: We took the same and informed pulmo team
They counselled the attenders to take to higher center in view of VATS for decortication as the trapped lung in long run may lead to permanent impairment of lung expansion and fibrosis
[23/07/24, 10:21:11 PM] Prachethan Gm Jnr Kam: The pts father gave the consent for ICD removal and it will be done tomorrow sir
[23/07/24, 10:32:56 PM] Sai Charam Kulkarni: Thank you bro
As you are daily visiting doctor.. what do you think Does she needs VATS based on your overall longitudinal observation..?
[23/07/24, 10:33:54 PM] Dr Rakesh Biswas Sir Hod Gm Kam: I don't think she needs vats at this point
[23/07/24, 11:31:39 PM] Dr Adithya Sir Gm Kam: Why did she have the HPT in the first place? Shouldn't TB be high on the cards?
[24/07/24, 7:56:34 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes but her symptoms have so far responded to our attempts at eliminating SP rather than MT
She is nearly asymptomatic other than the occasional thrombophlebitis fever spikes due to our continued fascination with IV antibiotics and ICTD into empty locules
[24/07/24, 3:34:10 PM] Dr Rakesh Biswas Sir Hod Gm Kam:
[25/07/24, 11:03:43 AM] Dr Adithya Sir Gm Kam: Recall from my textbook learning that anaerobes or MT more commonly known to cause HPTs than SP?
[25/07/24, 11:06:35 AM] Dr Rakesh Biswas Sir Hod Gm Kam: @917989589761 what attempts has the team made to rule out mycobacterial infection till date in this patient?
Please share the pleural fluid CBNAAT, ADA cell type cell count and sputum AFB
Anerobes are being covered anyways?
[25/07/24, 11:07:55 AM] Dr Adithya Sir Gm Kam: Yes can see the Metronidazole. Although Piptaz does cover what Metronidazole covers.
[25/07/24, 11:10:54 AM] Dr Adithya Sir Gm Kam: Also, we are seeing Amoxyclav treating sepsis quite well here. Antibiotic policy is quite strictly vetted
[25/07/24, 11:12:22 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes we began with that and @917989589761 felt that she deserved piptaz the very next dose
[25/07/24, 11:13:15 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Our policy is driven by big Pharma because we aren't funded by the tax payers
[25/07/24, 11:14:12 AM] Dr Rakesh Biswas Sir Hod Gm Kam: I guess piptaz at lib was very much in vogue when you were a PG here?
[25/07/24, 11:15:06 AM] Dr Adithya Sir Gm Kam: Yes largely because of QC in pharma. Not because the bugs are super resistant
[25/07/24, 11:22:07 AM] Prachethan Gm Jnr Kam: Pleural fluid Analysis :
Sugar -64(60-90)
Protein -3.5(0-2.5)
LDH - 2022(230-460)
Exudative
Pleural fluid ADA -27 (>30)
Pleural fluid cell count -
700 cells
(72% Neutrophils
28% Lymphocytes)
Sputum for C&S - poor quality ,No growth
Pleural fluid for CBNAAT -Negitive
Pleural fluid C&S - No growth
Patient was on Inj piptaz and metronidazole
Shifted to oral Levofloxacin and metronidazole since 3 days
[25/07/24, 11:49:52 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Pharma QC driven piptaz antibiotic stewardship
[25/07/24, 11:59:11 AM] Prachethan Gm Jnr Kam:
[25/07/24, 12:36:12 PM] Dr Adithya Sir Gm Kam: And the Piptaz itself is dodgy!
[25/07/24, 12:36:39 PM] Dr Adithya Sir Gm Kam: Clearly she is worsening and this can't be attributed to Thrombophlebitis alone?
[25/07/24, 12:37:19 PM] Dr Adithya Sir Gm Kam: I would still think this is TB. Wasn't she on long term immunosuppresion?
Afebrile whole day yesterday. WBC counts still rising! Hb fallen from 11 to 7 over 10 days! Patient wants to get discharged ASAP!@Sai Charam Kulkarni
[26/07/24, 11:11:42 AM] Sai Charam Kulkarni: They are in fear due to extreme counselling done by some eminent medical personals ( don’t know pgs / Sr/ etc ) in room beside Arogyasree office and room near scanning.
They called me and told they are ready to go anywhere to save her life.
[26/07/24, 11:32:26 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Anywhere away from the unit 2 team? This has been the perpetual theme here even when you were here?
[26/07/24, 11:34:03 AM] Dr Rakesh Biswas Sir Hod Gm Kam: The location appears to be pulmonology and they must be wanting to send her somewhere for VATs
[26/07/24, 11:38:15 AM] Sai Charam Kulkarni: They believe only in unit 2 that is why they still wants to stay with the team. But any particular reason they want to leave sir..?
[26/07/24, 11:43:16 AM] Sai Charam Kulkarni: @917989589761 does what’s change her current status..?
What is the cost of VATS..?
What is your review on doing VATS vs conservative management in your patient..?
[26/07/24, 11:50:57 AM] Sai Charam Kulkarni: @917989589761 is she fit for discharge..?
Hb drop is due to haemolysis , blood loss ..?
[26/07/24, 11:54:21 AM] Prachethan Gm Jnr Kam: She is symptomatically ok sir
No fever or breathlessness right now
Her Tlc Today is 26000 sir
but she is good
Hb drop may be due to combination of chronic inflammation and blood loss during and after ICD insertion
[26/07/24, 11:56:19 AM] Dr Rakesh Biswas Sir Hod Gm Kam: The only value add from VATs would be a good view of tubercles on the lung surface and vats guided pleural biopsy that may allow us to diagnose pleural tuberculosis with better certainty
[26/07/24, 11:57:04 AM] Dr Rakesh Biswas Sir Hod Gm Kam: @919154575937 can you update all the transcripts of the current admission in your case report EHR?
[26/07/24, 12:12:27 PM] Sai Charam Kulkarni: Thanks
[26/07/24, 12:13:07 PM] Sai Charam Kulkarni: Almost done sir just need to insert images and deidentifying is pending
[26/07/24, 12:13:12 PM] Sai Charam Kulkarni: Will share soon
[26/07/24, 12:45:35 PM] Dr Rakesh Biswas Sir Hod Gm Kam: There are some very nice Hrct videos of her repeated Hrct pre and post ICTD. Someone needs to collate those into YouTube
[26/07/24, 2:58:18 PM] Pt SLE: Naa frnd return to home in hospital
[26/07/24, 3:00:19 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @13135550002 how long can one continue oral levofloxacin started by @918328223112 for lung abscesses?
[26/07/24, 3:00:21 PM] Meta AI: The duration of oral levofloxacin treatment for lung abscesses typically ranges from 4-6 weeks, but can vary depending on the severity of the infection, patient response, and physician guidance. It's essential to follow the specific treatment plan and duration recommended by your healthcare provider.
Some general guidelines are:
- Mild to moderate cases: 4-6 weeks
- Severe cases or those with complications: 6-8 weeks or longer
- Cases with abscesses larger than 2 cm: 8 weeks or longer
Please consult your healthcare provider for personalized guidance, as they will assess your condition and adjust the treatment plan accordingly. <This message was edited>
[26/07/24, 3:31:27 PM] Dr Adithya Sir Gm Kam: Can it be possible she is bleeding into her thorax?
[26/07/24, 4:19:37 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @918332919067 please check her postural drop of blood pressure in supine v standing ASAP
DISCHARGE SUMMARY
Age/Gender : 22 Years/Female
Admission Date: 16/07/2024 09:39 AM
Diagnosis:
RIGHT MULTI-LOCULATED HYDROPNEUMOTHORAX SECONDARY TO ? RUPTURED LUNG ABSCESS ? LUPUS PLEURITIS
K/C/O SLE WITH LUPUS NEPHRITIS SINCE 3 YEARS S/P ICD REMOVAL ON 24/07/2024.
Case History and Clinical Findings
CHIEF COMPLAINTS-
C/O PAIN IN THE ABDOMEN SINCE 3 DAYS
C/O BREATHLESSNESS SINCE 1 DAY
HOPI-
PATIENT IS A KNOWN CASE OF SLE WITH LUPUS NEPHRITIS,SINCE 2 YEARS ON MEDICATION T.AZATHIOPRINE 50MG, T.PREDNISOLONE 20 MG TWICE A DAY. PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN SHE DEVELOPED PAIN ABDOMEN IN THE RIGHT HYPOCHONDRIUM, WHICH IS INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE,RADIATING TO RIGHT LOIN, AGGRAVATED SINCE YESTERDAY NIGHT , NOT ASSOCIATED WITH VOMITINGS AND LOOSE STOOLS.
H/O FEVER YESTERDAY NIGHT, LOW GRADE WITH NO CHILLS AND RIGORS.BREATHLESSNESS OF GRADE III-IV SINCE 3 DAYS AGGRAVATED SINCE YESTERDAY NIGHT,NOT RELIEVED ON REST ,ASSOCIATED WITH DRY COUGH.
H/O FACIAL PUFFINESS SINCE YESTERDAY PAST HISTORY-
K/C/O SLE WiTH LUPUS NEPHRITIS SINCE 2 YEARS H/O CARDIO EMBOLIC STROKE 2 YEARS BACK
H/O LIBMAN SACHS ENDOCARDITIS.
PERSONAL HISTORY:
SINGLE MIXED DIET
APPETITE NORMAL
BOWEL MOVEMENTS REGULAR MICTURITION NORMAL
NO KNOWN ALLERGIES
NO ADDICTIONS AND DRUG USE GENERAL EXAMINATION::
NOPALOR, CYNOSIS,ICTERUS,CLUBBING,LYMPHADENOPATHY,EDEMA. VITALS:
TEMPERATURE :100.3 F PR:98 BPM
RR:26CPM BP:110/80MM HG
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD,NO MURMURS,NO THRILLS
RESP: BAE+ ,NVBS+,DYSPNOEA PRESENT,WHEEZE PRESENT.PER ABDOMEN: SCAPHOID, SOFT,TENDERNESS PRESENTCNS: PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE, NO FOCAL NEUROLOGICAL DEFICIT.16/07/2024REFERRED TO GENERAL SURGERY I/V/O PAIN IN THE RIGHT UPPER QUADRANT SINCE 3 DAYS,ADVISED USG ABDOMEN, X-RAY ERECT ABDOMEN.16/07/2024REFERRED TO PULMONOLOGY I/V/O USG SHOWING B/L PLEURAL EFFUSION WITH LOCULATED COLLECTION. ADVISED HRCT CHEST.17/07/2024CASE REVIEWED BY GENERAL SURGERY ON 17/07/2024 BASED ON HRCT REPORT.DIAGNOSED AS RIGHT SIDED HYDROPNEUMOTHORAX SECONDARY TO ? RUPTURED ABSCESS, ADVISED TO PLAN FOR ICD INSERTION.CASE REVIEWED BY PULMONOLOGY ON 17/07/2024 BASED ON HRCT REPORT.DIAGNOSED AS RIGHT SIDED HYDROPNEUMOTHORAX SECONDARY TO ? RUPTURED ABSCESS, ICD INSERTION DONE.CASE REFERRED TO CTV SURGEON ON 20/07/2024 I/V/O RESIDUAL LOCULATED HYDROPNEUMOTHORAX POST ICD , ADVISED REPOSITION OF ICD, CONTINUE ICD WITH COLUMN MOVEMENT,SURGICAL INTERVENTION.COURSE IN THE HOSPITAL:A 22YR OLD FEMALE WHO IS A KNOWN CASE OF SLE WITH LUPUS NEPHRITIS ON TAB AZATHIOPRINE 50mg AND PREDNISOLONE 40MG ONCE DAILY, WAS BROUGHT TO CASUALTY WITH CHIEF COMPLAINTS OF PAIN ABDOMEN SINCE 3DAYS,BREATHLESSNESS SINCE 3DAYS, ASSOCIATED WITH LOW GRADE FEVER. VITALS AT PRESENTATION TEMP 100.3, PR 98BPM, RR 26CPM, BP 110/60MMHG, SPO2 94%ON RA, GRBS 106MG/DL. ON EXAMINATION HYPERRESONANT NOTE HEARD IN RIGHT INFRACLAVICULAR AREA, DECREASED BREATH SOUNDS IN RIGHT MA, IAA, ISA, WHEEZE PRESENT IN RIGHT ISA. ON FURTHER EVALUATION CHEST XRAY SHOWED MULTIPLE AIR FLUIDS LEVELS ON RIGHT SIDE. USG CHEST SHOWED MULTIPLE LOCULATIONS WITH THICK INTERNAL ECHOES IN ANTERIOR AND LOWER LATERAL CHEST WALL, SU DIAPHRAGMATIC COLLECTION WITH THICK INTERNAL SEPTATIONS. PULMONOLOGY OPINION WAS TAKEN IVO CHEST XRAY CHANGES, AND WAS ADVISED FOR HRCT CHEST WHICH SHOWED LARGE MULTILOCULATED RIGHT HYDROPNEUMOTHORAX CAUSING COMPRESSIVE COLLAPSE OF RIGHT LUNG. REVIEW PULMONOLOGY OPINION WAS TAKEN AND
PLACED 28FR ICD IN RIGHT 5TH INTERCOSTAL SPACE IN MIDAXILLARY AREA AND FIXED AT MARK 7 AFTER WHICH 250ML DRAIN WAS OBTAINED. TREATED WITH ANTIBIOTICS AND ANTIPYRETICS, AND SPIROMETRY AS ADVISED BY PULMONOLOGIST.PREDNISOLONE TAPERED TO 30MG/DAY. SOB SUBSIDED. PLEURAL FLUID ANALYSIS SUGGESTED EXUDATE. PLEURAL FLUID AND SPUTUM CULTURES SHOWED NO GROWTH, BLOOD AND URINE CULTURE SHOWEF NO GROWTH.REVIEW HRCT POST ICD SHOWED RESIDUAL LOCULATED HYDROPNEUMOTHORAX, SIGNIFICANT EXPANSION OF RIGHT LUNG, WITH CONSIDERABLE POCKETS OF OF LOCULATED HYDROPNEUMOTHORAX INVOLVING PARAVERTEBRAL PLEURA AND POSTERIOR COASTAL PLEURA, SMALL POCKETS OF LOCULATED PERIHEPATIC COLLECTION IN UPPER ABDOMEN. FEVER SPIKES WERE PRESENT.CTVS OPINION WAS TAKEN AND ADVISED TO REPOSITION OF ICD, AND THORACOSCOPY. AFTER DUE CONSENT ICD WAS REMOVED ON DAY8. PATIENT WAS IMPROVED CLINICALLY AND DISCHARGED IN HEMODYANAMICALLY STABLE CONDITION WITH ANTIBIOTICS FOR 2WEEKS.
Investigation 16/07/2024 HEMOGRAM:
HB:11.9% (1:25 PM)
TOTAL COUNT:12,100 CELLS/CUMM NEUTROPHILS:84 % LYMPHOCYTES:15 % EOSINOPHILS: 00% MONOCYTES:01 %
BASOPHILS: 00%
PCV: 34.9%
MCV: 89.5
MCH: 30.5
MCHC: 34.1
RBC: 3.90 MILLIONS/CUMM
PLATELETS: 5.66 LKHS/CUMM ESR:60MM-1ST HOUR
SEROLOGY: Negative
LIVER FUNCTION TEST (LFT)
Total Bilurubin 1.94 mg/dl Direct Bilurubin 1.00 mg/dl
SGOT(AST) 48 IU/L
SGPT(ALT) 221 IU/L
ALKALINE PHOSPHATASE 535 IU/L TOTAL PROTEINS 4.9 gm/dl
ALBUMIN 2.4 gm/dl
A/G RATIO 0.97
BLOOD UREA 51 mg/dl
SERUM CREATININE 0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 137 mmol/L
POTASSIUM 4.6 mmol/L
CHLORIDE 102 mmol/L
CALCIUM 1.04 mmol/L
SEROLOGY NEGATIVE BLOOD UREA 51 MG/DL BLOOD CREATININE : 0.9
BLEEDING TIME : 2 MIN 30 SECONDS CLOTTING TIME : 5 MIN HAEMOGLOBIN 9:00 PM-11.1 GM/DL
USG (16/07/24)
IMPRESSION: B/L PLEURAL EFFUSION (MILD)
LOCULATED COLLECTIONS IN THE SUBDIAPHRAGMATIC AREA,ANTERIOR AND LATERAL LOWER CHEST WALLS.
SUGGESTED HRCT FOR FURTHER EVALUATION.
HRCT-CHEST:(16/07/2024)
IMPRESSION:LARGE MULTILOCULATED RIGHT HYDROPNEUMOTHORAX CAUSING COMPRESSIVE COLLAPSE OF RIGHT LUNG.
MILD LEFT PLEURAL EFFUSION. LEFT LUNG NORMAL.
CHEST WALL EDEMA ON RIGHT SIDE.
17/07/2024
HEMOGRAM:
HB: 9.2% (1:25 PM)
TOTAL COUNT:12,100 CELLS/CUMM NEUTROPHILS:92 % LYMPHOCYTES: 05 %
EOSINOPHILS: 00% MONOCYTES:03 % BASOPHILS: 00%
PCV: 27.0%
MCV: 90.9
MCH: 31.0
MCHC: 34.1
RBC: 2.97 MILLIONS/CUMM
PLATELETS: 3.92 LKHS/CUMM PLEURAL FLUID LDH : 2,022 IU/L PLEURAL FLUID ADA : 27 U/L PLEURAL SUGAR : 64 MG/DL PLEURAL PROTEIN : 3.5 G/DL SERUM LDH : 238 IU/L
24HRS URINARY PROTEIN: 599MG/DAY- VOLUME OF 1100 ML
24 HRS URINARY CREATININE:0.8GM/DAY
17/07/2024
SPUTUM FOR CULTURE AND SENSITIVITY: >25 EPITHELIAL CELLS/CPF , <10 PUS CELLS/CPF MODERATE NO. OF GRAM POSITIVE COCCI IN SINGLES,MODERATE GRAM POSITIVE BACILLI SEEN,FEW GRAM NEGATIVE BACILLI SEEN.NORMAL OROPHARYNGEAL FLORA
GROWN.
PLEURAL FLUID CULTURE AND SENSITIVITY:(17/07/2024) MODERATE NUMBER OF PUS CELLS,NO ORGANISMS SEEN. NO GROWTH AFTER 48 HRS OF AEROBIC INCUBATION.
17/07/2024
PLEURAL FLUID CYTOLOGY REPORT:
MICROSCOPIC EXAMINATION: CYTOSMEAR STUDIED SHOWS NUMEROUS DEGENERATED NEUTROPHILS, FEW LYMPHOCYTES IN THE BACKGROUND AND HEMORRHAGES.NO EVIDENCE OF ATYPICAL CELLS.
18/07/2024
BLOOD FOR CULTURE AND SENSITIVITY: NO GROWTH AFTER 48 HRS OF AEROBIC INCUBATION
SPUTUM FOR CELLS : NORMAL OROPHARYNGEAL FLORA SEEN. 19/07/2024
REVIEW HRCT CHEST: POST ICD INSERTION:
IMPRESSION: RESIDUAL LOCULATED HYDROPNEUMOTHORAX WITH AN ICD TUBE IN-SITU. SIGNIFICANT EXPANSION OF RIGHT LUNG AS COMPARED TO PREVIOUS SCAN.
HOWEVER CONSIDERABLE POCKETS OF LOCULATED HYDROPNEUMOTHORA STILL REMAIN INVOLVING THE PARAVERTEBRAL PLEURA AND POSTERIOR COSTAL PLEURA. THICKENING VISCERAL PLEURA OF RIGHT LUNG-CONSIDER POSSIBILITY OF TRAPPED
LUNG.
MINIMAL LEFT PLEURAL EFFUSION.
SMALL POCKETS OF LOCULATED PERIHEPATIC COLLECTION IN UPPER ABDOMEN. 2D ECHO (20/07/2024)
-MILD AR (+),MILD MR(+),TRIVIAL TR(+), NO PAH.
-NO RWMA, NO AS/MS ,MILD LVH(+)
-GOOD LV SYSTOLIC FUNCTION.
-GRADE -I DIASTOLIC DYSFUNCTION (+), NO LV CLOT. 21/07/2024
BLOOD LACTATE- 15MG/DL
C-REACTIVE PROTEIN- 4.8 MG/DL HEMOGRAM-
HB:10.7 % (1:25 PM)
TOTAL COUNT:15,400 CELLS/CUMM NEUTROPHILS:88 % LYMPHOCYTES:08 % EOSINOPHILS: 01% MONOCYTES:03 %
BASOPHILS: 00%
PCV: 32.1%
MCV: 91.7
MCH: 30.6
MCHC: 33.3
RBC: 3.50 MILLIONS/CUMM
PLATELETS: 4.50 LKHS/CUMM
LIVER FUNCTION TEST (LFT)
Total Bilurubin 0.54 mg/dl Direct Bilurubin 0.21 mg/dl SGOT(AST) 15 IU/L
SGPT(ALT) 37 IU/L
ALKALINE PHOSPHATASE 207 IU/L TOTAL PROTEINS 4.7 gm/dl
ALBUMIN 2.3 gm/dl
A/G RATIO 0.96 FBS - 111 MG/DL 22/07/2024
HS-TROPONIN-1:-
GLYCATED HAEMOGLOBIN:-6.0 % HEMOGRAM:ON 24/7/24 HAEMOGLOBIN:8.5gm/dl
TOTAL COUNT:20,000N/L/E/M/B : 85/11/00/04/00PCV:24.9M C V :88.9M C H:30.3pgM C H
C:34.1%RBC COUNT :2.80 millions/cummPLATELET COUNT :4.50 lakhs/cu.mm 26/07/2024:
HEMOGRAM:
HB:7.7%
TOTAL COUNT:26,000 CELLS/CUMM NEUTROPHILS:88 % LYMPHOCYTES:08 % EOSINOPHILS: 01% MONOCYTES:00 %
BASOPHILS: 00%
PCV: 22.3%
MCV: 88.9
MCH: 30.6
MCHC: 34.4
RBC: 2.50 MILLIONS/CUMM
PLATELETS: 5.4 LKHS/CUMM
Treatment Given(Enter only Generic Name)
INJ NEOMOL 1GM IV/SOS
HIGH FLOW O2 @ 12-14 LIT/ MIN WITH FACE MASK INCENTIVE SPIROMETRY
ICD CARE
IV FLUIDS 1. NS WITH OPTINEURON /OD
INJ. METROGYL 500MG IV/BD X 11,( INJ-6 DAYS, TABLET- 4 DAYS) INJ PIPTAZ 4.5 GM IV/BD X 6 DAYS
INJ PAN 40 MG IV/OD
TAB. LEVOFLOX 5OOMG X 4 DAYS TAB AZATHIOPRINE 50 MG PO/OD TAB PREDNISOLONE 30MG PO/OD TAB ULTRACET 1/2 TAB PO/QID TAB PCM 500MG PO/QID
SYP ASCORIL -D PLUS 10 ML PO/TID
Advice at Discharge
TAB. LEVOFLOX 5OOMG PO/OD X 2 WEEKS TAB. METROGYL 400MG PO/TID X 2 WEEKS TAB AZATHIOPRINE 50 MG PO/OD
TAB PREDNISOLONE 25MG PO/OD- 2 WEEKS FOLLOWED BY 20 MG FOR 2 WEEKS TAB PCM 500MG PO/QID SOS
SYP ASCORIL -D PLUS 10 ML PO/TID INCENTIVE SPIROMETRY
Follow Up
REVIEW TO GM OPD AFTER 2 WEEKS
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: 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:26/07/2024 Ward:ICU
Unit:II
[26/07/24, 4:43:23 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Some soul searching:
[26/07, 16:20] opd reviewer during the first symptom : Reviewed her in the OPD today as she's complaining of right hypochondrium pain her fingers in the image pointing towards the site of pain
[26/07, 16:21] Pushed Communicator:
1 week before current admission..
Could we have diagnosed at that time sir??
[26/07, 16:29] PaJR coordinator: You mean the ultrasound of the abdomen done by the radiology at that time should have detected it?
[26/07, 16:36] Pushed Communicator : No sir
A chest xray done at that time
[26/07, 16:39] PaJR coordinator: Yes perhaps although pleuritis may not be visible on chest X-ray
The pre test probability would have been lower
Except now that this experience is imprinted in our mind we could even want to order a chest X-ray in a similar situation.
A lot of our current work hinges on trying to develop case based reasoning systems that can provide precision medicine support that wouldn't allow us to miss what we missed
[26/07/24, 4:44:38 PM] ~ Vyshnavi: Bp in supine position 130/90
Standing 120/90 sir
[09/08/24, 10:49:53 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @919154575937 any update from this patient?
[10/08/24, 12:45:06 PM] Pt SLE: Ninna vamting aendi sir prblm m ldu ega
[10/08/24, 1:46:56 PM] Sai Charam Kulkarni: జ్వరం దగ్గు ఏమైనా ఉందా..?
[10/08/24, 1:47:36 PM] Pt SLE: M ldu sir
[10/08/24, 3:14:14 PM] Pt SLE: Daggu undi light gaa
[11/08/24, 8:18:16 PM] Dr Rakesh Biswas Sir Hod Gm Kam: What medication and what dose is she on currently?
[11/08/24, 8:43:57 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @918500225142 can you elaborate on what was meant by "decreased width of opening mouth & intensity of sound, throat pain since 3 days" in your history here 👇
https://mutyapuraghavendra.blogspot.com/2022/09/a-20-year-female-with-pedal-edema-and.html?m=1
[11/08/24, 9:20:28 PM] ~ Raghavendra: ok sir
[12/08/24, 7:47:38 AM] Sai Charam Kulkarni: @919133006151 em tablets vaadthunnavo photos pettu.
[12/08/24, 7:50:40 AM] Sai Charam Kulkarni: Okay. Ela undi ippudu..?
[12/08/24, 7:51:42 AM] Pt SLE: Kk sir daggu undi anthe
[12/08/24, 11:21:07 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Need to rule out kochs
[12/08/24, 11:21:40 AM] Sai Charam Kulkarni: Dagguthy themda emina ostunda..?
[12/08/24, 11:22:38 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Good idea. Ask her to collect her 24 hour sputum in a clean transparent glass and share the 24 hour volume and image here everyday
[12/08/24, 11:39:12 AM] Pt SLE: Noo sir
[14/08/24, 12:51:18 PM] Dr Rakesh Biswas Sir Hod Gm Kam: 👆@919154575937 @918328223112 @919652955915 is the suspected mycobacterial antigen being partially taken care of by this quinolone? Who decided to give her levofloxacin?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9187489/
[14/08/24, 3:42:01 PM] Dr Chandana Gm Kam: Sir, 👆🏻
She was on piptaz and metrogyl in hospital. she improved and was discharged on oral Levofloxacin and metronidazole.
[14/08/24, 3:49:00 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Yes absolutely
We were thinking aloud if levofloxacin has something to do with her current course uncertainty in case she is still holding an undiagnosed mycobacterium
Also if you recall the pulmonology never submitted that she was alright. They were hell bent on her going for VATs
[14/08/24, 3:51:59 PM] Dr Chandana Gm Kam: Yes sir
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