21-01-2026
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.
[10.41 am, 21/01/2026] PPM 1: EMR CDSS (conversational decision support system) notes in a human agentic workflow between hu1 and hu2 human user 1 and 2:
[19/01, 21:40] Hu1 2023: Her RR is 24 to 28
taking breath with accessory muscle usage
[19/01, 21:41] Hu1 2023: does she requires reintubation
[19/01, 21:49]hu2: Not unless she develops fatigue and hypoventilation suggested by hypercapnia
[19/01, 21:49] Hu1 2023: She is going into distress
[19/01, 21:49] Hu1 2023: in between she is awakened
[19/01, 21:50] Hu1 2023: Post extubation chest xray
[19/01, 21:50] Hu1 2023: This is after 2 hrs extubation
[19/01, 21:50] Hu1 2023: under room air
[19/01, 21:51] Hu1 2023: Auscultation she is having laryngeal stridor, some wheeze in anterior chest
[19/01, 21:52] Hu1 2023: Abg now
[19/01, 21:52]hu2: Looks like severe hypoxia possibly due to air still escaping from the tracheal perforation? Can you share the initial history with me as I have forgotten from Saturday
[19/01, 21:53]hu2: BP stable? Creatinine? Is the metabolic acidosis due to increased lactate?
[19/01, 21:55] Hu1 2023: Bp heart rate stable sir
[19/01, 21:57] Hu1 2023: This is room air no sir, may be bcz of that hypoxia?
[19/01, 21:58] Hu1 2023: Her investigation chart
[19/01, 22:01] Hu1 2023: What to do now?
[19/01, 22:01] Hu1 2023: will re intubate her?
[19/01, 22:02]hu2: Currently her ABG PaO2 on O2 (how much fiO2?) is already very high!
[19/01, 22:02]hu2: Not for hypoxia which is already being controlled with Fio2. Please mention the FiO2
[19/01, 22:02] Hu1 2023: This is now. She is on O2 10 lit with hudson mask
[19/01, 22:03]hu2: Yes and it's too much oxygen fio2 as per the ABG paO2
[19/01, 22:03] Hu1 2023: Yes sir there is no hypoxia it seems
[19/01, 22:03]hu2: Then what's the current need for intubation?
[19/01, 22:04]hu2: She's not hypoventilating either
[19/01, 22:04]hu2: We need to reduce the FiO2 to prevent oxygen toxicity
[19/01, 22:05] Hu1 2023: I'm in dilemma
[19/01, 22:05] Hu1 2023: Weather to intubate or not?
[19/01, 22:06] Hu1 2023: With that stridor, is she having laryngeal or tracheal edema
Which is causing her respiratory distress??
[19/01, 22:07] Hu1 2023: If tracheal perforation is leaking that subcutaneous emphysema should spread
[19/01, 22:08] Hu1 2023: Case extubated at 3 30 pm today. It's almost 6 hrs now
[19/01, 22:09]hu2: Has it spread?
[19/01, 22:09] Hu1 2023: No
[19/01, 22:10]hu2: The video sound suggests a wheeze.
What are the current auscultation findings?
[19/01, 22:11] Hu1 2023: laryngeal stridor, anterior wheeze mild. Left isa decreased breath sounds
[19/01, 22:13]hu2: Have we tried nebulization?
[19/01, 22:13] Hu1 2023: Yes
[19/01, 22:14] Hu1 2023: after nebs it's coming down and after some time developing again
[19/01, 22:14]hu2: That means there is a bronchoconstriction
What medications were given in the nebulizer?
[19/01, 22:15] Hu1 2023: Budecort
[19/01, 22:15] Hu1 2023: Duolin
[19/01, 22:15] Hu1 2023: Shall I try adrenaline nebs
[19/01, 22:16] Hu1 2023: Iv hydrocort also given
[19/01, 22:21]hu2: Repeat the budecort again
[19/01, 22:21] Hu1 2023: Is this is stridor or wheeze?
[19/01, 22:25]hu2: Stridor
[19/01, 22:26]hu2: Can reintubate her.
Check out this case of post extubation stridor 👇
[19/01, 22:26] Hu1 2023: Seems Ent opinion taken
they may plan for tracheostomy 🥺
[19/01, 22:27]hu2: Yes can. Will be better as reintubation could be difficult. Can get anesthesia help if contemplating reintubation.
[10.47 am, 21/01/2026] PPM 1: https://youtube.com/shorts/roDuNreaJhk?si=tWrW1RKRlrPfQEfZ
https://youtu.be/chPG9PkaU9g?si=HzurW0Ch6yHlFaQV
[4.08 pm, 21/01/2026] PPM 1: https://youtube.com/shorts/PooBZvH9-dw?si=JfkA-knx9B-4FK86
CT brain video of the patient. 👆
[4.08 pm, 21/01/2026] PPM 1: https://youtube.com/shorts/PooBZvH9-dw?si=JfkA-knx9B-4FK86
CT brain video of the patient. 👆
[10.50 am, 28/01/2026] PPM 1: EMR summary @PPM3 same PaJR sociotechnical story as 57M shared now
Age/Gender: 80 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 16/01/2026 01:31 PM
Discharge Date: 22/01/2026 02:42 PM
Diagnosis
TYPE II RESPIRATORY FAILURE (RESOLVED) SECONDARY TO? LARYNGEAL EDEMA?OSA? COMMUNITY ACQUIRED PNEUMONIA
EUVOLEMIC HYPONATREMIA SECONDARY TO? SIADH (RESOLVED)
RIGHT PNEUMOTHORAX (RESOLVED) SECOMDARY TO? BAROTRAUMA-S/P RIGHT ICD
REMOVED(DAY-5)
COMMUNITY ACQUIRED PNEUMONIA (RESOLVING)
S/P MECHANICAL VENTILATION(16/1/26)
S/P EMERGENCY TRACHEOSTOMY(POD -3)
GTCS SECONDARY TO DYSELECTROLYTEMIA (RESOLVED)
GRADE II BEDSORE (RIGHT GLUTEAL REGION)
OBSTRUCTIVE SLEEP APNEA
TOBACCO DEPENDENCE
URINARY TRACT INFECTION(ENTEROCOCCUS SPECIES ISOLATED)
K/C/O HYPERTENSION SINCE 14 YEARS
Case History and Clinical Findings
PATIENT WAS BROUGHT TO CASUALTY IN ALTERED SENSORIUM SINCE TODAY MORNING.
HISTORY OF PRESENTING ILLNESS: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL
YESTERDAY NIGHT, THEN TODAY MORNING WAS FOUND ON BED IN ALTERED SENSORIUM
i.e DROWSY BUT AROUSABLE TO PAINFUL STIMULUS, ABNORMAL BREATH
SOUNDS(STRIDOR+)
Page-2
KIMS HOSPITALS
PT HAD A/H/O FALL - HIP FRACTURE- R THR DONE 1 MONTH AGO.FOLLOWED BY AFTER2
WEEKS DEVELOPED DIFFICULTY IN BREATHING,COPIOUS SPUTUMFOR WHICH TREARED
WITH ANTIBIOTICS X 5DAYS-HB IMPROVED BREATHING AND DECREASED SPUTUM
PRODUCTION AND DAILY NEBULIZATION WERE CONTINUED SINCE THEN.
NO H/O COUGH,FEVER,CHEST PAIN,PROFUSE SWEATING.
H/O FALL FROM BED 10 DAYS AGO,BED RIDDEN SINCE THEN DUE TO FRACTURE OF RIGHT
HIP AT THE SAME LOCATION.H/O SLURRING OF SPEECH SINCE 7 DAYS.NO H/O
DECREASED URINE OUTPUT,URINARY INCONTINENCE,HEAD TRAUMA.
PAST HISTORY: K/C/O HTN SINCE 14 YEARS ON UNKNOWN MEDICATION.
H/O RIGHT THR DONE 1 MONTH AGO.H/O USAGE OF ANTIPLATELETS FOR CAD
PROPHYLAXIS.
N/K/C/O T2DM, ASTHMA, COPD, EPILEPSY, CVA, THYROID DISORDERS.
PERSONAL HISTORY: MARRIED, DECREASED APPETITE, MIXED DIET, REGULAR BOWEL AND BLADDER MOVEMENTS, NO ALLERGIES, DAILY TOBACCO SNUFF SINCE CHILDHOOD.
GENERAL EXAMINATION: PALLOR +, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA.
VITALS: TEMP:98 F, BP- 110/70MMHG, PR-87 BPM, RR-28 CPM
SYSTEMIC EXAMINATION-CVS-S1S2 HEARD, RS-BAE+,B/L DIFFUSE RALES +STRIDOR +, P/ASFT,
NON TENDER
CNS:B/L PINPOINT PUPILS, DROWSY,AROUSABLE TO PAINFUL STIMULI, E2V2M4-- E4V5M6
AFTER CO2 WASHOUT WITH NEBS,AMBU VENTILATION,O2 SUPPLEMENT.
POWER AND TONE -COULDNOT BE ELICITED
REFLEXES : RT :B +2 , T - , S - ,K +2 ,A - , P -FLEXION
LT :B +2 , T - , S - ,K +2 ,A - , P -FLEXION
ORTHOPEDICS REFFERAL WAS DONE AND THEIR ADVICE WAS FOLLOWED.
PULMONOLOGY REFFERAL WAS DONE AND THEIR ADVICE WAS FOLLOWED.
NEUROLOGY REFERRAL WAS DONE AND THEIR ADVICE WAS FOLLOWED.
ENT REFERRAL WAS DONE AND THEIR ADVICE WAS FOLLOWED.
EMERGENCY TRACHEOSTOMY UNDER GA(20/1/26) WAS DONE.
Investigation
HEMOGRAM (16/1/26): HB-12.5, PCV-40.2 TLC-23000, RBC-4.6, PLT-4.5
HEMOGRAM (17/1/26): HB-8.7, PCV- 26.3TLC-14900, RBC-3.1, PLT-4.0
HEMOGRAM (18/1/26): HB-8.1, PCV-24.3 TLC-12900, RBC-2.8, PLT-3.2
HEMOGRAM (19/1/26): HB-7.7, PCV-24.4 TLC-12400, RBC-2.8, PLT-3.4
HEMOGRAM (20/1/26): HB-8.7, PCV-26.9 TLC-11300, RBC-3.09, PLT-3.71
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KIMS HOSPITALS
HEMOGRAM (21/1/26): HB-8.3, PCV-26.1 TLC-12800, RBC-3.0, PLT-3.6
HEMOGRAM (23/1/26): HB-9.0, PCV-27 TLC-11900, RBC-3.1, PLT-3.1
RFT(16/1/26 ): UREA-73 CREATININE-1.10, SODIUM-127, POTASSIUM-4.2, CHLORIDE-90.
RFT(17/1/26 ): UREA-75 CREATININE-1.2, SODIUM-122, POTASSIUM-4.8, CHLORIDE-88.
RFT(18/1/26 ): UREA-56.20 CREATININE-1.30, SODIUM-127, POTASSIUM-3.7, CHLORIDE-92.
RFT(19/1/26 ): UREA-45 CREATININE-1, SODIUM-130, POTASSIUM-3.7, CHLORIDE-95.
RFT(20/1/26 ): UREA-35 CREATININE-0.8, SODIUM-135, POTASSIUM-3.7, CHLORIDE-99.
RFT(21/1/26 ): UREA-38 CREATININE-0.7, SODIUM-133, POTASSIUM-3.3, CHLORIDE-94.
RFT(23/1/26 ): UREA-38 CREATININE-0.6, SODIUM-129, POTASSIUM-3.2, CHLORIDE-90.
LFT(16/1/26 ): TB 0.74 DB 0.17 SGPT 27 SGOT -40 ALP 354 TP 6.6 ALB -3.66 GLO 2.94 A/G 1.24
CUE(16/1/26 ): PALE YELLOW CLEAR ,ACIDIC, ALBUMIN +30 ,SUGAR NIL PUS CELLS 3-4
EPITHELIAL CELLS 2-4 RBC, CASTS, CRYSTALS - NIL
RBS (16/1/26 ): 183, FBS(17/1/26)-128, FBS(18/1/26)- 92
SEROLOGY-NEGATIVE
BLOOD GROUPING AND TYPING- O POSITIVE
PT-17,INR-1.25,APTT-34
D-DIMER(16/1/26)-1800
SERUM OSMOLALITY-235
URINARY ELECTROLYTES- NA+ 156, K+ 12.3, CL-180
THYROID PROFILE(17/1/26)-T3-0.6, T4-13.5, TSH-5.17
THYROID PROFILE(19/1/26)-T3-0.4, T4-10.6, TSH-3.26
ABG(17/1/26)- PH-7.354, PCO2-35.7, PO2-228 SO2-99.9, CHCO3-19.4
ABG(18/1/26)- PH-7.35, PCO2-33.30, PO2-61 SO2-92, CHCO3-19
ABG(20/1/26)- PH-7.340, PCO2-35.5, PO2-100 SO2-98.5, CHCO3-18.6
ABG(23/1/26)- PH-7.393, PCO2-43.2, PO2-145 SO2-99.4, CHCO3-25.8
ABG(PRE INTUBATION)- PH-7.09, PCO2-73.5, PO2-82.1 SO2-93.2, CHCO3-21.5
ABG(POST INTUBATION)- PH-7.221, PCO2-46.3, PO2-67.5 SO2-91.9, CHCO3-18.3
BLOOD C/S-NO GROWTH
URINE C/S-NO GROWTH
MICROSCOPIC EXAMINATION-2-3 PUS CELLS SEEN,10^4 CFU/MLCOLONY COUNT
ORGANISM-ENTEROCOCCUS SPECIES
AMPICILLIN,CIPROFLOXACIN GENTAMICIN HIGH LEVEL,LEVOFLOXACIN,PENCILLIN-GRESISTANT
FOSFOMYCIN,LINEZOLID,NITROFURANTOIN,VANCOMYCIN-SENSITIVE
2D ECHO (/1/26)-
NO RWMA,MILD LVH+
MILD TR+ WITH PAH(ECCENTRIC JET MR+)
TRIVIAL MR+/ PR+(AR-PHT 628 M/SEC)
SCLEROTIC AV, NO AS/MS.IAS -INTACT
EF-60% GOOD LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION+
MINIMAL PE+,NO LV CLOT
IVC SIZE (1.50CM),NON COLLAPSING
2D ECHO REVIEW(19/1/26)
NO RWMA,MILD LVH+
MODERATE TR+ WITH PAH(ECCENTRIC JET MR+)
MILD AR+.TRIVIAL MR+,NO PR
SCLEROTIC AV, NO AS/MS.IAS -INTACT
EF-60% GOOD LV SYSTOLIC FUNCTION
GOOD LV/RV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION+
MINIMAL PE+,NO LV CLOT
IVC SIZE (1.25CM)
USG ABDOMEN AND PELVIS(17/1/26)
GRADE I RPD CHANGES IN THE RIGHT KIDNEY
RAISED ECHOGENICITY OF LEFT KIDNEY
RIGHT RENAL CORTICAL CYSTS
ECHOGENIC GALL BLADDER SLUDGE
HRCT THORAX PLAIN(16/1/26)-
THE LUNG PARENCHYMAICD,
ET INSITU,NG TUBE NOTED.
CONSOLIDATION IN B/L LOWER LIMBS,POSTERIOR AND SUPERIOR BASAL SEGMENTS
FEW GGO'S IN B/L UPPER LOBES
EXTENSIVE EMPHYSEMA IN ATERIOR CHEST WALL.
MILD EXTRA PLEURAL AIR IN B/L THORACIC CAVITY
PLEURA: MINIMAL PNEUMOTHORAX, MID PNEUMOMEDIASTINUM.
B/L MINIMAL PLEURAL EFFUSION.
BONE: DEGENRATIVE CHNAGES
VISUALIZED UPPER ABDOMEN-LEFT KIDNEY UPPER CALYCEAL CALCULUS(MODERATE)-16MM
GALL BLADDER-MULTIPLE TINY GB CALCULI
MDCT BRAIN PLAIN (16/1/26)-
SMALL HYPODENSE AREAS IN THE SUBCORTICAL WHITE MATTER OF B/L TEMPORAL
LOBES-?MILD LEUKOENCEPHALOPATHY CHANGES
CHRONIC LACUNAR INFARCT IN THE BODY OF RIGHT CAUDATE NUCLEUS
CONFLUENT B/L PERIVENTRICULAR AND DEEP WHITE MATTER HYPODENSITIES-CHRONIC WHITE MATTER ISCHAEMIC CHANGES
MILD DIFFUSE AGE RELATED CEREBRAL ATROPHY
DURAL CALCIFICATIONS LARGEST MEASURING 9-10MM IN THE MIDLINE FALX AND RIGHT CEREBELLAR HEMISPHERE
DIFFUSE SEVERE EMPHYSEMA INVOLVING SUBCUTANEOUS AND MUSCULAR PLANES OF THE LEFT MAXILLARY REGION DISSECTING INTO DEEP FASCIAL PLANES OF NECK.
MODERATE LEFT PERIORBITAL EMPHYSEMA
MODERATE MUCOSAL THICKENING OF THE RIGHT MAXILLARY SINUS AND SPHENOID
SINUS WITH PERIOSTEAL THICKENING
MILD DNS TO THE RIGHT
MILD DEGENRATIVE CHANGES IN THE VISUALIZED PART OF SPINE.
Treatment Given (Enter only Generic Name)
RT FEEDS-50ML WATER 2NDHOURLY,100ML MILK 4TH HOURLY
IVF NS/RL @ 50ML /HR
INJ.HYDROCORT 200MG IV STAT
NEB WITH MUCOMIST STAT
INJ MIDAZOLAM 2G IV STAT
INJ.VECURONIUM 2G IV STAT
INJ.PIPTAZ 4.5 GM IV STAT FOLLOWED BY
INJ.PIPTAZ 4.5 G IV TID 1-1-1
INJ.OPTINEURON 1 AMP IN 500ML NS IV OD
INJ.HYDROCORT 100ML IV/BD 1-0-1
INJ.NEOMOL 1G IV SOS
INJ.FENTANYL+ ATRACURIUM @4ML/HR
INJ.3% NACL @15ML/HR
INJ.GLYCOPYRROLATE 1AMPIV IN 100ML NS IV/BD 1-0-1
Page-6
KIMS HOSPITALS
INJ.ENOXAPARIN 40MG S/C OD 8AM -0-0
INJ.LEVIPIL 500MG IV/BD 1-0-1 X 1 WEEK
INJ.DOXYCYCLINE 100MG IV/BD 1-0-1
TAB.CHYMORAL FORTE RT/BD 1-0-1
TAB.AMLONG 5MG PO/OD 8AM-0-0
TAB.TAXIM-O 200MG PO/BD 1-0-1
TAB.NITROFURANTOIN 100MG PO/BD 1-0-1
SYP.CREMAFFIN 15ML PO/HS 0-0-15ML
NEOSPORIN POWDER L/A QID1-1-1-1
NEB WITH IPRAVENT 8TH HOURLY, MUCOMIST 6TH HOURLY,UDECORT 12TH HOURLY
ET AND ORAL SUCTIONING 4TH HOURLY
TRACHEOSTOMY AND ORAL CARE 2ND HOURLY
CHEST PHYSIOTHERAPY 4TH HOURLY,POSITION CHANGE 2ND HOURLY
PHYSIOTHERAPY OF B/L UL AND LL
Advice at Discharge
HOME OXYGENATION
TAB.TAXIM-O 200MG PO/BD 1-0-1 X 7 DAYS
TAB.NITROFURANTOIN 100MG PO/BD 1-0-1 X 7DAYS
TAB.LEVIPIL 500MG PO/BD 1-0-1 X 1 WEEK
TAB.CHYMORAL FORTE RT/BD 1-0-1 X 5DAYS
TAB.AMLONG 5MG PO/OD 8AM-0-0 TO BE CONTINUED
SYP.CREMAFFIN 15ML PO/HS 0-0-15ML X 3DAYS
NEOSPORIN POWDER L/A 4TH HOURLY
NEB WITH DUOLIN 8TH HOURLY, MUCOMIST 6TH HOURLY,BUDECORT 12TH HOURLY
KEEP ET TUBE DEFLATED IF MAINTAINING ON ROOM AIR
TRACHEOSTOMY AND ORAL CARE 2ND HOURLY
CHEST PHYSIOTHERAPY 4TH HOURLY,POSITION CHANGE 2ND HOURLY
PHYSIOTHERAPY OF B/L UL AND LL
Follow Up
REVIEW TO ENT OPD AFTER 5DAYS WITH METALLIC TRACHEOSTOMY TUBES (SIZED 26 AND
28) FOR PLAN FOR DECANnULATION
REVIEW TO GM OPD AFTER 1 WEEK
Discharge Date
Date:23/1/26
Ward: FMW
Unit: V
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