THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER 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.
[20-09-2025 16:41] PPM 1: @PPM3 can you share the opening history or ask the intern to send it ASAP?
[20-09-2025 16:45] PPM 1: The main point of interest for this case report @CR were the serial ECGs of the myocardial infarction, this patient developed after hospitalization that was noticed right after the endotracheal intubation! @Meta AI @PPM4 how common is the reported incidence of that?
[20-09-2025 16:46] Meta AI: Myocardial infarction after endotracheal intubation is a serious complication, especially in patients with pre-existing coronary artery disease. While there's no specific incidence rate provided for myocardial infarction directly caused by endotracheal intubation, we can look at related factors.
Endotracheal intubation can cause significant cardiovascular responses, including:
- Increased Heart Rate and Blood Pressure: This can lead to increased cardiac workload, potentially worsening myocardial ischemia.
- Electrocardiographic Changes: Ischemic changes, such as ST-segment depression, can occur during airway manipulation. However, short ischemic episodes (<10 minutes) haven't been shown to directly correlate with postoperative myocardial infarction.
It's worth noting that patients with underlying coronary artery disease are more susceptible to these complications. The exact incidence might vary depending on individual patient factors, such as¹:
- Presence of coronary artery disease
- Type of anesthesia used
- Patient's overall health status
To better understand the relationship between endotracheal intubation and myocardial infarction, it's crucial to consider the context of the patient's condition and the specific circumstances surrounding the intubation.
If you're looking for more information on this topic or would like to discuss further, please let me know!
[20-09-2025 16:46] Meta AI: https://clinicalgate.com/physiologic-and-pathophysiologic-responses-to-intubation/
[20-09-2025 16.47] PPM 1: 1st
[20-09-2025 16.47] PPM 5: Sir couldn't it more likely be due to a side effect of the drugs used during intubation than the intubation itself? 2nd
3rd
4th
5th
[20-09-2025 16:49] PPM 1: 12/9/25
[20-09-2025 16:50] PPM 1: @Meta AI what is the reported incidence of myocardial infarction due to drugs used during intubation vs due to other factors? Please support your statements with perplexity styled references
[20-09-2025 16:51] Meta AI: Myocardial infarction after endotracheal intubation can indeed be caused by the drugs used during the procedure rather than the intubation itself. Let's break down the potential culprits and their associated risks:
## Drugs Used in Rapid Sequence Intubation (RSI)
- Propofol: Can cause cardiovascular depression leading to hypotension, which may increase the risk of myocardial infarction, especially in patients with pre-existing cardiovascular disease. The typical dose is 1.5-3 mg/kg IV, with a rapid onset and duration of action around 5 minutes.
- Ketamine: May increase heart rate and blood pressure due to its cardiostimulatory properties, potentially worsening myocardial ischemia. The induction dose is 1-2 mg/kg IV, with an onset of approximately 30 seconds and a dose-dependent sedation duration of 5-10 minutes.
- Etomidate: Generally considered safe for patients with cardiovascular instability, as it doesn't significantly alter hemodynamics. However, it may cause adrenal insufficiency, which could potentially impact cardiovascular stability. The typical dose is 0.3 mg/kg IV, with an onset of 0.5-1 minute and duration of action around 3-5 minutes.
- Succinylcholine: Can cause bradycardia, especially in children, and increase serum potassium levels, which may lead to cardiac complications. The dose is 1.5 mg/kg IV, with an onset of 45 seconds and duration of action around 6-10 minutes.
- Fentanyl: Can cause hypotension and bradycardia, especially at high doses, which may decrease myocardial oxygen demand but also potentially worsen cardiac function. The pretreatment dose is 1-3 mcg/kg IV, with an onset of 1-2 minutes and duration of action around 30 minutes to 1 hour.¹ ² ³
## Reported Incidence
The exact incidence of myocardial infarction due to drugs used during intubation versus other factors is difficult to determine, as it depends on various factors such as patient demographics, medical history, and specific circumstances surrounding the intubation. However, studies suggest that:
- The incidence of awareness with paralysis during RSI is around 2.6%, with a higher risk associated with rocuronium compared to succinylcholine.
- The use of succinylcholine has been linked to increased mortality in severe traumatic brain injury patients, although its use is still recommended in certain situations.
- Propofol and dexmedetomidine are preferred for sedation in mechanically ventilated patients due to decreased ICU length of stay, duration of mechanical ventilation, and delirium.
In conclusion, while the exact incidence of myocardial infarction due to drugs used during intubation is unclear, it's essential to carefully consider the patient's medical history, hemodynamic status, and potential risks associated with each medication when selecting agents for RSI.
[20-09-2025 16:51] Meta AI: https://www.msdmanuals.com/professional/critical-care-medicine/respiratory-arrest/medications-to-aid-intubation
[20-09-2025 16:51] Meta AI: https://jomi.com/article/299.11/pharmacology-for-rapid-sequence-intubation-(rsi)-airway-management-in-trauma-patients
[20-09-2025 16:51] Meta AI: https://emedicine.medscape.com/article/109739-overview
[20-09-2025 17:06] PPM 1: 👆the other point of interest is that if people have studied the over utilisation of chest x-rays in ICU settings, root causes and how to optimise these @Meta AI @PPM4
[20-09-2025 17:06] Meta AI: Studies have indeed looked into the overutilization of chest X-rays (CXRs) in ICU settings, and here's what they've found:
Root Causes of Overutilization:
- Lack of awareness among healthcare professionals about the low diagnostic yield of routine CXRs
- Habit or tradition of ordering daily CXRs without specific clinical indications
- Defensive medicine or fear of missing potential complications
- Limited knowledge about alternative imaging modalities, such as ultrasound
Optimizing CXR Use in ICU:
- Clinically Indicated Approach: The American College of Radiology (ACR) recommends obtaining CXRs only when clinically indicated, such as:
- Change in Patient's Clinical Condition: sudden respiratory or cardiovascular deterioration
- Post-Line/Tube Insertion: after insertion of endotracheal tubes, central venous catheters, or other devices
- Alternative Imaging Modalities: using ultrasound or other modalities to reduce radiation exposure and costs
- Education and Awareness: educating ICU staff about the low diagnostic yield of routine CXRs and promoting evidence-based practices
- Protocol-Based Approach: implementing restrictive CXR protocols, which have been shown to reduce CXR orders without affecting patient outcomes
Benefits of Optimizing CXR Use:
- Reduced radiation exposure for patients and staff
- Lower healthcare costs
- Decreased risk of hospital-associated infections
- Improved resource allocation
According to studies, adopting a clinically indicated approach to CXRs in ICU can reduce orders by up to 60% without affecting patient outcomes. By optimizing CXR use, healthcare professionals can improve patient care while minimizing unnecessary testing and costs.¹ ²
[20-09-2025 17:06] Meta AI: https://www.ccjm.org/content/86/9/582
[20-09-2025 17:06] Meta AI: https://litfl.com/routine-daily-chest-x-ray/
[20-09-2025 17:16] PPM 4: Certainly! Here is the outline of the answer on chest X-ray overutilization in ICU settings:
- *Introduction*: Overview of chest X-ray overutilization in ICUs and its implications, based on recent studies.
- *Extent of overutilization*: Data on unnecessary CXRs, citing specific studies and statistics.
- *Root causes*: Habitual practices, perceived necessity, institutional culture, and financial factors.
- *Optimization strategies*: Multidisciplinary teams, education, EHR modifications, and clinical decision support.
- *Implementation challenges*: Resistance to change, training issues, and resource constraints.
- *Future directions*: Advanced imaging technologies, AI integration, and personalized protocols.
- *Conclusion*: Summary of key points and the importance of evidence-based practices.
Then, I will now begin writing the main body of the answer.
-------
# Chest X-Ray Overutilization in ICU Settings: Root Causes and Optimization Strategies
## 1 Introduction: The Scope of Unnecessary Chest Radiography in Critical Care
Chest X-rays (CXRs) represent one of the *most frequently performed* imaging studies in intensive care units (ICUs) worldwide. Despite substantial evidence demonstrating the *limited clinical utility* of routine daily CXRs in critically ill patients, this practice remains remarkably persistent across healthcare systems. The American College of Radiology (ACR) first stopped recommending daily CXRs in 2008 and strengthened its stance to "usually not appropriate" in 2011 and 2014, yet *implementation gaps* between evidence and practice persist . This comprehensive review examines the *root causes* behind CXR overutilization in ICU settings, evaluates the *evidence-based strategies* for optimization, and proposes *implementation frameworks* to align clinical practice with current guidelines. The imperative for change extends beyond cost savings to encompass *patient safety, **radiation exposure reduction, and overall **care quality improvement* in critical care environments.
The persistence of routine daily CXR practice represents a fascinating case study in *medical tradition* versus *evidence-based practice. Despite numerous studies showing that on-demand imaging does not impact ICU length of stay, duration of mechanical ventilation, morbidity, or mortality, many institutions continue this practice due to **deeply ingrained protocols, **perceived medicolegal protection, and **resistance to practice change* . Understanding both the evidence and the implementation challenges is essential for developing effective optimization strategies.
## 2 Extent of Overutilization: Quantifying the Problem
Multiple studies have demonstrated *significant overordering* of CXRs in ICU settings. A 2023 study examining CXR use in a cardiothoracic ICU found that *65.7%* of performed CXRs did not meet ACR Appropriateness Criteria, with only 3.8% of these non-indicated studies showing actionable or significant findings compared to 13.0% of indicated CXRs . This suggests not only substantial overutilization but also *diminished diagnostic yield* when CXRs are performed without specific clinical indications.
The scale of unnecessary imaging is considerable. At Cleveland Clinic, researchers reported an average of *375 portable CXRs per day* across their health system in 2018 before implementing reduction initiatives . Similarly, a study in Saudi Arabian ICUs found that *96.8%* of ICUs performed daily routine chest X-rays, with 64% of clinicians reporting this practice applied to all admitted patients . These numbers highlight the *pervasiveness of this practice* despite evidence against its utility.
Research shows that the majority of CXRs (55.9%) in cardiothoracic ICUs are performed for "routine daily" monitoring, followed by support device monitoring (12.4%) and new ICU transfer (10.4%) . This distribution demonstrates the *disproportionate emphasis* on routine studies rather than indicated ones, representing a significant opportunity for improvement in resource utilization and care efficiency.
## 3 Root Causes of CXR Overutilization in ICU Settings
### 3.1 Habitual Practice and Traditional Teaching
The *deeply entrenched nature* of daily CXR practice represents one of the most significant barriers to change. For decades, daily routine CXRs were considered standard of care in ICUs, based on the theoretical need to monitor *endotracheal tube position, **central venous catheter placement, and **developing pulmonary pathologies* . This practice became embedded in medical education and training, creating *generational propagation* of the protocol despite emerging evidence against its utility.
Many clinicians who trained under this paradigm continue to practice based on *historical precedent* rather than current evidence. A survey of ICU clinicians in Saudi Arabia revealed that despite 73% believing the current daily routine CXR protocol should be replaced with on-demand policy, the practice continued in 96.8% of ICUs . This *belief-practice discrepancy* highlights how institutional protocols and habits can perpetuate outdated practices even when clinicians recognize the need for change.
### 3.2 Perceived Medico-legal Protection
Many clinicians order daily CXRs based on *defensive medicine* considerations rather than clinical necessity. The fear of missing a critical finding, such as a *malpositioned endotracheal tube* or *developing pneumothorax, drives continued utilization of routine imaging . This perspective is reinforced by **medicolegal concerns*, where clinicians worry about liability for adverse events that might theoretically have been detected earlier with daily imaging.
Interestingly, studies have shown that the *diagnostic yield* of routine daily CXRs is remarkably low. In one analysis, only 3.8% of non-indicated CXRs had actionable findings compared to 13.0% of indicated studies . Furthermore, research demonstrates that *physical examination* and *point-of-care ultrasound* often provide more accurate and timely information about tube positioning and pulmonary status than routine CXRs.
### 3.3 Institutional Culture and Protocol Inertia
*Structural barriers* within healthcare systems present significant challenges to changing CXR ordering practices. Many institutions have *standing order sets* that include daily routine CXRs for all intubated patients or those with certain devices . These automated orders create *systemic momentum* that continues unless actively disrupted through deliberate protocol changes.
The *multidisciplinary nature* of ICU care also complicates practice change. Intensivists, surgeons, nurses, respiratory therapists, and radiologists may have different perspectives on the necessity of daily CXRs, creating challenges for building consensus around practice change . Additionally, the *high turnover* of trainees in teaching hospitals necessitates continuous education efforts, as each new cohort arrives with varying levels of knowledge about appropriate CXR use.
### 3.4 Financial Structures and Billing Considerations
In some healthcare systems, *financial incentives* may inadvertently promote overutilization of diagnostic imaging. While this is not the primary driver in most cases, the fee-for-service model can create *disincentives for reduction* efforts unless institutions deliberately align financial structures with value-based care .
Table: Primary Root Causes of CXR Overutilization in ICU Settings
| *Category* | *Specific Factors* | *Impact Level* |
|--------------|----------------------|------------------|
| *Cultural & Educational* | Traditional teaching practices | High |
| | Generational propagation of habits | High |
| | Resistance to changing established routines | Medium |
| *System & Structural* | Automated standing orders in EHR | High |
| | Multidisciplinary coordination challenges | Medium |
| | High trainee turnover in academic centers | Medium |
| *Perceptual & Psychological* | Medicolegal concerns | High |
| | Overestimation of diagnostic yield | Medium |
| | "Better safe than sorry" mentality | Medium |
| *Financial* | Fee-for-service reimbursement models | Low-Medium |
| | Departmental revenue generation pressures | Low |
## 4 Evidence-Based Strategies for Optimizing CXR Utilization
### 4.1 Multidisciplinary Quality Improvement Initiatives
*Structured collaboration* between services is essential for successful practice change. At Kings County Hospital, a multidisciplinary team including representatives from radiology, surgery, internal medicine, and nursing successfully implemented an intervention that reduced portable CXR utilization by *37%* between June and December without increasing unplanned extubations or ventilator days . This approach leveraged *shared ownership* of the problem and solution, creating buy-in across specialties.
The most effective teams include *project champions* from each stakeholder group who can influence their colleagues and disseminate the evidence base for practice change. These champions serve as *local influencers* who can address specialty-specific concerns and model appropriate ordering behavior. Regular meetings and clear communication channels help maintain momentum and address barriers as they arise.
### 4.2 Education and Awareness Campaigns
*Targeted education* is crucial for addressing knowledge gaps and misconceptions about CXR utility. Effective educational initiatives should highlight several key points: daily CXRs rarely change management; alternatives exist for monitoring device placement (e.g., *endotracheal tube position documentation, **central line insertion depth visualization); and more accurate methods are available for assessing fluid status (e.g., **point-of-care ultrasound, **body weight measurements, **input/output data*) .
Education must be *ongoing and adaptive, particularly in teaching hospitals with rotating trainees. At Kings County Hospital, faculty members emphasized the new approach during rotation orientation and reinforced these strategies during daily rounds . **Weekly email reminders* and *visual cues* at workstations served as continuous reinforcement of the restrictive, event-driven approach to ordering radiographs.
### 4.3 Electronic Health Record (EHR) Modifications
*System-level changes* to ordering processes can effectively reduce unnecessary CXRs by creating friction against reflexive ordering. At Cleveland Clinic, providers altered the EHR options for chest imaging so that providers could only order daily CXRs for patients with cardiac support devices or who had undergone cardiac and thoracic surgery, and required providers to indicate a specific reason for the need in this population . This intervention resulted in a *23.5% overall decrease* in average daily portable CXRs .
Similarly, researchers at the University of Vermont Medical Center removed the "daily" order option from the portable chest radiograph order within the EHR and added a prompt to the ICU rounding checklist to ask clinicians whether a CXR was clinically indicated that day. This multifaceted approach decreased CXRs by *64%* in the medical ICU and *35%* in the surgical ICU without increasing adverse events .
### 4.4 Clinical Decision Support and Appropriateness Criteria
Implementing *ACR Appropriateness Criteria* as a standard for ordering CXRs provides an evidence-based framework for decision-making. These criteria recommend selective ordering of chest radiographs rather than routine daily studies, specifically indicating CXRs after specific procedures (e.g., endotracheal tube placement, central line insertion, chest tube placement) or for specific clinical concerns (e.g., acute respiratory deterioration, fever in immunocompromised patients) .
*Audit and feedback* mechanisms help sustain practice change by providing data on ordering patterns. At Cleveland Clinic, researchers provided feedback to ICU directors about which providers were utilizing portable daily CXRs, creating accountability and highlighting opportunities for improvement . This data-driven approach allows for *targeted interventions* with providers who continue to order unnecessary studies.
Table: Effective Interventions for Reducing CXR Overutilization and Their Impacts
| *Intervention Type* | *Specific Strategies* | *Reported Effectiveness* |
|-----------------------|-------------------------|----------------------------|
| *Educational Initiatives* | Evidence presentations on low yield of routine CXRs | Variable |
| | Highlighting radiation exposure risks | |
| | Training on alternative assessment methods | |
| *EHR Modifications* | Removal of "daily" order option | 23.5-64% reduction |
| | Required clinical justification fields | |
| | Order sets based on ACR criteria | |
| *Process Changes* | Discontinuing standing orders | 35-37% reduction |
| | Multidisciplinary rounding checklist prompts | |
| | Policy change to on-demand only | |
| *Audit & Feedback* | Provider-level ordering reports | Enhanced sustainability |
| | Complication rate monitoring | |
| | Cost savings transparency | |
## 5 Implementation Challenges and Considerations
### 5.1 Addressing Resistance to Change
*Physician resistance* represents a significant barrier to implementing restrictive CXR policies. Some intensivists and surgeons may perceive protocol changes as *cost-cutting measures* that potentially compromise patient safety rather than evidence-based quality improvement . Addressing these concerns requires transparent communication about the *evidence base* for change, emphasis on *patient safety benefits* (reduced radiation exposure, less sleep disruption, decreased infection risk), and data showing *non-inferiority* of patient outcomes with restrictive strategies.
The *framing of the initiative* significantly impacts its reception. Positioning the change as *enhancing care quality* rather than simply reducing costs helps align stakeholders around the common goal of patient-centered care . Sharing data from peer institutions that have successfully implemented similar changes can alleviate concerns about safety and efficacy.
### 5.2 Special Population Considerations
While evidence supports reducing routine CXRs in most ICU patients, *specific subpopulations* may warrant different approaches. Cardiac surgery patients, those with *extracorporeal membrane oxygenation (ECMO), and patients with **unstable airway devices* might benefit from more frequent monitoring . These nuances should be incorporated into protocols rather than implementing blanket restrictions.
At Cleveland Clinic, researchers recognized that cardiac and thoracic surgery patients might have different needs and thus created specific ordering options for these populations while still requiring clinical justification . This *tailored approach* acknowledges clinical variability while maintaining an overall restrictive policy.
### 5.3 Balancing Reduction with Adequate Monitoring
An important consideration in reducing routine CXRs is ensuring that *clinically indicated* studies are still obtained promptly. Overly restrictive policies might cause clinicians to hesitate ordering necessary CXRs, potentially missing important diagnoses . To address this concern, the University of Vermont Medical Center added a prompt to the ICU daily rounding checklist to query whether a CXR was clinically indicated . This *balancing measure* helped ensure that appropriate studies were not missed while reducing unnecessary ones.
## 6 Future Directions and Innovative Approaches
### 6.1 Point-of-Care Ultrasound as an Alternative Modality
*Bedside ultrasound* is emerging as a valuable alternative to CXRs for many ICU monitoring applications. Research shows that point-of-care ultrasound can more accurately assess *fluid status, **pulmonary pathologies, and **endotracheal tube position* than portable CXRs . Implementing ultrasound-based protocols requires *training investment* but offers the potential for *reduced radiation exposure, **real-time assessment, and **decreased costs*.
The ACR Appropriateness Criteria note that chest ultrasound may be appropriate for certain ICU applications, though evidence is still evolving . As technology improves and training becomes more widespread, ultrasound may replace CXRs for many indications in critical care settings.
### 6.2 Artificial Intelligence and Clinical Decision Support
*Advanced clinical decision support* systems integrated with EHRs show promise for further optimizing CXR utilization. These systems can provide *real-time feedback* on ordering appropriateness based on patient-specific factors, suggest *alternative imaging modalities* when appropriate, and flag orders that don't meet evidence-based criteria .
*Artificial intelligence* applications might also help identify patients who would benefit from CXRs based on electronic clinical data, potentially increasing yield while reducing unnecessary studies. These technologies represent the next frontier in diagnostic stewardship but require careful validation and implementation to avoid unintended consequences.
### 6.3 Standardized Outcomes Monitoring
Developing *standardized metrics* for tracking the impact of CXR reduction initiatives will facilitate comparison across institutions and help identify best practices. Key metrics might include CXRs per 1000 ventilator days (excluding procedure days), rates of missed diagnoses, and adverse event rates . *Collaborative networks* sharing these metrics could accelerate implementation of effective strategies across healthcare systems.
## 7 Conclusion
The overutilization of chest X-rays in ICU settings represents a significant opportunity for *value-based improvement* in critical care. Evidence consistently demonstrates that transitioning from routine daily to clinically indicated CXRs reduces *resource utilization, **costs, and **radiation exposure* without increasing adverse events. Successful implementation requires *multidisciplinary collaboration, **education, **EHR modifications, and **ongoing monitoring* to ensure compliance and identify opportunities for improvement.
While challenges exist, particularly related to *practice change resistance* and *concerns about missed diagnoses, the experience of numerous institutions shows that restrictive CXR policies can be implemented safely and effectively. Future developments in **point-of-care ultrasound* and *artificial intelligence-based clinical decision support* may further optimize imaging utilization in critical care settings.
As healthcare continues to emphasize value-based care, reducing unnecessary diagnostic imaging represents both a *clinical imperative* and an *ethical responsibility* to provide high-quality, patient-centered care without unnecessary harm or expense. The evidence supports abandoning routine daily CXRs in favor of an indicated, thoughtful approach to imaging in critically ill patients.
Table: Key Recommendations for Optimizing CXR Use in ICU Settings
| *Domain* | *Recommendations* | *Expected Outcomes* |
|------------|---------------------|------------------------|
| *Education & Training* | Regular evidence reviews for staff | Increased awareness of appropriate use |
| | Training on alternative assessment methods | Reduced reflexive ordering |
| | Radiation safety education | Enhanced patient safety |
| *Protocol Development* | Implement ACR Appropriateness Criteria | 30-50% reduction in unnecessary CXRs |
| | Create special population guidelines | Tailored approach for complex patients |
| | Develop procedure-driven ordering protocols | Improved yield of obtained CXRs |
| *System Changes* | Modify EHR order sets | Reduced automated daily orders |
| | Implement clinical decision support | Improved ordering appropriateness |
| | Add checklist prompts during rounds | Balancing of reduction with need |
| *Monitoring & Feedback* | Track CXR/utilization metrics | Sustained practice change |
| | Monitor complication rates | Assurance of safety |
| | Provide provider-level feedback | Accountability for ordering practices |
[21-09-2025 10:51] PPM 2: Was she on long term steroids she stopped suddenly?
[21-09-2025 11:20] PPM 1: 👆@PPM6 @PPM3
[21-09-2025 11:59] PPM 7: Sir propofol, ketamine, etomidate or succinylcholine was not used during intubation
[21-09-2025 11:59] PPM 7: Midazolam and atracurium initially then fentanyl.
[21-09-2025 13:07] PPM 1: Thanks
[23-09-2025 10:14] PPM 1: The EMR summary below. @PPM6 we didn't address her respiratory failure requiring ventilation and myocardial infarction in the discharge diagnosis!👇
Age/Gender: 80 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 12/09/2025 02:40 PM
Name of Treating Faculty
[SR]
Diagnosis
ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA
DRUG INDUCED NEUROGLYCOPENIA
Case History and Clinical Findings
PT WAS BROUGHT TO CASUALITY IN UNRESPONSIVE STATE SINCE 8:30 AM912/9/25)
C/O FEVER SINCE 5 DAYS
C/O ITCHING OVER DORSUM OF FEET AND HANDS FROM 3-4 MONTHS .
PT WAS APPARENTLY NORMAL 3-4MONTHS BACK THEN SHE DEVELOPED ITCHING OVER DORSUM OF FOOT WHICH IS BILATERAL AND ALSO ON DORSUM OF HAND.
C/O FEVER SINCE 5-6 DAYS WHICH IS SUDDEN IN ONSET, INTERMITTENT TYPE, HIGH
GRADE, ASSOCIATED WITH CHILLS AND RIGOR.
PT WAS NOW BROUGHT TO CASUALITY IN UNRESPONSIVE STATE
H/O COUGH SINCE 2 -3 YEARS AGGREVATED SINCE 5 DAYS PRODUCTIVE TYPE
ASSIOCIATED WITH WHITISH SPUTUM
H/O LOOSE STOOLS 3 DAYS BACK 3 EPISODES PER DAY FOR 2 DAYS RESOLVED UNDER
MEDICATION .H/O GIDDINESS SINCE 1 YEAR AGGREAVTED ON STANDING FROM SUPINE
POSITION.
K/C/O OF T2DM SINCE 10 YRS ON TAB GLIMI 500MG OD
K/C/O HTN SINCE 4 YRS ON UNKNOWN MEDICATION
PULMONOLOGY REFFERAL 14/9/25 WAS DONE AND ADVISE FOR HRCT TEST
Investigation
HEMOGRAM :(12/9/25) HB 8.3 WBC 10900, RBC 3.1MILLION, PCV 24.1, NEUTROPHILLS 48 LYM
44
** Tentative Date Page-2
KIMS HOSPITALS
RBS :462
SEROLOGY: HBS AG POSITIVE HCV, HIV NEGATIVE
RFT: UREA 32, CREAT 1.3, NA+ 136 K+3.6, CL 98.
LFT: TOTAL BILURUBIN 0.53, DIRECT 0.19, SGPT 79.6, SGOT 170, ALP 487, T PROTEIN :6.2 A/G
1.0
LIPID PROFILE: CHOL :100, TGLY:184, HDL 25, VLDL 36 .92
ABG PH 7.3, PCO2 25.3, PO2 133, HCO3- 16.0
HEMOGRAM :(13/9/25) HB 9.6 WBC 9200, RBC 3.4 MILLION, PCV 28.1, NEUTROPHILLS 45 LYM
50
URINE FOR KETONE BODIES: NEGATIVE.
HEMOGRAM :(14/9/25) HB 9.8 WBC 9900, RBC 3.6 MILLION, PCV 27.1, NEUTROPHILLS 46 LYM
44
MRI IMPRESSION OLD INFRACTS IN LEFT FRONTAL LOBE
CHRONIC LACUNAR INFRACT IN LEFT STRATIOCAPSULAR REGION.
ABG [14/9/25] PH 7.38 ,PCO2 21.107, HCO3 12
RFT 14 /9/25 UREA 30 ,CRET 1.20 ,URIC ACID 3.40,CALICUM 8.8 ,PHOSPOROUS 2.2,NA + 138
K+ 4.56 CL 98
LFT 14/9/25 TOTAL BILRUBIN 0.53, DIRECT BILU , 0.19, ALT 79.6 AST 170 TOTAL PROTEIN 6.2
ALP 487 ALBUMIN 3.1
PULMONOLOGY REFERRAL I/V/O ALTERED SENSORIUM SECONDARY DRUG INDUCED
HYPOGLYCEMIA, ADVISE HRCT, 2D ECHO
14/9/25 2D ECHO EF 56% IVC1.0 COLLAPSING, NO RWMA MILD TRP, NO PAH, TRIVIAL MR/AR
FAIR TO GOOD LV SYSTOLIC FUNCTION GRADE 1 DIASTOLIC DYSFUNCTION
HEMOGRAM :(15/9/25) HB 10.7 WBC 12800 ,RBC 3.7 MILLION ,PCV 30.6 ,NEUTROPHILLS 76
LYM 18
ABG [15/9/25] 7: 00 AM PH 7.34 ,PCO2 25.5, PO2 229, HCO3 16.9
ABG [15/9/25]11: 00 AM PH 7.30, PCO2 31.7, PO2 290, HCO3 17.
DENGUE NEGATIVE
LFT [ 15/9/25] TOTAL BILRUBIN 1.0, DIRECT BILRUBIN, 0.18 ALT 70 AST 84 TOTAL PROTEIN 6.9
ALP 452 ALBUMIN 3.4
RFT [15 /9/25] UREA 35, CRET 1.3, URIC ACID 3.90, CALICUM 9.1, PHOSPOROUS 3.7, NA + 133 K+ 3.4
15/9/25 2D ECHO EF 41% IVC1.2 NON-COLLAPSING, MILD MR, TRIVIAL AR, MODERATE LV
DYSFUNCTION, GRADE1 DIASTOLIC DYSFUNCTION, MINIMAL PE
** Tentative Date Page-3
KIMS HOSPITALS
OBG REFERRAL [15/9/25] I/V/ O BLOOD-STAINED DIAPER - ON BLOOD-STAINED DIAPER P/V
BLOOD STAIN + NO ACTIVE BLEEDING NOTED
ADV: BETADINE PACKING OD TO BE CONTINUED W/F BLEEDING PV
ABG [16/9/25] PH 7.47, PCO2 22.8, PO2 78.5, HCO3 18.4
LFT [16/9/25] TOTAL BILRUBIN 1.00, DIRECT BILRUBIN, 0.18, ALT AST 84 TOTAL PROTEIN 5.9 ALP 246, ALBUMIN 2.9
RFT [ 16 /9/25] UREA 65, CRET 1.2, URIC ACID 5.80, CALICUM 9.8, PHOSPOROUS 3.4, NA + 135 K+ 3.1 CL 99
HEMOGRAM :(16/9/25) HB 10.1 WBC 15400, RBC 3.6 MILLION, PCV 29.9, NEUTROPHILLS 72
LYM 17
CHEST X RAY AP VIEW IMPRESSION RIGHT LOWER LOBE AND UPPER LOBE COLLAPSE AND CONSOLIDATION
RETICULONODULAR OPACITIES IN B/L HILAR REGION AND RIGHT LUNG MIDDLE ZONE
CUE COLOUR PALE YELLOW, ALBUMIN +30 MG/DL, SUGARS NIL, URINE KETONE BODIES
NEGATIVE
CARDIOLOGY REFERRAL: MODERATE LV DYSFUNCTION IN CARDIOGENIC SHOCK
ADVICE: CONSERVATIVE MANGEMENT
RFT [ 17/9/25] UREA 81, CRET 1.2, URIC ACID 6.40, CALICUM 9.8, PHOSPOROUS 3.2, NA + 132 K+3.7, CL 99
ABG [17/9/25] PH 7.44, PCO2 19.8, PO2 182, HCO3 17
LFT [17/9/25] TOTAL BILRUBIN 1.84, DIRECT BILRUBIN, 0.51 ALT 42 AST 86 TOTAL PROTEIN 5.9 ALP 246, ALBUMIN 2.9
LIPID PROFILE: TOTAL CHOLESTROLS:126, TRGLY 2.60 HDL 31, LDL 67, VLDL 0.52.
HBA1C 7.3 APT 33T0 SEC,.PT 17.0 SEC, INR 1.20.
HEMOGRAM [17 /9/25] HB :9.1 WBC 18000, RBC 3.2 MILLION, PCV 27.2, NEUTROPHILLS 76
CUE: ALB 30MG/DL, UKB NEGATIVE, SUGARS NIL.
ABG [18/9/25] PH 7.43, PCO2 26.1, PO2 80.2, HCO3 21.8
RFT [ 18/9/25\] UREA 81, CRET 1.6, URIC ACID 6.90, CALICUM 9.4, PHOSPOROUS 2.9, NA + 135 K+ 3.6, CL 98
HEMOGRAM :(18/9/25) HB 6.8 WBC 12100, RBC 2.4 MILLION, PCV 20.2, NEUTROPHILLS 76 LYM 15 BLOOD GROUPING B POSITIVE.
ABG [19/9/25] PH 7.41, PCO2 29.1, PO2 110, HCO3 20.6
HEMOGRAM :(19/9/25) HB 9.2 WBC 18000, RBC 3.2 MILLION, PCV 28.2, NEUTROPHILLS 86 LYM 8
** Tentative Date Page-4
KIMS HOSPITALS
RFT [19/9/25] UREA 80, CRET 1.4, URIC ACID 6.90, CALICUM 9.8, PHOSPOROUS 4.8, NA + 138, K+ 5.2, CL 101
ABG 19/9/25 PH 7.38, PCO2 38.5, PO2 28.6, HCO3- 22.3.
RFT [20/9/25] UREA 78.9, CRET 1.3, URIC ACID 6.30, CALICUM 9.9, PHOSPOROUS 2.79, NA + 134 K+ 3.7, CL 94
ABG [20/9/25] PH 7.46, PCO2 21.1, PO2 79, HCO3 15
ET CULTURE AND SENSITIVITY GRAM STAIN GRAM POSITIV YEAST CELLS, GRAM POSITIVE
BACILLI, AND COCCI ARE SEEN CULTURE STAPYLOCOCCUS HEMOLYTIC ISOLATED
[METHICILLIN RESISTANT]
ABG [20/9/25] PH 7.45, PCO2 21.0, PO2 79.2, HCO3- 17.3.
RFT UREA 78, CREAT 1.30, URIC ACID 6.30, CA+2 9.9, NA+ 134, K+3.7, CL-94
HEMOGRAM 20/9/25 HB 8.1, WBC 10400, RBC 2.9, PCV 23.0
ABG 21/9/25 PH 7.48, PCO2 23.70, PO2 76, HCO3 - 18.
HEMOGRAM HB 9.2, WBC 8300, RBC 3.3, PCV 26.7
RFT UREA 79.0, CREAT 1.20, URIC ACID 5.80, CA+2 9.5, PO4-2 2.5, NA+132, K+3.9 CL-96.
ABG 22/9/25 PH 7.445, PCO2 27.9, PO2 83.8, HCO3 - 18 .8
HEMOGRAM HB 12.4, WBC 8700, RBC 4.1, PCV 36.5
RFT UREA 75, CREAT 1.10, URIC ACID 5.20, CA+2 10, PO4-2 3.1, NA+128, K+3.8 CL-90.
LFT [22/9/25] TOTAL BILRUBIN 3.18, DIRECT BILRUBIN, 0.49 ALT 48 AST 56 TOTAL PROTEIN
6.3 ALP 236, ALBUMIN 2.9
Treatment Given (Enter only Generic Name)
1.RT FEEDS 100ML OF MILK 4 TH HOURLY
50 ML WATER 2 ND HOURLY
2.IVF NS @750ML/HR
3.INJ: MONOCEF 1G ML/IV/BD
4.INJ: PAN 40MG /IV /OD
5.INJ: ZOFER 4MG/IV/SOS
6.INJ: OPTINEVRON 1 AMP IN 100ML NS/IV/OD
7.NEBULISATION WITH DUOCIN AND BUDECORT 8TH HOURLY
8.ORAL SUCTION 4 TH HOURLY
Follow Up
REVIEW TO MEDICINE OPD IN 2 WEEKS
When to Obtain Urgent Care
** Tentative Date Page-5
KIMS HOSPITALS
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/Attendant 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: Ward: Unit:
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