30-01-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
PPM 1 - This was his cranial MRI in 2022 with multiple vague macro and micro vasculopathic changes.
PPM 1 - It also showed a sphenoidal mass although it wasn't noticed in the MRI report in 2022 but was emphasized in this admission!
PPM 1 - This was reported in 2024!
PPM 1 - Conclusion in 2024 although this film isn't available. The film available is dated 2022.
Ward afternoon session:
Patient centred notes on longevity:
I'm right now looking at an 87M lying in front of me in the ward bed 6 and clearly he has lived long but since last 3 years he has slowly lost his brain functioning and even when I ask his name he is unable to tell me more than 10% of it in Telugu! He is not oriented well enough to time, place and person and while
remembers his past and family members his communication with them and ability to form new connections is seriously hampered due to his inability to communicate as well as remember!
But overall on going through his external medicine events and internal medicine findings, we think the cause is a vascular neurodegenerative disorder. Will add him to our project on it here:
:https://96sanjanapalakodeti.blogspot.com/2023/05/ajnd-paper.html?m=1
I wonder what longevity really depends on?
Is it just good genes?
Or is it good environment (non toxic, non damaging to cells and vessels made of cells)?
Or is it behavioural? How we behave with other beings and this planet to create persistent and long connections?
01-02-2025
Today we tried to make him sit up which he did well and stand where he couldn't straighten his legs and bent from his knees.
PPM 1 - Other additional history and findings by PG.
PPM1 -👆 Notice the change in the sphenoidal mass from 2022 here.
EMR SUMMARY
His EMR summary post discharge today 👇
Age/Gender : 87 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 27/01/2025 07:01 AM
Diagnosis
ALTERED SENSORIUM SECONDARY TO ACUTE ISCHEMIC STROKE ALZHEIMERS DISEASE ;ATYPICAL PARKINSONISM
PRE RENAL (AKI)
B/L MILD HYDRONEPHROSIS
MYCETOMA IN RIGHT SPHENOIDAL SINUS H/O CVA 2 YEARS AGO
Case History and Clinical Findings
CHIEF COMPLAINTS:
C/O PAIN ABDOMEN SINCE 1 DAY HOPI:
PT WAS APPARENTLY ASYMPTOMATIC 1 DAY AGO LATER HE DEVELOPED PAIN ABDOMEN WHICH WAS SUDDEN IN ONSET GRADUALLY PROGRESSIVE ASSOCIATED WITH DRAGGING TYPE OF PAIN INCREASES ON TAKING FOOD AND RELIVES ON TAKING MEDICATION
H/O VOMITING PRESENT 1 EPISODE 1 DAY AGO WITH FOOD AND WATER AS CONTENTS,NON BILIOUS,NON PROJECTILE
H/O FEVER PRESENT 2 DAYS AGO
H/O NOT PASSING STOOLS SINCE 1 DAY
H/O LOOSE STOOLS PRESENT SINCE 10 DAYS PAST HISTORY:
K/C/O CVA SINCE 2 YEARS AND IS ON MEDICATION
H/O ? GALLSTONE SURGERY (DOCUMENTS NOT FOUND) 10 YEARS AGO
PERSONAL HISTORY DIET-MIXED
SLEEP-ADEQUATE APPETITE- NORMAL
BOWEL MOVEMENTS- REGULAR MICTURITION- BURNING +,DRIBBLING + NO ADDICTIONS
GENERAL EXAMINATION PT IS C/C/C TEMP.AFEBRILE
PR98 BPM
BP 120/80 MMHG RR 18/MIN
SPO2 99%@RA GRBS 164 MG/DL
SYSTEMIC EXAMINATION:
CVS:S1 S2 HEARD , NO MURMURS RS:BAE +,NVBS
P/A:SOFT,NT, NO ORAGANOMEGALY CNS:
TONE RIGHT LEFT
UL INCREASED INCREASED LLINCREASED INCREASED POWER RIGHT LEFT
UL CAN NOT ELICITED CAN NOT ELICITED LLCAN NOT ELICITED CAN NOT ELICITED REFLEXES B +2 +3
T+ +3 S - -
K +2 +1
A - -
P FLEXION FLEXION SENSORY;
ANTEROLATERAL SPINOTHALAMIC UL INTACT INTACT
LL INTACT INTACT DORSAL COLUMN UL INTACT INTACT LL INTACT INTACT
GCS: E4V5M6 ,PUPILS- B/L REACTIVE TO LIGHT(SLUGGISH)
NEUROSURGERY REFERRAL I/V/O MYCETOMA IN THE RIGHT SPHENOID SINUS ADVICE: NO ACTIVE NEUROSURGICAL INTERENTION
CONSIDER NEUROPHYSICIAN OPINION PSYCHIATRY REFERRAL I/V/O ICU PSYCHOSIS ADVICE:TAB.HALOPERIDOL 0.5MG PO/SOS REVIEW SOS
GEN SURGERY REFERRAL I/V/O BED SORES ADVICE: 2ND HRLY POSITION CHANGE
AIR BED
SALINE DRESSING
OINT. MUPIROCIN FOR L/A
Investigation
FHBsAg-RAPID 27-01-2025 08:46:AM Negative
Anti HCV Antibodies - RAPID 27-01-2025 08:46:AM Non Reactive COMPLETE BLOOD PICTURE (CBP) 27-01-2025 08:46:AM HAEMOGLOBIN 13.0 gm/dl 17.0-13.0 gm/dl TOTAL COUNT 16900
cells/cumm 10000-4000 cells/cumm NEUTROPHILS 92 % 80-40 %LYMPHOCYTES 04 % 40-20
%EOSINOPHILS 00 % 6-1 %MONOCYTES 04 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET
COUNT 1.74SMEAR Normocytic normochromic blood picture with neutrophilic leucocytosis
COMPLETE URINE EXAMINATION (CUE) 27-01-2025 08:46:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN Trace SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil RFT 27-01-2025
08:46:AM UREA 129 mg/dl 50-17 mg/dl CREATININE 3.0 mg/dl 1.3-0.8 mg/dl URIC ACID 5.8 mmol/L
7.2-3.5 mmol/LCALCIUM 10.0 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 5.0 mg/dl 4.5-2.5
mg/dl SODIUM 132 mmol/L 145-136 mmol/LPOTASSIUM 5.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
101 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 27-01-2025 08:46:AM Total Bilurubin 1.03 mg/dl 1-0 mg/dl Direct Bilurubin 0.21 mg/dl 0.2-0.0 mg/dl SGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 29 IU/L 45-0
IU/LALKALINE PHOSPHATASE 133 IU/L 119-56 IU/LTOTAL PROTEINS 6.2 gm/dl 8.3-6.4 gm/dl ALBUMIN 3.07 gm/dl 4.6-3.2 gm/dl A/G RATIO 0.98ABG 27-01-2025 09:05:AM PH 7.41PCO2
22.7PO2 52.3HCO3 14.3 St.HCO3 17.4BEB -8.5BEecf -9.4TCO2 29.2O2 Sat 85.4O2 Count 13.3 RFT 28-01-2025 02:57:AM UREA 108 mg/dl 50-17 mg/dl CREATININE 1.4 mg/dl 1.3-0.8 mg/dl URIC
ACID 4.3 mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 3.2 mg/dl 4.5-
2.5 mg/dl SODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
104 mmol/L 98-107 mmol/LRFT 28-01-2025 11:39:PM UREA 68 mg/dl 50-17 mg/dl CREATININE 0.9
mg/dl 1.3-0.8 mg/dl Uric ACID 3.0 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9 mg/dl 10.2-8.6
mg/dl PHOSPHOROUS 2.64 mg/dl 4.5-2.5 mg/dl SODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM
4.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 104 mmol/L 98-107 mmol/L
RFT 30-01-2025 12:00:AM UREA 50 mg/dl 50-17 mg/dl CREATININE 0.9 mg/dl 1.3-0.8 mg/dlURIC
ACID 2.1 mmol/L 7.2-3.5 mmol/LCALCIUM 8.7 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 2.5 mg/dl 4.5-
2.5 mg/dl SODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE
98 mmol/L 98-107 mmol/LRFT 30-01-2025 02:18:AM UREA 47 mg/dl 50-17 mg/dl CREATININE 0.9
mg/dl 1.3-0.8 mg/dl URIC ACID 2.0 mmol/L 7.2-3.5 mmol/LCALCIUM 9.1 mg/dl 10.2-8.6
mg/dl PHOSPHOROUS 2.55 mg/dl 4.5-2.5 mg/dl SODIUM 132 mmol/L 145-136 mmol/LPOTASSIUM
3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107 mmol/L
T3, T4, TSH 31-01-2025 11:52:PM T3 0.48 ng/ml 1.87-0.87 ng/mlT4 10.25 micro g/dl 12.23-6.32
micro g/dl TSH 3.37 micro Iu/ml 5.36-0.34 micro Iu/ml RFT 02-02-2025 10:11:PM UREA 53 mg/dl 50-
17 mg/dl CREATININE 0.8 mg/dl 1.3-0.8 mg/dl Uric ACID 2.0 mmol/L 7.2-3.5 mmol/LCALCIUM 8.9
mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 2.0 mg/dl 4.5-2.5 mg/dl SODIUM 134 mmol/L 145-136
mmol/LPOTASSIUM 3.7 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98 mmol/L 98-107 mmol/L
COMPLETE URINE EXAMINATION (CUE) 03-02-2025 11:33:AM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN +SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS, Nil Salts Nil AMORPHOUS DEPOSITS Absent OTHERS Nil RFT 04-02-2025
07:06:AM UREA 32 mg/dl 50-17 mg/dl CREATININE 0.8 mg/dl 1.3-0.8 mg/dl URIC ACID 2.0 mmol/L
7.2-3.5 mmol/LCALCIUM 9.2 mg/dl 10.2-8.6 mg/dl Phosphorous 2.5 mg/dl 4.5-2.5 mg/dl SODIUM
132 mmol/L 145-136 mmol/LPOTASSIUM 3.9 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 98 mmol/L 98-107 mmol/L
MRI BRAIN PLAIN DONE ON 27/1/25:
IMPRESION:-
1) FEW TINY TO SMALL ACUTE INFARCTS SEEN INVOLVING THE CORTEX AND SUBCORTICAL WHITE MATTER OF LEFT OCCIPITAL LOBE
2) SMALL AREA OF NEUROPARENCHYMAL LOSS WITH SURROUNDING GLIOSIS IN LEFT ANTERIOR FRONTRAL LOBE AND RIGHT POSTERIOR FRONTAL LOBE-S/O CHRONIC INFARCTS
3) FEW TINY CHRONIC INFARCTS IN B/L CENTRAL SEMIOVALE AND B/L THALAMI,BASAL GANGLION,CEREBELLUM
4) EXTENSIVE B/L CEREBRAL WHITE MATTER ,FLAIR HYPERINTENSITY WITHOUT DIFFUSION RESTRICTION-S/O-LEUKOARAIOSIS
5) FEW TINY MICRO HEMORRHAGES NOTED IN SUB-CORTICAL WHITE MATTER OF B/L FRONTAL LOBES AND RIGHT THALAMUS
6) MILD CEREBRAL AND MIDBRAIN ATROPHY
7) T1 HYPERINTENSE MATERIAL IN RIGHT SPHENOID SINUS MEASURING 18 MM
?MYCETOMA
8) REST OF BRAIN STEM IS NORMAL
9) CRANIO-VERTEBRAL AND CERVICO-MEDULLARY JUNCTIONS ARE NORMAL
10) SELLA, Pituitary AND PARASELLAR ARE NORMAL
11) STALK AND HYPOTHALAMUS ARE NORMAL.POSTERIOR PITUTARY BRIGHT SPOT IS NORMAL
MRI PLAIN DONE ON 3/02/25:
IMPRESSION:-
AS COMPARED TO PREVIOUS SCAN DONE ON 27/01/25,NEW SMALL ACUTE INFARCT SEEN IN RIGHT PARIETAL LOBE AND NEW TINY SUBACUTE INFARCT IN RIGHT CEREBELLAR HEMISPHERE
USG ABDOMEN DONE ON 27/01/25: IMPRESSION:-
B/L MILD HYDRONEPHROSIS ASCITIS
2D ECHO DONE ON 28/1/25 IMPRESSION:
CONCENTRIC LVH+ ; NO RWMA TRIVIAL MR+/AR+/TR+, NO PAH SCLEROTIC AV , NO AS/MS EF=55% , RVSP= 36MMHG
FAIR TO GOOD LV SYSTOLIC FUNCTION GRADE 1 DIASTOLIC DYSFUNCTION + IVC SIZE 1CM COLLAPSING
NO PE, NO LV CLOT
Treatment Given(Enter only Generic Name)
1) RT FEEDS -50ML WATER 2ND HOURLY
-100ML MILK 4THHOURLY 2] IVF NS AT 75 ML/HR
3] INJ MEROPENEM 1 GM IV /BD
4] INJ CLINDAMYCIN 600 MG IV /TID
5] INJ PAN 40 MG IV/OD
6] INJ THIAMINE 200 MG IV/TID
7] INJ PCM 1 GM IV/SOS
8] INJ OPTINEURON 1 AMP IN 100 ML NS /IV/ OD
9] TAB ITRACONAZOLE 100 MG RT/BD
10] TAB PCM 650 MG RT/BD
11] TAB ECOSPIRIN AV {75/20} RT/HS
12] TAB MET XL 12.5 MG RT/OD
13] TAB STROCIT PLUS RT/BD
14] PHYSIOTHERAPY OF RIGHT UL, LL
15] NEOSPORIN POWDER L/A TID
16] NEB WITH IPRAVENT - 4TH HRLY BUDECORT 4TH HRLY
MUCOMIST 6TH HRLY
17] POSITION CHANGE 2ND HRLY
Advice at Discharge
1)RT FEEDS -50ML WATER 2ND HOURLY
-100ML MILK 4THHOURLY
2] TAB PCM 650 MG RT/TID X 5 DAYS
3] TAB THIAMINE 100 MG RT/TID X 20 DAYS
4] TAB REJUNEX CD3 RT/OD X 15 DAYS 5] TAB ECOSPRIN AV 75/20 HS TO CONTINUE
6] TAB METXL 12.5 MG RT/OD TO CONTINUE
7] TAB STROCIT PLUS RT BD FOR 20 DAYS
NEOSPRIN POWDER FOR LOCAL APPLICATION ON BED SORE TID MUPURPCIN OINTMENT FOR LOCAL APPLICATION ON BED SORE TID REFRESH EYE DROPS 2 DROPS TID
ORAL AND EYE CARE
REGULAR UPPER LIMD AND LOWER LIMB PHYSIOTHERAPY POSITION CHANGE 2ND HRLY
Follow Up
REVIEW TO GM OPD 10 DAYS / SOS
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:06/02/25 Ward: AMC
Unit: I
PA - The patient is taking medicines daily 3 times and ragi java 4hrly per day.
He is feeling better.
PPM 1 - Can they share an image of all the medicines they are giving?
In what way is the patient better?
What were his problems in order of priority that have changed for the better? What exactly changed?
PA -
PA - Administering this 👆 to the patient daily 4 times.
The patient is having cough and congestion in the chest.
PPM 1 - @PPM4 @PPM5 need to see the chest X-ray of this patient.
11-02-2025
PPM 4 - 
PPM 1 - Thanks any other properly taken chest X-ray?
18-02-2025
PA - Since 13 days the patient is being fed through ryles tube. When should the tube be changed (for how many days). Giving medicine regularly. Please advise doctor.
PPM 1 - Can be changed once in two weeks.
Most important is mobilization and activities.
They need to share his daily hourly mobilization and activities.
PA - The patient has become very weak and is bedridden and is not able to do his regular activities.
The patient needs the ryles tube to be changed and they have no access to any hospital nearby.
PPM 1 - They'll have to bring him here then to change his ryles tube as well as encourage daily mobilization under direct observation and guidance of a trained person.
PA - The patient is not opening his eyes. Not well.
PPM 1 - Yes I got that. We need a trained person there locally to even interact and know about the patient. This is how home health care systems will need to develop currently with trained people available around each patient locally.
PA - The patient has to come by ambulance.
PPM 1 - This patient discharged a few days back (see description box) may be reaching our emergency. I'm assuming you both are on duty. Please evaluate and admit @PPM6 and @PPM7.
PPM 6 - Okay sir.
PPM 1 - 👍
No comments:
Post a Comment