2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.





CASE 1:


PaJr group:

https://chat.whatsapp.com/Exz8ZyhxUfN7YxVvAImbLp


Blog:


https://kandhadatejaswinirollno66.blogspot.com/2023/08/a-78yr-old-male-with-prerenal-aki-left.html





[29/08/23, 4:36:04 PM] Rakesh Biswas Sir: Left leg? What's the radiological diagnosis? Why is the tibia bent?


[29/08/23, 4:39:07 PM] Tejaswini Kandhada: Yes sir it is left leg


[30/08/23, 3:11:03 PM] Tejaswini Kandhada: 30/08/23


Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)



S

Patient complaints of left lower limb swelling 

Burning micturition +

No complaints of fever,vomitings,loose stools


O

Patient is conscious/coherent/cooperative 

Temp:96.4F

Bp: 110/80  mmhg

PR: 79 bpm, regular 

RR: 24 cpm

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 


A

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD


P

1)IV fliuds NS @50ml/hr

2)Inj Meropenem 1gm IV/BD

3)Inj.Metrogyl 500mg IV/TID

4)Inj.Pan 40mg IV/OD

5)Inj.Lasix 80mg IV/TID

6)Tab.Chymerol forte PO/TID

7)Tab.MVT PO/OD

8)Tab.Vit C PO/OD

9)Tab.Ecosprin AV 75/10 PO H/S

10)Tab.MET XL 25mg PO/OD

11)MGSO4 dressing

12)left lower limb elevation


[30/08/23, 3:20:47 PM] Rakesh Biswas Sir: How was HFpEF diagnosed?


[30/08/23, 3:39:19 PM] Tejaswini Kandhada: His apical impulse felt at 6 th intercostal space sir

X ray shows cardiomegaly and in 2decho all chambers are dialted with normal ejection fraction sir


[30/08/23, 4:07:48 PM] Rakesh Biswas Sir: Dilated heart and preserved ejection fraction would be unusual. 


Please share his chest X-ray, Ecg and Echo video


[30/08/23, 4:30:26 PM] Tejaswini Kandhada: He had H/O left tibia fracture 8yrs back for which interlocking nail has been used then after 2yrs of implant he has developed necrotising fasciitis and cellulitis after that implant has been removed sir


[30/08/23, 4:30:40 PM] Tejaswini Kandhada: It might be malunion sir


[31/08/23, 12:27:37 PM] Tejaswini Kandhada: 31/08/23


Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)



S :

Patient complaints of left lower limb swelling 

Burning micturition has been resolved

No complaints of fever,vomitings,loose stools


O :

Patient is conscious/coherent/cooperative 

Temp:96.4F

Bp: 120/90  mmhg

PR: 78 bpm, regular 

GRBS : 121 mg/dl

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 


A :

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD


P :

1)IV fliuds NS @50ml/hr

2)Inj Meropenem 1gm IV/BD (D5)

3)Inj.Metrogyl 500mg IV/TID (D5)

5)Inj.Lasix 80mg IV/TID

6)Tab.Chymerol forte PO/TID

8)Tab.Vit C PO/OD

9)Tab.Ecosprin AV 75/10 PO H/S

10)Tab.MET XL 25mg PO/OD

11)MGSO4 + Glycerine dressing

12)left lower limb elevation


[31/08/23, 6:57:09 PM] Rakesh Biswas Sir: Image of his cellulitis?


[31/08/23, 6:57:22 PM] Rakesh Biswas Sir: Case report link?


[01/09/23, 11:36:06 AM] Tejaswini Kandhada: 01/09/23


Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Kranthi (PGY2)

Dr.Navya (PGY1)



S :

Patient complaints of left lower limb swelling,c/o foreign body sensation in left ear since yesterday night

No complaints of fever,vomitings,loose stools


O :

Patient is conscious/coherent/cooperative 

Temp:98.5F

Bp: 120/70  mmhg

PR: 72 bpm, regular 

GRBS : 97 mg/dl

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 


A :

Left lower limb cellulitis with prerenal AKI

HFpEF secondary to CAD


P :

1)IV fliuds NS @50ml/hr

2)Inj Meropenem 1gm IV/BD (D5)

3)Inj.Metrogyl 500mg IV/TID (D5)

5)Inj.Lasix 80mg IV/TID

6)Tab.Chymerol forte PO/TID

8)Tab.Vit C PO/OD

9)Tab.Ecosprin AV 75/10 PO H/S

10)Tab.MET XL 25mg PO/OD

11)MGSO4 + Glycerine dressing

12)left lower limb elevation


[01/09/23, 10:31:10 PM] Rakesh Biswas Sir: Well healed



CASE 2:


PaJr group:


https://chat.whatsapp.com/ERx2dM37PR51baX3vhkPzB


Blog:


https://kandhadatejaswinirollno66.blogspot.com/2023/08/75yr-old-male-with-aki-secondary-to.html


[28/08/23, 3:20:50 PM] Rakesh Biswas Sir: Fever Chart?




Daily WBC counts ?


Clinical images?


[28/08/23, 3:20:56 PM] Rakesh Biswas Sir: Which ward?


[29/08/23, 11:48:51 AM] Tejaswini Kandhada: Ward 10 sir


[29/08/23, 12:01:23 PM] Rakesh Biswas Sir: Case report link?


[29/08/23, 12:01:51 PM] Rakesh Biswas Sir: Further processing?👇


https://medicinedepartment.blogspot.com/2023/08/project-illustration-of-how-to-process.html?m=0


[30/08/23, 12:12:56 PM] Tejaswini Kandhada: 30/08/23


Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)



S

Patient complaints of both lower limbs swelling (right > left) 

Fever has been resolved

No complaints of vomitings,loose stools


O

Patient is conscious/coherent/cooperative 

Temp:98.4F

Bp: 120/70  mmhg

PR: 84 bpm, regular 

RR: 21 cpm

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 


A

Right lower limb cellulitis with prerenal AKI


P

1)Inj.Linezolid 600mg IV/BD

2)Inj.Augmentin 1.2mg IV/TID

3)Inj.PAN 40mg IV/OD

4)T.Chymerol forte PO/TID

5)MGSO4 dressing for right lower limb cellulitis

6)2egg whites/day

7)Right lower limb elevation

8)IV fluids NS@50ml/hr


[31/08/23, 12:45:59 PM] Tejaswini Kandhada: 31/08/23


Date of admission : 27/08/23

Dr.Rakesh Biswas (HOD)

Dr.Sushmitha (SR)

Dr.Nishitha (PGY2)

Dr.Navya (PGY1)



S

Patient complaints of both lower limbs swelling (right > left) 


O

Patient is conscious/coherent/cooperative 

Temp:98.4F

Bp: 110/80  mmhg

PR: 92 bpm, regular 

RR: 20 cpm

SPO2: 98% at RA

CVS: S1 S2+ , no murmurs heard

RS: Bilateral air entry+, NVBS heard

CNS: NFAD

P/A: Soft, no organomegaly, bowel sounds heard 


A

Right lower limb cellulitis with prerenal AKI


P

1)Inj.Linezolid 600mg IV/BD

2)Inj.Augmentin 1.2mg IV/TID

3)Inj.PAN 40mg IV/OD

4)T.Chymerol forte PO/TID

5)MGSO4 dressing for right lower limb cellulitis

6)2egg whites/day

7)Right lower limb elevation

8)IV fluids NS@50ml/hr


[31/08/23, 4:59:48 PM] Rakesh Biswas Sir: Where is the picture of his limbs with cellulitis? 


Share his FBS, PpBs values since admission


[02/09/23, 9:50:15 AM] Tejaswini Kandhada: FBS-83mg/dl


[02/09/23, 9:50:46 AM] Rakesh Biswas Sir: No PpBs since admission?


[02/09/23, 9:51:11 AM] Rakesh Biswas Sir: Share both limbs together always for comparison


[02/09/23, 9:51:20 AM] Tejaswini Kandhada: Ok sir


[02/09/23, 9:51:31 AM] Tejaswini Kandhada: Sir he is not a known case of diabetes


[02/09/23, 9:52:10 AM] Rakesh Biswas Sir: That doesn't matter 


To know we need PpBs after every meal


[02/09/23, 9:53:11 AM] Tejaswini Kandhada: Ok sir



CASE 3:


PaJr group:

https://chat.whatsapp.com/GveWZ8lnOUP22KgXylJa8y


Blog:


https://kandhadatejaswinirollno66.blogspot.com/2023/09/57yr-old-male-came-to-opd-with-chief.html


[03/09/23, 9:21:34 AM] Rakesh Biswas Sir: Clinical images DP of abdominal and biceps lateral view

[03/09/23, 2:21:18 PM] Rakesh Biswas Sir: Bedside autonomic function tests? Did you review the literature around it? Please share what you learned

[03/09/23, 2:21:41 PM] Rakesh Biswas Sir: Share the link in 2018 group

[03/09/23, 2:21:48 PM] Rakesh Biswas Sir: The group link

[03/09/23, 6:03:50 PM] Tejaswini Kandhada: Autonomic function tests
Heart rate variability during -
Orthostatic testing
Valsalva manoeuvre
during deep breathing
Cold pressor test
*ORTHOSTATIC TESTING:
In supine position - BP:140/80mmHg
                                  PR:80bpm
In standing position (after 3min) - BP:140/90mmHg
                                                           PR:81bpm
-no significant postural drop
-no C/O dizziness,feeling of syncope or palpitations

*DURING DEEP BREATHING:
His BP - 150/80mmHg
       PR-80bpm
*VALSALVA MANOEUVRE:
On voluntary forced expiration of patient against resistance - his BP was 140/90mmHg
               
-no symptoms of diarrhoea,urinary retention,urinary urgency
-no abnormal dryness of skin



CASE 4:


PaJr group:



Blog:




[06/09/23, 8:17:00 PM] Rakesh Biswas Sir: Was he admitted on 22/8?

Check out his case report link from then 

Share this link in the 2018 ward group

[06/09/23, 8:31:07 PM] Tejaswini Kandhada: No sir he is not admitted here

[06/09/23, 8:31:16 PM] Tejaswini Kandhada: He went to some gvt hospital

[06/09/23, 8:33:11 PM] Rakesh Biswas Sir: You mean he is not admitted here now or he was not admitted here then but is admitted here now?

[06/09/23, 8:34:20 PM] Tejaswini Kandhada: He was not admitted here then sir

[06/09/23, 8:34:28 PM] Tejaswini Kandhada: Now he is admitted here only

[07/09/23, 9:49:05 AM] Tejaswini Kandhada: 07/09/23

Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)


S
Pain in the abdomen has been reduced
Fever has been resolved

O
Patient is conscious/coherent/cooperative 
Temp:97.9F
PR: 86 bpm, regular 
Bp: 120/80  mmhg
GRBS-84mg/dl
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A: Soft, no organomegaly, bowel sounds heard 

A
ACUTE ON CHRONIC PANCREATITIS

P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/BD
5)Inj.Zofer 4mg IV/SOS
6)Inj.PCM 1gm IV/SOS If temp >101F
7)monitor vitals 2nd hrly
8)Temp 4th hrly

[07/09/23, 1:08:02 PM] Rakesh Biswas Sir: Acute pancreatitis has soft abdomen?

[07/09/23, 2:34:20 PM] Tejaswini Kandhada: No sir

[07/09/23, 3:09:01 PM] Tejaswini Kandhada: Tenderness is present in left iliac region

[07/09/23, 3:14:45 PM] Rakesh Biswas Sir: Left Iliac tenderness can be due to pancreatitis!!?

[07/09/23, 3:16:40 PM] Tejaswini Kandhada: Epigastric and left hypochondriac region

[07/09/23, 3:16:45 PM] Tejaswini Kandhada: Sir

[07/09/23, 3:24:07 PM] Rakesh Biswas Sir: How would you explain it?

[07/09/23, 4:39:28 PM] Tejaswini Kandhada: Sir now i clearly palpated and the tenderness is in the left lumbar region sir
Which can be the manifestation of acute pancreatitis

[07/09/23, 4:43:57 PM] Rakesh Biswas Sir: Share link to articles with quotes to the relevant portions instead of PDF

[07/09/23, 4:48:24 PM] Tejaswini Kandhada: Left flank pain as the sole manifestation of acute pancreatitis 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726822/pdf/v022p00452.pdf

[08/09/23, 1:17:12 PM] Tejaswini Kandhada: 08/09/23

Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)

S
Patient complaining of Pain in  left lumbar region since morning 

O
Patient is conscious/coherent/cooperative 
PR: 86bpm, regular 
Bp: 110/60  mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region

A
ACUTE ON CHRONIC PANCREATITIS

P
1)Liquid diet
2)IV fliuds NS,RL,DNS @75ml/hr
3)Inj Monocef 1gm IV/BD
4)Inj.PAN 40mg IV/OD
5)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 2nd hrly

[08/09/23, 7:21:25 PM] Rakesh Biswas Sir: Share the CT images

[09/09/23, 10:10:21 AM] Tejaswini Kandhada: 





09/09/23

Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)


S
Pain in  left lumbar region since yesterday

O
Patient is conscious/coherent/cooperative 
PR: 84bpm, regular 
Bp: 100/70  mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region

A
ACUTE ON CHRONIC PANCREATITIS

P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 4th hrly
7)Inj.Octreotide 100mg SC/TID



CASE 5:


PaJr group:



Blog:


[15/09/23, 2:34:15 PM] Rakesh Biswas Sir: Update?

[15/09/23, 2:55:51 PM] Tejaswini Kandhada: 15/09/23

Date of admission : 07/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)


S
B/L knee pains since 2days
Pain at the site of suture(lower lip laceration)

O
Patient is conscious/coherent/cooperative 
PR: 72bpm, regular 
Bp: 110/70  mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A:soft,non tender,bowel sounds heard

A
Generalized tonic clonic seizure secondary to non compliance with B/L grade4 osteoarthritis of knee

P
1)Tab.Sodium valproate 200mg po/od
2)Tab.Taxim 200mg po/bd
3)Tab.pan 40mg po/od
4)Tab.Zerodol-p po/bd
5)Tab.Ultracet po/bd
6)Chlorhexidine mouth wash po/tid 
7)Tab.Dolo 650mg po/tid

[15/09/23, 4:17:03 PM] Rakesh Biswas Sir: Utility of taxim?

[15/09/23, 5:39:02 PM] Tejaswini Kandhada: Sir it was prescribed by omfs team as they did suture for the laceration of lower lip


CASE 6:





CASE 7:


PaJr group:



[20/09/23, 4:30:34 PM] Rakesh Biswas Sir: Well done history @918309872582

[20/09/23, 4:39:08 PM] Rakesh Biswas Sir: Share this link in the 2018 opd group

[20/09/23, 5:22:16 PM] Tejaswini Kandhada: Ok sir



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