Traces of his work during his internship (original post here - https://kandrucherishrollno68.blogspot.com/2023/09/traces-of-my-work-during-my-internship.html )
September 04, 2023
Case 1
[31/08/23, 10:33:04 AM] intern1: soap notes
31:8:23
ICU Bed 3
Dr.resident1SR)
Dr.resident2(PGY2)
DR.resident3(PGY1)
S: No Fever Spikes
O: Pt is Sedated and Intubated
GCS- E1V1M1
PR-80bpm
RR-15cpm
BP-60/40 mmhg
@20ml/hr NORAD
@14ml/hr DOBU
ACMV Mode
FiO2 @70
SPO2 98%
RS: BLAE +
NVBS
CVS: S1S2 +, No murmurs
CNS:
Tone :Normal B/L both UL&LL
Power : Unable to elicit
Reflexes: Absent B/L in both UL & LL
I/O 1900/200ml
GRBS 327mg/DK
A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done) 2 years back
P:
1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr
2. INJ DOBUTAMINE 1AMP (5ml) + 45ml NS @ 10 ml /hr
3. INS 3% NACL @ 50 ml/hr I.V /stat
4. INJ PIPTAZ 2.25 gm IV/TID
5. TAB AZITHROMYCIN 500 mg RT/OD
6. NEB WITH BUDECORT + IPRAVANT 6 Th hourly
7. RT FEEDS 100 ml water 2 nd hourly
200 ml milk 4 Th hourly
8. MONITOR VITALS TEMP; PR; RR ; spo2
9. POSITION CHANGE EVERY HOURLY
10. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr
11. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr
12. INJ HAI ACC to GRBS
[31/08/23, 3:44:59 PM] Prof: Please share the post admission transfer events of yesterday in detail as to how and why the patient had to undergo CPR @intern2 @intern3
[31/08/23, 3:52:38 PM] Prof: Did he have any recent trauma @inter2 ?
That's not clear! In the description it's mentioned years and here it's mentioned weeks. Please clarify
[31/08/23, 6:04:12 PM] intern1: Yes Sir H/0 trauma (slip and fall from steps) 3 weeks back and also
H/o Rt proximal femur fracture Intramedullary Interlocking nailing done 10 years back
[31/08/23, 6:28:04 PM] intern1: Sir the Patient t was shifted from Ortho ward at around 11:30 am in an altered state but the patient was responding when called by his name and obeying commands. At that time the Vitals were
PR-134bpm
BP-60/40mmhg
RR-10cpm
Then Patient was shifted to ICU immediately and ABG and S.Electrolytes were sent.Ionotropic support was started with INJ. DOBUTAMINE and INJ. NORAD. On reporting Sod was found to be 122mEq/L and diagnosis was Altered Sensorium secondary to hyponatraemia. Further Sodium correction was given. After giving correction of 3%Nacl, Sodium was found to be 124mEq/L and patient’s condition didn’t improve. Again Sodium Correction was kept with 3%Nacl @ 30ml/hr. On auscultation grunting was observed and saturations decreased to below 90% with O2 support and also Neb with Budecort and Ipravent was done. Inspite of all these efforts patient’s saturations didn’t improve and continuously decreased to around 78% to 80% and decision to intubate was taken. During intubation Patient went to cardiac arrest and 3 cycles of CPR was done, ROSC was achieved and patient was kept on ventilator ACMV VC mode with FiO2 100%.
[01/09/23, 9:37:14 AM] intern1: soap notes
1:9:23
ICU Bed 3
Dr.resident1(SR)
DR.resident3(PGY2)
DR.resident5(PGY1)
S: No Fever Spikes
O: Pt is on Mechanical Ventilator
GCS- E1V1M1
PR-130bpm
RR-14cpm
BP-100/60 mmhg
@10ml/hr NORAD
@10ml/hr DOBU
ACMV Mode
FiO2 @30
SPO2 99%
RS: BLAE +
Decreased BS in IAA with crepts present in Lt IMA; Rt MA, IMA, IAA
CVS: S1S2 +, No murmurs
CNS:
Tone :Normal B/L both UL&LL
Power : Unable to elicit
Reflexes: Absent B/L in both UL & LL
Brain stem reflexes:
Pupillary reflex- absent
Corneal reflex- absent
Conjunctival reflex- absent
Gag reflex- Present
Occulocephalic reflex- Present
P/A- Soft, NT
I/O 1900/200ml
GRBS 327mg/DK
A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago
S/P Post CPR status with chronic calcific Pancreatitis
P:
1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr
2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr
3. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr
4. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr
5.TAB AZITHROMYCIN 500 mg RT/OD
6.NEB WITH BUDECORT + IPRAVANT 6 Th hourly
7.INJ THIAMINE 1 Amp In 100 ml NS IV/BD
8.RT FEEDS 200 ml water 2 nd hourly
200 ml milk 4 Th hourly
9.MONITOR VITALS TEMP; PR; RR ; spo2
10.POSITION CHANGE EVERY HOURLY
11.INJ HAI ACC to GRBS
12.INJ.MEROPENEM 500mg IV/BD
13.INJ HEPARIN 500 IU S.c/ QID
15.INJ LEVIPIL 1gm IV/BD
[01/09/23, 9:45:27 AM] Prof: 👆The EF is much more than 44% in this video taken yesterday @919676979003 where it appears to be 60% and the only other prominent finding is the LVH that appears absent in his Ecg (but that just reflects the 30% sensitivity of Ecg to pick up LVH)
Possible that he may have developed cardiogenic shock pre arrest which is when the 44% Echo was done? Can you share that video if possible?
[01/09/23, 9:46:13 AM] intern1: Yes sir
[01/09/23, 10:06:09 AM] intern1: Sir the video wasn’t taken sir I’ll try to find the report
[01/09/23, 10:07:07 AM] intern1: Update @9am Sir
Temp is 101
[02/09/23, 4:10:15 PM] Prof: Please share all the events that happened around him from falling 3 weeks back to presenting at our hospital
[03/09/23, 10:04:28 AM] intern1: Sir the patient fell from staircase 1 month back. Then he had severe pain of lower back radiating to his lower limbs. So he was taken to a nearby hospital in Nalgonda where X-rays and they were told that no fracture was found, he was also taken to another hospital and the same happened again. Then CT scan was done wherein they found the L5 unstable burst fracture with PLC injury and a belt was given to contain the fracture along with some analgesics for the pain. As the patient wasn’t compliant to the treatment given and the pain was severe he was brought to our hospital and he was advised L4 L5 S1 posterior stabilisation.
[03/09/23, 10:16:36 AM] intern1: Sir the whole 3 weeks span of him coming to our hospital he was having good appetite, he was compliant with his OHAs, he had no other complaints except for his pain
[03/09/23, 10:17:02 AM] intern1: Should I ask the attenders anything in particular sir?
[03/09/23, 10:21:40 AM] Prof: Ask them what was he doing hourly in the past three weeks and was it any different from before he fell down
[03/09/23, 10:22:25 AM] intern1: After coming to our hospital he had three episodes of vomiting, non bilious, non foul smelling ,food particles as content. The morning before he was shifted to ICU
[03/09/23, 10:47:00 AM] intern1: He used to just lie down on bed the entire day sir and there were no irregularities observed by the attenders sir
[03/09/23, 11:20:49 AM] Prof: Was he bedridden before the fall three weeks ago?
[03/09/23, 11:23:15 AM] intern1: No sir
[03/09/23, 11:24:07 AM] intern1: He wasn’t bedridden, he used to do his daily activities sir
[03/09/23, 11:44:02 AM] Prof: What were his hourly daily activities?
[03/09/23, 12:01:43 PM] intern1: Sir He used to wake up at 6 Am
Does his daily activities by 7:30 Am
Breakfast around 9:00 Am
Has lunch by 1:00 Pm
And then takes a nap
Evening he chats with neighbours and has his dinner around 8:30pm
And sleeps by 9:30 pm
[03/09/23, 12:35:43 PM] Prof: These were same even after the fall since last three weeks?
[03/09/23, 6:46:36 PM] intern1: Yea sir but he used to not do his daily activities and he used to just lie down on bed the whole day
[03/09/23, 7:49:34 PM] Prof: That means he was bed ridden after the fall
Case 2:
[31/08/23, 7:00:29 AM] Prof: 58 is a strange pulse rate for a person in pain @919676979003 ?
[31/08/23, 7:00:59 AM] Prof: Clinical images, blood sugars, CBC?
[31/08/23, 7:48:09 AM] intern1: Sir will update the fever chart and all the investigations now sir
[31/08/23, 7:50:08 AM] Prof: A standing image of lateral abdomen and biceps
[31/08/23, 7:51:05 AM] intern1: Yes sir
[31/08/23, 7:52:39 AM] intern1: Yes sir for someone in pain ,they are generally tachy
[31/08/23, 7:53:06 AM] intern1: Even the ECG showed Brady sir
[31/08/23, 7:53:35 AM] intern1: I’ll upload everything by 9 sir
[31/08/23, 9:34:50 AM] intern1: GRBS
12 pm - 200
8pm-208
10pm-125
31/8
2AM-220
7AM-220
[31/08/23, 12:25:58 PM] intern1: 31/08/2023
Ward : ward
Unit : 2
DOA : 30/08/2023
S :
C/o abdominal pain decreased
(Dull aching in lower abdomen)
Nausea+
Stools not passed
Flatus passes +
O:
Patient is conscious, coherent
No Pallor, icterus,clubbing, cyanosis, lymphadenopathy, oedema.
Vitals :
Temp Afebrile
BP- 130/90mmHg
PR -86bpm
RR-16 cpm
CNS: NFND
CVS: S1,S2 heard , no murmurs.
RS: BAE, NVBS, no added sounds.
P/A: Rigid,NT
Pain in lower abdomen
Bowel sound 3/min
Sluggish
A: Acute Pancreatitis with alcoholic ketosis with k/c/o DM ll since 6 months with indirect hyperbilirubinemia
P:
IV fluids @75 ml/hr
Inj. Neomol 1Amp in 500 ml NS/IV/BD
Inj pantop 40 mg IV/OD/BBF
Inj Zofer 4 mg IV/BD
[31/08/23, 5:03:45 PM] Prof: Is he really having lumbar lordosis or the image has been taken in that manner to match his suspected type 2 diabetes? Or is it type 3?
[01/09/23, 12:25:40 PM] intern1: Image has been taken like that sir
Case 3
[23/08/23, 2:28:52 PM] Prof: Update her FBS,PPBS And HBA1C @intern2 @intern3
[23/08/23, 2:47:50 PM] Prof: What is the difference between ionized and serum and how are both done separately?
[23/08/23, 2:51:09 PM] intern1: Sir S.Calcium is the total calcium in the blood whereas Ionised calcium is the active form of calcium or the free calcium
[25/08/23, 11:24:44 AM] intern1: soap notes
25:8:23
Female medical ward-8
Dr.resident6(SR)
Dr.resident2(PGY2)
DR.resident5(PGY1)
S:
Neck pain decreased compared to yesterday.
Headache decreased compared.
1 Episode of Vomiting- Yesterday night
No Fever spikes
Stools passed
O:
pt is C/C/C
No signs of pallor, Icterus, clubbing, cyanosis,lymphedenopathy, pedal edema
BP: 120/80mmhg
PR: 78bpm
RR: 18cpm
Temp: 96.2 F
Cvs: S1,S2 heard, No murmurs
RS:BAE+
P/A: distended and non tender
CNS: No FND
Neck Examination
Restriction of movements decreased
Able to flex and extend
Neck stiffness -
kernig’s sign -
Brudzinki sign -
A:
NECK PAIN-CERVICAL RADICULOPATHY (C5-C6) with Paraspinal Spasm
K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO secondary to Vertebro basilar insufficiency
WITH DENOVO THYROID DISEASE (HYPOTHYRODISM) WITH Left CERVICAL LYMPHEDENOPATHY WITH DENOVO DMII
P:
1.INJ. Diclofenac Im/sos
2.T.Dolo 650 mg po/sos
3.T. Nicardia 10 mg po/sos
4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg
5.T. vertin 8 mg po/bd
6.T. Thyronorm 75 mcg po/od
7.T. Metformin 500 mg po/be
8.T. Cinod 10 mg po/od
9.T. Myoril 2ml IM/BD
10.INJ. Zofer 4mg IV/SOS
11.INJ.PAN 40mg/IV/OD
12.T.PREGABA 75MG/PO/HS
[25/08/23, 2:57:10 PM] Prof: Peripheral vertigo everyday since 4 years!!?
[25/08/23, 2:57:51 PM] Prof: You have updated just one patient today?
You have only work responsibility for just one patient throughout the day?
[25/08/23, 3:03:43 PM] intern1: Sir as there are only 2 interns in each Unit we’ve been called to help The interns in OP sir.
[25/08/23, 3:10:49 PM] intern1: Vertigo only since the past 10 days Sir
[25/08/23, 4:38:18 PM] Prof: If there is two interns and one patient in the ward it's logical to have one intern go and help in opd
[25/08/23, 4:38:58 PM] intern1: Yes Sir we are helping Unit 5 on their OP days
[25/08/23, 4:40:31 PM] Prof: Not we. Only one of the two interns who doesn't have a patient in the ward
[25/08/23, 4:41:07 PM] intern1: Yes Sir
[28/08/23, 9:03:06 AM] intern1: soap notes
28:8:23
Female medical ward-8
Dr.resident4(SR)
Dr.resident2(PGY2)
DR.resident5(PGY1)
S:
Neck pain decreased .
No Episodes of Vomiting since yesterday and Na
No Fever
sleep adequate
Stools not passed
O:
pt is C/C/C
No signs of pallor, Icterus, clubbing, cyanosis,lymphedenopathy, pedal edema
BP: 120/80mmhg
PR: 82bpm
RR: 16cpm
Temp: Afebrile
Cvs: S1,S2 heard, No murmurs
RS:BAE+
P/A: soft and non tender
CNS: No FND
Neck Examination
Restriction of movements decreased
Neck stiffness -
kernig’s sign -
Brudzinki sign -
Finger finger incoordination absent
Finger nose incoordination absent
Spine tenderness absent
Nystagmus absent
EOM movements absent
Diplopia absent
No Increased ICT features
Cervical LN palpable in Lt occipital triangle
No palpable axillary LN
A:
NECK PAIN-CERVICAL RADICULOPATHY (C5-C6) with Paraspinal Spasm
K/C/O HTN SINCE 4 YEARS WITH PERIPHERAL VERTIGO secondary to Vertebro basilar insufficiency
WITH DENOVO THYROID DISEASE (HYPOTHYRODISM) WITH Left CERVICAL LYMPHEDENOPATHY WITH DENOVO DMII with Migraine
P:
1.INJ. Diclofenac Im/sos
2.T.Dolo 650 mg po/sos
3.T. Nicardia 10 mg po/sos
4.T. Losartan+T. Hydrochlorothiazide 50mg/ 12.5 mg
5.T. vertin 8 mg po/bd
6.T. Thyronorm 75 mcg po/od
7.T. Metformin 500 mg po/be
8.T. Myoril 2ml IM/BD
9.INJ. Zofer 4mg IV/SOS
10.INJ.PAN 40mg/PO/OD
11.T.PREGABA 75MG/PO/HS
12.T.Clonazepam 0.25mg PO/HS
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