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.
[4.51 PM, 02/01/2026] PPM 1: Handwritten initial assessment
[4.53 pm, 02/01/2026] PPM 1: @PPM3 can you share the clinical assessment during this time at 26/12/25 during the initial assessment? Please share the subsequent serial ECGs after this done on 26/12/25
[4.56 pm, 02/01/2026] PPM 1: @PPM3 after the clinical findings and clinical images please share a few representative daily update notes since 26/12/25 including today's before and after your intervention in the afternoon
[7.48 pm, 02/01/2026] PPM 1: EMR Summary of this patient during 26/12/25
: 75-Year-Old Male*
Clinical Summary*
Chief Complaints:
- Decreased urine output (1 day, sudden onset, progressively worsening)
- Swelling over penis and scrotum (2 months, gradual progression)
- History of trauma with Foley's catheter 2 months ago
- Left intertrochanteric fracture 2 months ago;?hemiarthroplasty performed
Known Conditions (K/C/O):
- Cerebrovascular accident (CVA) 10 years ago with left hemiparesis and mouth deviation; on Aspirin 75 mg OD
- Hypertension (HTN) for 10 years; on Telma H 40/12.5 mg OD
- Type II Diabetes Mellitus (DM) for 10 years; on Metformin 250 mg OD
- Seizure disorder (10 years ago); stopped medications after few months
- Regular alcohol consumption; stopped 2 months ago
- No history of smoking
General Examination:
- Conscious but irritable
- Vitals: Afebrile, BP 120/90 mmHg, RR 16/min, Pulse 113 bpm, SpO2 99% on room air
Systemic Examination:
- Cardiovascular: S1S2 present, no murmurs
- Respiratory: Bilateral normal vesicular breath sounds
- Abdomen: Soft, non-tender
- CNS: Power and reflexes charted (details abbreviated)
Family History: Not significant
Primary Diagnoses:
- Acute ischemic stroke (AIS) with infarcts in the right hippocampus
- Chronic hypertension with microangiopathy
- Acute on chronic kidney disease (CKD) with severe metabolic acidosis
- Fournier’s gangrene with paraphimosis, perianal abscess, scrotal cellulitis, and urethral rupture
- Non-healing ulcer over left foot (status post incision and drainage under spinal anesthesia)
- Status post two sessions of hemodialysis
Chronic Conditions:
- Type 2 diabetes mellitus (T2DM)
- Hypertension (HTN)
- Previous cerebrovascular accident (CVA) with left hemiparesis
Recent Clinical Course:
- Transferred from surgery to nephrology due to decreased renal function
- Complaints include:
- Memory loss for immediate events (3 months)
- Decreased urine output and scrotal swelling (1 day)
- History of:
- Slip and fall with left hip injury → total hip replacement (THR)
- Becoming bedridden post-surgery
- Wound over left foot
- No signs of urinary dribbling or burning micturition
Hemogram Trends (26–29 Dec 2025)*
- Hemoglobin (HB): Gradually increased from 8.0 to 9.3 g/dL — still below normal, indicating anemia.
- Packed Cell Volume (PCV): Slight improvement from 24.6% to 28.1%.
- Total Leukocyte Count (TLC): Rose significantly from 15,500 to 22,400 — may suggest infection or inflammation.
- RBC Count: Increased from 3.10 to 3.5 million/μL — still low.
- Platelet Count (PLC): Fluctuated, with a drop to 2.6 lakh/μL on 29th — could indicate bone marrow suppression or consumption.
---
🧬 Renal Function Test (RFT) Trends
- Urea: Dropped from 123 to 94 mg/dL — improvement post-dialysis.
- Serum Creatinine (S. Cr.): Decreased from 3.4 to 2.1 mg/dL — indicates better kidney clearance.
- Electrolytes (Na, K, Cl): Fairly stable — no major imbalances noted.
---
🌬️ Arterial Blood Gas (ABG) Analysis
- pH: Slightly acidic on 26th (7.30), improved to near-normal (7.327) on 27th.
- PCO₂: Increased from 28 to 39.9 mmHg — suggests reduced respiratory compensation.
- PO₂: Improved from 105 to 143 mmHg — better oxygenation.
- HCO₃⁻: Rose from 13 to 20.5 mmol/L — indicates correction of metabolic acidosis.
---
🩺 Other Notes
- Reflexes: Normal (+2 to +3), no lateralizing signs.
- Dialysis: Two sessions completed on 25th and 26th Dec — likely contributing to improved renal parameters.
MRI Findings
- Cerebral Hemispheres (Right> Left): Fazekas Grade III chronic small vessel ischemic changes.
- Cerebral Atrophy: Moderate, diffuse, bilateral.
- Microhemorrhages: Multiple, involving bilateral deep grey nuclei and subcortical regions of frontal, parietal, and temporal lobes.
- Indicative of chronic hypertension microangiopathy.
---
💊 Treatment Plan (Generic Names)
Nutrition & Fluids:
- RT feeds: 100 ml milk every 4 hours
- Water: 50 ml every 2 hours
Medications:
- Injections:
- Piptaz (Piperacillin/Tazobactam) 2.25 gm IV TID
- Metrogyl (Metronidazole) 500 mg IV TID
- Pan (Pantoprazole) 40 mg PO OD
- Zofer (Ondansetron) 4 mg IV SOS
- HAI (Human Albumin Injection) SC TID
- Optineuron (Multivitamin) 1 amp in 100 ml NS IV OD
- Tablets:
- Cinod (Cilnidipine) 10 mg PO BD
- Calcimax-D3 (Calcium + Vitamin D3) PO OD
- Nodosys (Sodium Bicarbonate) 2 gm BD
- Ecosprin-AV (Aspirin + Atorvastatin) PO HS
🍼 Feeding Instructions
- Milk: 100 ml every 4 hours via RT (Ryle's Tube)
- Water: 50 ml every 2 hours
---
💊 Medications
Injectables:
- Piptaz (Piperacillin/Tazobactam): 2.25 gm IV, three times daily (TID)
- Metrogyl (Metronidazole): 500 mg IV, TID
- Pan (Pantoprazole): 40 mg orally, once daily (OD)
- Zofer (Ondansetron): 4 mg IV, single dose (SO)
- HAI (Human Actrapid Insulin): Subcutaneous (SC), TID
- Optineuron: 1 ampoule in 100 ml normal saline IV, OD
Tablets:
- Cinod (Cilnidipine): 10 mg orally, twice daily (BD)
- Calcimax-D3: Orally, OD
- Nodosis (Sodium Bicarbonate): 2 gm orally, BD
- Ecosprin-AV (Aspirin + Atorvastatin): Orally, at bedtime (HS)
---
📅 Follow-Up
- Review with General Surgery (GS), General Medicine (GM), and Nephrology as needed (SOS)
---
🚨 When to Seek Urgent Care
- In any emergency, immediately contact your consultant doctor or go to the emergency department
---
🛡️ Preventive Care
- Avoid self-medication
- Do not miss prescribed medications
🩺 Summary of Medical Report Findings
Blood Gas & Coagulation
- ABG (28/12/25): Mild respiratory alkalosis (pH 7.373, low PCO2), normal PO2, slightly low bicarbonate.
- D-Dimer: Elevated at 5700 – suggests possible thrombotic activity.
- Troponin I: Elevated at 22.6 – indicates myocardial injury.
- Coagulation Profile: PT 17, INR 1.25, APTT 34 – mildly prolonged PT.
Liver Function (LFT)
- Mildly elevated ALP (222), low albumin (2.2), low A/G ratio (0.73) – possible liver dysfunction or chronic illness.
Imaging
- Ultrasound Abdomen/Pelvis: Grade I renal parenchymal disease in both kidneys.
- 2D Echo:
- No regional wall motion abnormality.
- Concentric LV hypertrophy, mild mitral regurgitation, trivial aortic and tricuspid regurgitation.
- Grade II diastolic dysfunction, EF 60%, minimal pericardial effusion.
- MRI Brain:
- Acute infarcts in bilateral centrum semiovale and right hippocampus.
- Chronic lacunar infarcts in basal ganglia and pons.
- Large area of encephalomalacia in right occipital/temporal lobes.
- Fazeka’s Grade III small vessel ischemic changes.
- Moderate cerebral atrophy and multiple microhemorrhages in deep grey nuclei.
---
These findings suggest a complex clinical picture involving:
- Cardiovascular stress or injury
- Chronic small vessel cerebrovascular disease
- Renal and hepatic compromise
- Evidence of both acute and chronic brain infarcts
No comments:
Post a Comment