Hello everyone ! I am a resident in Medicine department currently posted in ICU and my daily schedule for the week is detailed here: https://docs.google.com/docum
- So I was posted in nephrology last month and ICU this month . So this is the first time me being in peripheral postings and it was really nice critical care experience especially with CKD patients...few of which I would like to share although I don't have any videos of the procedures as most of them were emergency procedures .Will definitely try to collect more data and videos from next time .
So one day when I had night shifts and when i was in ckd ward ..I got a call from my intern who told one of my ckd pt BP was 280/120 and he was complaining of breathlessness . So I freaked out and asked him to check again and was he really sure about it . He was like yes ma'am..to my suprise it was actually 280/120 when I checked it too..this was my first time hearing a BP of 280 !!!
- I immediately called my co pg who is posted in ICU ..and shifted my patient to ICU and we started him on high flow oxygen ,gave maximum doses of lasix ,labetalol 20 mg STAT and started Nitoglycerin drip too ..but the patient was in severe distress and was having this classical pink frothy sputum..so with great difficulty we Intubated him , as it was covid season and we barely even had masks at that point of time . But post intubation after some time patient had cardiac arrest ..we started CPR but inspite of all efforts we couldn't revive him.
- Intern posted on that night shift ..it was his first duty as a medicine intern but learned taking abg ,cpr ,intubation everything in one night posting .
- During my nephrology posting I learned how to put a central line ,indications for dialysis and also how to change few settings on dialysis machine like isolate ,ultrafiltrate which was thought to me by one of our dialysis technician who has been working here for long time and he is a very experienced person.
- Some other CKD patient experiences I would like to share in my next blog
So this E- book is mandatory requirement to assess our daily attendance in terms of our mental presence and our daily learning achievements in the medicine department where every PG Resident here shall by 8:00 PM (unless it's an admission day) provide a brief log of what they have done cognitively as well as hands on for that day from 8:00 AM to 8:00 PM.
My daily log is summarised under the following headings :
1) Case based learning
a) Inpatient
b) Outpatient
c) ICU
2) Thesis
a) That day's thesis case data
b) Questions around cases or even study design etc
3) Theory knowledge acquisition for end term summative assessment:
Paper I: Basic Medical Sciences
Paper II: Medicine and allied specialties including pediatrics, dermatology &
psychiatry
Paper III: Tropical Medicine and Infectious Diseases
Paper IV: Recent Advances in Medicine
4) Procedures done with video evidence (with patient deidentied).
As I'm currently working in ICU ,I'm hereby sharing a case of :
75 yr old female present with complaints of altered sensorium since 1 day .
Patient had history of fall at home and sustained injury to left wrist joint 2 days ago . Patient was oriented and conscious following injury .
Next day patient developed altered sensorium .
There was no history of head trauma ,headache ,ent bleed ,seizures.
There was no history of fever ,vomittings ,loose stools .
No history of sob ,pedal edema ,chest pain ,decreased urine output ,no history of strenous work
No history of sweating ,palpitations ,decreased food intake .
No history of weakness or any other focal neurological deficit.
No history of blurring of vision ,photophobia ,
No hisotry of yellowish discoloration of skin, vomitings and pain abdomen , no history of alcohol intake.
Past history -
- Patient is a k/c/o Diabetes mellitues -2 since 15 yrs on Tab GLIMIPERIDE 1 mg and Metformin 500mg OD.
-K/c/o HTN since 15 yrs on Telmisartan 40mg and hydrochlorothiazide 12.5 mg OD.
History of dry cough at night times.
Past history of pulmonary tuberculosis 15 yrs back ,used treatment .
History of biomass exposure present.
Personal history -
Normal Appetite
Mixed diet , regular bowel and bladder habits and sleep is adequate .
On examination :
Patient was drowsy , in altered state .
GCS - E 2V4M4
Bp -160/100
Pulse -94bpm
Respiratory rate - 18/min
Spo2 - 75%on RA .with 8-10 lit of oxygen -94%
Temp - 99 F
Moderately build and nourished.
Pallor present ,Mild icterus ,no cyanosis ,clubbing ,lymphadenopathy and odema .
Systemic examination :
- CVS -. S1 S2 HEARD .NO MURMURS .
- RS - BILATERAL AIR ENTRY PRESENT .
Bilateral fine crepitations present in ISA,IAA,MA.
Right side - Fine crepitations present in Interscapular areas.
-P/A - soft ,non tender ,no organomegaly ,bowel sounds present .
- CNS -
Patient is in altered sensorium .Not oriented to time ,place ,person .
GCS -E2V4M4
Pupils - bilateral mature cataract present .so couldn't be appreciated.
No neck stiffness ,kernigs sign negative .
Motor examination -
- Power - couldn't be elicited as patient not obeying commands . But patient was moving all limbs .
-Tone - normal
Reflexes - right left
Biceps - +2 couldn't be elicited as fracture present .
Triceps - +1.
Supinator. +1.
Knee -+2. +2
Ankle - +1 +1
Plantar -bilateral flexor
Cranial nerves and sensory system and cerebellum couldn't be evaluated as pt was in altered mental status.
DD - ? Subdural hemorrhage/CVA ,
Septic encephalopathy
Respiratory acidosis.
Hyponatremia
Hypoxic encephalopathy
Encephalitis,
Uremia .
Investigations :
1)Cbp - HB - 10.8g /dl ,RBC COUNT - 4.23 million /mm3 , TLC - 15,200cells /mm3
Neutrophils - 80 ,lymphocytes - 9
MCV - 81.5
PCV -34% ,platelets -1.87 lakhs.
Normocytic .mild hypochromic.
2)RBS - 190 mg/dl
3)Magnesium - 2.10 mg/dl
4) RFT : Urea - 58 mg/dl ,s.creat - 0.7 mg/dl,
Calcium - 9.5 mg/dl
Uric acid - 3.5 mg/dl
Na -139meq/l ,potassium - 3.4 meq/l,chloride - 102 meq/l
5) ESR - 90 mm/hr
6) LFT :
Total bilirubin - 1.20mg/dl
Direct bilirubin -0.3 mg/dl
SGOT -370 u/l
SGPT -305 u/l
ALP - 79 u/l ,albumin - 4 ,GGT -17 U/L
7) CUE : Color -pale yellow ,acidic ,albumin-trace ,sugars -1+ ,ketones -negative ,bilesalts and bile pigments - negative ,
Pus cells - 1-2 /hpf
RBC -2-3 /hpf
Epithelial cells - 1-2 /hpf
8) T3- 0.58
T4- 6.67
Tsh -0.81 u/l
9) ABG - ph -7.33 ,pco2-48 mg/dl ,po2 - 72mg/dl , HCO3 -28 mmol/l ,BEb -2.10
O2 sat - 90%( mild respiratory acidosis ).
10) 2d echo - RA ,RV DILATED . MODERATE PAH ,good lv systolic function (EF-60%) ,NO RWMA , grade 1 diastolic dysfunction
Concentric lvh , no lv clot ,no PE.
11) X RAY OF LEFT WRIST JOINT :
Impacted comminuted fracture of distal radius
Fracture of ulnar styloid process.
F/s/o - left colles fracture.(POP cast was done)
12) X ray HIP JOINT - normal
13) CT BRAIN PLAIN - Diffuse crebral atrophy woth small vessel ischemic changes .
14) CHEST X RAY PA VIEW :(This xray was 2 days after HRCT) - RIGHT LOWER LOBE CONSOLIDATION .
BILATERAL PLEURAL EFFUSION .
16) HRCT :
LRTI with B/L pleural effusion.
Right heart failure
Hepatitis
Left colles fracture
K/c/o Dm-2 ,HTN ,Old pulmonary koch .
TREATMENT :
1) HEAD END ELEVATION .
2) O2 inhalation @ 6-7 lit to maintain spo2 atleast 88-90%.
3) Air bed and frequent position change 2nd hrly.
4)RT FEEDS MILK PLUS PROTEIN POWDER.
RT FEEDS FREE WATER .
5) INJ PANTOPRAZOLE 40 mg IV OD.
6) INJ PIPTAZ 4.5 GM IV TID
7) INTERMITTENT BIPAP
8) INJ LASIX 20MG IV BD .
9 ) INJ OPTINEURON 1 AMP IN 100ML NS IV OD .
10) NEBULIZATION WITH DUOLIN AND MUCOMIST 8TH HRLY .
11)TAB ULTRACET 1/2 TAB/RT BD
12) TAB SHELCAL 500MG /RT /OD
13) INJ HAI S/C according to sliding scale.
13) T NICARDIA 10MG /RT/OD.
14) IVF NS 1 unit @ 30ml/hr.
15) GRBS CHARTING ,VITALS MONITORING
16) STRICT I/O CHARTING.
Theory topic :
We have discussed about "TUMOUR LYSIS SYNDROME" during 2-4 class discussion :
U can watch full video on :
https://youtu.be/Bvr-mM416eI
Tumour lysis syndrome refers to the constellation of metabolic disturbances that occurs when large numbers of neoplastic cells are killed rapidly, leading to the release of intracellular ions and metabolic byproducts into the systemic circulation.Clinically, the syndrome is characterized by rapid development of hyperuricemia,hyperkalemia, hyperphosphatemia, hypocalcemia, and acute kidney injury.
- Tumor lysis syndrome arises most commonly after the start of initial chemotherapeutic treatment, but spontaneous cases have increasingly been documented in patients with high-grade hematologic malignancies.
- It is typically associated with bulky, rapidly proliferating, treatment-responsive tumors-typically, acute leukemias and high-grade non-Hodgkin lymphomas such as Burkitt lymphoma.
- Rapid tumor cell turnover results in release of intracellular contents into the circulation. This release can alter renal elimination and cellular buffering mechanisms, leading to numerous metabolic derangements.
- Clinically significant tumor lysis syndrome can occur spontaneously, but it is most often seen 48-72 hours after initiation of cancer treatment. Hyperkalemia is often the earliest laboratory manifestation. Hyperkalemia and hyperphosphatemia result from rapid cell lysis .
- Hypocalcemia is a consequence of acute hyperphosphatemia with subsequent precipitation of calcium phosphate in soft tissues.
Here is a rare case of tumour lysis syndrome with hypercalcemia in DLBCL( diffuse large B cell lymphoma) hypercalcemia because of para neoplastic syndrome in 15% DLBCL cases.
Link :https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4192206/.
I'm currently still working on my thesis project which I would like to upload in my next E-log session.
Thank you !!
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