2. Evidence based data wise workflow log collated by the intern with clickable and verifiable links.

Evidence based data wise workflow log collated by the intern with clickable and verifiable links.

I am Kasarabadha Sampath ,Intern from 2k18 batch.

Case 1:

Blog: 72 year old male with B/L Lower Limb weakness

Pajr:

https://chat.whatsapp.com/JNwDDlalC8TLXjwIsR3u53

[26/08/23, 4:09:42 PM] Rakesh Biswas Sir GM HOD: 👆@918099474777 

@919502479628 Please share the PaJR and case report link

[26/08/23, 4:11:29 PM] Sampath Kasarabadha: Okay sir

[27/08/23, 2:59:38 PM] Rakesh Biswas Sir GM HOD: https://chat.whatsapp.com/JNwDDlalC8TLXjwIsR3u53

Other than falling with eyes open and mild disturbances in the heel shin test video what other signs suggest involvement of the cerebellum in this man who has this gradually progressive ataxia since 5 years? 

What is his joint position and vibration sense? 

Areflexia and reduced nerve conduction velocity suggests associated axonal demyelinating neuropathy but what does the conduction blocks in addition suggest?

@918328223112 @919652955915 @918099474777 @918790889907 @918790321828

[27/08/23, 3:13:50 PM] ~ Aditya Samitinjay: Blog link please?

[27/08/23, 6:51:33 PM] Rakesh Biswas Sir GM HOD: 👆@919502479628

[27/08/23, 8:18:12 PM] ~ Aditya Samitinjay: Looking forward to this. Thank you.

[27/08/23, 8:20:23 PM] Rakesh Biswas Sir GM HOD: While it materializes can we see how to answer the question of confirming if the man's inability to stand with eyes open is specific to cerebellar or could it even be just due to his neuropathy?

[27/08/23, 8:32:39 PM] ~ Aditya Samitinjay: From whatever information I have

Problem Representation - 72/M with? Chronic Progressive Gait instability, areflexia and axonal neuropathy on NCS

Guided exam - would do a full cerebellar exam (Dysdiadochokinesis, intention tremor, past pointing, nystagmus with HINTS exam, heel shin, finger nose and finger finger)

We have data that he is falling with eyes open and also has impaired heel shin on both sides, suggesting a midline cerebellar involvement? Checking for nystagmus and delayed corrective saccades can weigh it in favor of a cerebellar lesion.

As alluded to, vibration and proprioception can weigh it in favor of a sensory neuropathy.

Really big data gaps which need some filling here. Looking forward to more info.

[28/08/23, 10:45:25 AM] Rakesh Biswas Sir GM HOD: Here's the case report prepared by @919502479628 👇

https://kasarabadhasampathrollno71.blogspot.com/2023/08/cidp.html

Please guide him how to develop it further @918328223112 @919652955915

[28/08/23, 12:00:56 PM] ~ Dr.Chandana Vishwanatham: https://kasarabadhasampathrollno71.blogspot.com/2023/08/cidp.html

Firstly , we’ll done @919502479628 

Can improve the blog by adding individual muscle testing of lower limbs.

Heel knee test can be misleading ,may be he is unable to do it because of the neuropathy.

His gait appears to be a little high stepping kind of gait ,but it is not as clear as in a patient of peroneal palsy because is this patient the muscles supplied by tibial nerve are also affected,so I suggest you to check dorsi flexion and plantar flexors power separately if not already done .

…………..

Coming to the NCS report:

In Upper limbs :

NCS shows reduced _*motor conduction velocity *_in Right median nerve with *conduction Block * and 

*reduced motor conduction velocity * in left mediam Newe. There is *conduction block * across right ulnar nerve.

This is suggesting demyelination (along with absent reflexes)

…………..

In Lower limbs:

*Absent MUAPS  * in Bilateral peroneal nerve and *reduced CMAP*  in B/L TibialNerves . 

Reduced CMAP ,MUAPS is not always axonal,This can also be due to demyelination when there is a conduction block.For this we need to know the conduction velocity and presence of any conduction block in tibial and peroneal nerves which is not given in this report.

If there is conduction block and conduction velocity is slow with reduced CMAP it is demyelination and not necessarily axonal.

…………

sensory conductions show *absent SNAP*  in Right median nerve with absent SNAP in Bilateral sural nerves.

The same applies for sensory nerves ,reduced /absent SNAP can be there in demyelination,we need to know the conduction velocity in these nerves.

If conduction velocity is also decreased it is sensory motor demyelination (CIDP)

[28/08/23, 12:04:22 PM] ~ Dr.Chandana Vishwanatham: Any drop in CMAP amplitude or area of more than 20% implies conduction block and any increase in the CMAP duration of more than 15% signifies temporal dispersion; both are hallmarks of demyelination

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4329247/#:~:text=Any%20drop%20in%20CMAP%20amplitude,both%20are%20hallmarks%20of%20demyelination.

[28/08/23, 12:07:25 PM] ~ Dr.Chandana Vishwanatham: And what about upper limb muscles? All muscles 5/5? @919502479628

[28/08/23, 12:10:23 PM] Vivek Kurma Sir GM PG: Ma'am will do all the individual muscle testing and upload it by today evening

[28/08/23, 12:23:40 PM] Rakesh Biswas Sir GM HOD: Very well done inputs 👏👏

Can we explain away his inability to stand with his eyes closed as not cerebellar but simply part of his chronic upper and lower limb demyelination?

[28/08/23, 12:27:42 PM] Sampath Kasarabadha: Thank you mam

I will do individual muscle testing  with help of Vivek sir mam

[27/08/23, 2:56:11 PM] Rakesh Biswas Sir GM HOD: Other than falling with eyes open and mild disturbances in the heel shin test video what other signs suggest involvement of the cerebellum in this man who has this gradually progressive ataxia since 5 years? 

What is his joint position and vibration sense? 

Areflexia and reduced nerve conduction velocity suggests associated axonal demyelinating neuropathy but what does the conduction blocks in addition suggest?

[27/08/23, 3:02:18 PM] Rakesh Biswas Sir GM HOD: Please share his complete case report link with all the images and videos collected yesterday asap @919676979003 @919502479628

[28/08/23, 8:04:55 AM] Sampath Kasarabadha: https://kasarabadhasampathrollno71.blogspot.com/2023/08/cidp.html

[28/08/23, 9:55:34 AM] Rakesh Biswas Sir GM HOD: Thanks YouTube all videos and share them in the patient's examination findings in your case report link

[28/08/23, 9:56:09 AM] Sampath Kasarabadha: Okay sir

[28/08/23, 11:23:45 AM] Kims Himaja Mam GM PG1: Higher mental functions:

Patient is conscious oriented to time place and person 

Speech and language :Normal

Memory :intact( Recent,Immediate,Remote)

Hallucinations -absent

Cranial Nerves:

CN -1:

Sence of Smell - Normal 

CN-2: Normal

CN-3:                                Right                Left

i)EOM movement -          Full                     Full

ii)Direct Light Reflex-      present.           present

iii) Consensual Light Reflex present       Present 

iv) Accommodation Reflex   present      present

v)Ptosis                              Absent            absent 

CN 5:

Sensory over face & buccal mucosa - Normal on both sides

Motor - masseter, Temporalis:Normal

Reflexes - Corneal,Conjunctival Normal.

CN-7

No Deviation of Mouth

Motor:

Nasolabial fold -present on  both sides

Occipito frontalis - Good

Buccinator - Good.

Sensory: Normal

CN-8:

Rinne test positive in both ears

Weber test centralised 

CN-9 and 10 :Uvula,palatal arches movements -Normal 

Gag reflex - N

CN-11:intact

CN-12:intact

Motor System:

Bulk:

Upper limbs:Normal

Lower Limbs:Normal

Tone:

Upper limbs:Normal

Lower Limbs:Normal

Power:               Right.        left

Upper Limb       5/5             5/5

 Lower Limb      3/5.            4/5

Reflexes:          Right           Left

Biceps:               1+                1+

Triceps:              1+                 1+

Supinator:          1+                    1+

Knee:                Absent         absent 

Ankle:                Absent        absent

Planter:              Mute           Mute

Sensory system:

                               Right.                 Left 

Crude touch :    

Upper Limb            Present.             present

Lower Limb           Present               Present 

Pain :

Upper Limb            Present.             present

Lower Limb           Present               Present 

Fine touch:

Upper Limb            Present.             present

Lower Limb           Present               Present 

Vibration: 

Upper limb:              Right.                    Left

1) Styloid:      Present(6.7 sec)         present(6.9 sec)

2)olecranon process:present (7.3 sec) present (7.1 sec)

3)Acromion process:present(10.2 sec) present(9.6 sec)

Lower Limb :

1) Tibial tuberosity : can’t sense vibration 

2)Shaft of Tibia:can’t sense vibration 

3)Medial Malleolus:can’t sense vibration 

Position sense:      

                                   Right             Left

Upper Limb              10/10           10/10

Lower Limb              5/10              4/10

-Graphaesthesia-Postive

-Stereognosis-Positive

Cerebellar signs:

-Titubation:absent

-Nystagmus:absent

-Dysarthria:absent

-Hypotonia:absent

-Intention tremor:absent

-Coordination

a.Finger Nose test: Normal 

b.Heel Knee test:Impaired 

c. Dysdiadokokinesia: Negative( able to perform rapid alternative movements)

Signs of Meningeal Irritation:

Neck stiffness: absent 

Kernig’s sign :absent

Brudzinski’s sign:absent

[28/08/23, 11:31:06 AM] Rakesh Biswas Sir GM HOD: @919502479628 All these findings been added to the case report link? 

Are we sure his upper limb power is normal proportionate to his upper limb muscle bulk?

[28/08/23, 11:31:26 AM] Kims Himaja Mam GM PG1: Yes sir

[28/08/23, 11:31:31 AM] Kims Himaja Mam GM PG1: His upper limb power is normal

[28/08/23, 11:31:41 AM] Sampath Kasarabadha: Yes sir added.

Case 2:

Blog: 60 year old male with Uncontrolled blood sugars with right lower limb 

cellulitis

PaJR: https://chat.whatsapp.com/KNxQxkhWBebELtdUj05vmE

[26/08/23, 10:15:06 AM] Sampath Kasarabadha: S: Blood sugars were reduced to 240 mg/dl

Magnesium sulphate and Glycerine dressing was done for Cellulitis.C/o hiccups 

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp:97.7 F

PR:68 CPM

BP:110/60 MM/HG

GRBS: 288 mg/dl

CVS: S1 ,S2 heard

RS:B/L AE present 

P/A:Soft, tenderness at epigastrium region .

No rigidity,Guarding.

CNS:NAD

A:Right lower limb cellulitis with Uncontrolled Blood sugars

P:

1)Inj. PIATAZ 2.25 gm IV /TID

2)Inj.

CLINDAMYCIN 600 mg IV/TID

3) Inj.HAI 

S/C TID before meals

Acc to GRBS

4)INJ  NPH S/C B/D

Acc. to GRBS

5)Tab. NODOSIS 500mg

PO/BD

6) Tab PAN 40 mg IV/BD

7)TAB SHELCAL PO/OD

8)GRBS 7 point Profile

9)BP, PR, RR monitoring

[30/08/23, 12:40:24 PM] Sampath Kasarabadha: S: C/o hiccups  present

Fever subsided.

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp: afebrile

PR:84 BPM

BP:130/80 MM/HG

GRBS: 187 mg/dl

7 points GRBS:

8AM :255 mg/dl

10AM : 355 mg/dl 

2PM :  311 mg/dl 

4PM :208 mg/dl

8PM: 146 mg/dl 

10 PM: 252 mg/dl

2AM: 189 mg/dl

CVS: S1 ,S2 heard

RS:B/L AE present 

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

A:Right lower limb cellulitis with Uncontrolled Blood sugars With AKI 

P:

1)IV FLUIDS NS @75ml/hr

2)Inj. PIPTAZ 2.25 gm IV /TID

3)Inj.

CLINDAMYCIN 600 mg IV/TID

4)Inj.HAI 

S/C TID before meals

Acc to GRBS +

Inj. NPH S/C BD

5)Tab PAN 40 mg IV/BD

6)TAB SHELCAL PO/OD

7)Syp Lactulose  15 ml PO/OD

8)INJ METACLOPRAMIDE 5 mg PO/OD

9)GRBS 7 point Profile

10)BP, PR, RR monitoring

[31/08/23, 9:14:35 AM] Sampath Kasarabadha: S: C/o hiccups  present

Fever spike present 

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp: 98.7 F

PR:92 BPM

BP:130/80 MM/HG

GRBS: 120 mg/dl

GRBS:

8AM :187 mg/dl

2PM :  224 mg/dl 

4PM : 186 mg/dl

8PM: 107 mg/dl 

10 PM: 134 mg/dl

2AM: 95 mg/dl

CVS: S1 ,S2 heard

RS:B/L AE present 

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

A:Right lower limb cellulitis with Uncontrolled Blood sugars With AKI 

P:

1)IV FLUIDS NS @75ml/hr

2)Inj. Monocef 1gm IV / BD 

3)Inj.HAI 

S/C TID before meals

Acc to GRBS 

4)Inj. NPH S/C BD

5)Tab PAN 40 mg IV/BD

6)TAB SHELCAL PO/OD

7)Syp Lactulose  15 ml PO/OD

8)INJ METACLOPRAMIDE 5 mg PO/OD

9)SYP POTKLOR 15 ml in 1 glass of water PO/TID 

10)GRBS 7 point Profile

11)BP, PR, RR monitoring

[31/08/23, 11:35:19 AM] Rakesh Biswas Sir GM HOD: Image of his right lower limb?

[31/08/23, 11:35:54 AM] Rakesh Biswas Sir GM HOD: Share all the blood sugar values day wise

[31/08/23, 11:36:06 AM] Sampath Kasarabadha: Okay sir

[31/08/23, 11:37:17 AM] Rakesh Biswas Sir GM HOD: The arm should be fully visible in the image and not cropped posteriorly as in this patient

[31/08/23, 2:32:12 PM] Sampath Kasarabadha: On admission night 

25/08/23

9pm -563 mg/dl

10PM- 445 mg/dl

11 PM -409 mg/dl

12 AM- 360 mg/dl

1 AM -287 mg/dl

2AM- 262 mg/dl

3 AM- 256 mg/dl

4 AM -241 mg/dl

5 AM -245 mg/dl 

6 AM-251 mg/dl

7 AM- 244 mg/dl

8 AM- 240. mg /dl

On 26/08/23

8AM:240 mg/dl

10AM:288 mg/dl

2PM:245 mg/dl

4PM: 320 mg/dl

8PM:346 mg/dl

10PM:318 mg/dl

2AM:155 mg/dl

On 27/08/23

8AM:181 mg/dl

10AM:285 mg/dl

2PM:243 mg/dl

4PM: 235mg/dl

8PM:213 mg/dl

10PM:248mg/dl

2AM:310mg/dl

On 28/08/23

8AM:286mg/dl

10AM:357mg/dl

2PM:313mg/dl

4PM: 303mg/dl

8PM:310mg/dl

On 29/08/23

8AM:255mg/dl

10AM:355mg/dl

2PM:311mg/dl

4PM: 208mg/dl

8PM:146mg/dl

10PM:252mg/dl

2AM:241mg/dl

On 30/08/23

8AM: 187mg/dl

2PM:224mg/dl

4PM: 186mg/dl

8PM:107mg/dl

10PM:134mg/dl

2AM:95mg/dl

[31/08/23, 2:55:34 PM] Rakesh Biswas Sir GM HOD: Since yesterday the sugars appear to be fair control. Please share the interventions done always for every sugar value documented

[31/08/23, 2:56:55 PM] Sampath Kasarabadha: Okay sir I will update it

[02/09/23, 9:34:21 AM] Sampath Kasarabadha: S: C/o hiccups present 

Fever spike present 

Stools passed

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp: 98.5F

PR:86 BPM

BP:130/70 MM/HG

GRBS: 120mg/dl

GRBS:

8AM :200mg/dl (14HAI +12NPH)

10AM :222 mg/dl

2PM : 122mg/dl (10U HAI)

4PM :98mg/dl

8PM: 117mg/dl  (12HAI +10NPH)

10 PM: 204mg/dl

2AM: 142mg/dl

CVS: S1 ,S2 heard

RS:B/L AE present 

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

A:Right lower limb cellulitis with Uncontrolled Blood sugars With AKI 

P:

1)IV FLUIDS NS @75ml/hr

2)Inj. Monocef 1gm IV / BD 

3)Inj.HAI 

S/C TID before meals

Acc to GRBS 

4)Inj. NPH S/C BD

5)Tab PAN 40 mg IV/BD

6)TAB SHELCAL PO/OD

7)Syp Lactulose  15 ml PO/OD

8)INJ METACLOPRAMIDE 5 mg PO/OD

9)GRBS 7 point Profile

10)BP, PR, RR monitoring

Case3:

Blog: https://kasarabadhasampathrollno71.blogspot.com/2023/09/is-online-e-log-book-to-discuss-our.html

PaJR: https://chat.whatsapp.com/FhjO0aULYedCaK0rGMQwHW

[11/09/23, 10:53:20 AM] Sampath Kasarabadha: S:No fever spike present 

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp:97.6F 

PR:80BPM

BP:120/70 MM/HG

CVS: S1 ,S2 heard

RS:B/L AE present 

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

A:Pyrexia secondary to ?Clinical Malaria

P:

1)IV FLUIDS NS @100ml/hr

2)Inj. Doxycycline 100 mg IV /BD

3)Inj. OPTINEURIN 1 amp in 100 ml NS

4)Inj. Neomol 1 gm  IV/SOS

5)Inj.Zofer 4 mg IV/SOS

6)Tab DOLO 650 mg PO/TID

7)Temp charting 

8)Monitor Vitals

[11/09/23, 4:36:09 PM] Rakesh Biswas Sir GM HOD: Any literature on iv doxycycline for clinical malaria?

Case 4:

Blog: https://kasarabadhasampathrollno71.blogspot.com/2023/09/blog-post.html

PaJR:

https://chat.whatsapp.com/C6nzVBqiGFTHBFxMb2NFCG

[12/09/23, 2:23:15 PM] Sampath Kasarabadha: S:No fever spike present 

Cough productive present.

SOB present.

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp:97.6F 

PR:90BPM

BP:130/80 MM/HG

GRBS:136mg/dl

RR:21CPM

RS:B/L AE present ,Wheeze present in B/L suprascapular , Infrascapular, mammary area

CVS: S1 ,S2 heard

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

Haemoglobin:10.1 g%

RBC: 4.3million/mm3

Platelet count:2.2lakhs/mm3

TLC:12,600 cells /mm3

A:Pyrexia secondary to  Lower Respiratory tract infection,H/o Bronchial Asthma(Exacerbation)

P:

1)IV FLUIDS NS @75ml/hr

2)Inj Amoxicoav 1.25 gm/IV/ TID

3)Tab Azithromycin 500 mg / po/ od

4) Nebulization with Duolin 8 th hourly,Budecort 12 th hourly 

5)Inj Hydrocort 100 mg /IV/Stat

 6)Inj. Neomol 1 gm  IV/SOS

7)Monitor vitals

[13/09/23, 10:31:57 AM] Sampath Kasarabadha: S:No fever spike present 

Cough productive present.

SOB present 

O:

On examination 

Patient is conscious coherent and cooperative. No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp:96.7F 

PR:96BPM

BP:130/90 MM/HG

RR:22CPM

RS:B/L AE present ,Wheeze present in B/L suprascapular , Infrascapular, mammary area

CVS: S1 ,S2 heard

P/A:Soft, non tender

No rigidity,Guarding.

CNS:NAD

A:H/o ?Bronchial Asthma(Infective Exacerbation)

P:

1)IV FLUIDS NS @75ml/hr

2)Inj Amoxicoav 1.25 gm/IV/ TID

3) Nebulization with Duolin 8 th hourly,Budecort 12 th hourly 

4)Inj. Neomol 1 gm  IV/SOS

 5)Tab Monteleukast LC PO/HS

6)INJ Pan 40 mg  IV/OD

7)TAB PCM 650 mg po/sos

8)Monitor vitals

[13/09/23, 10:35:07 AM] Rakesh Biswas Sir GM HOD: 👍

[13/09/23, 10:35:36 AM] Rakesh Biswas Sir GM HOD: Share link in group

[13/09/23, 10:36:50 AM] Sampath Kasarabadha: Okay sir

Shared

Case 5:

PaJR:

https://chat.whatsapp.com/BwAsdscyHAUL8m6VmnBpX6

[23/08/23, 6:09:33 PM] Rakesh Biswas Sir GM HOD: Share the images and select one with maximum representation of this patient in the DP

[23/08/23, 6:11:30 PM] Santhoshini Kims: Ok sir

[23/08/23, 6:15:01 PM] Sampath Kasarabadha: Limb pictures just after debridement sir

[23/08/23, 6:15:38 PM] Rakesh Biswas Sir GM HOD: Share this in the DP

[23/08/23, 6:17:13 PM] Sampath Kasarabadha: Okay sir

[24/08/23, 12:12:15 PM] Sampath Kasarabadha: 24/8/2023

Ward: ICU

Unit:5

DOA:19/8/23

 

S:

Fever spikes present yesterday during hemodialysis.

Patient developed hypotension and fall in spo2.

Patient intubated in th morning i/v/o fall in spo2

O: 

Patient is drowsy but arousable

Vitals:

BP: 80/60 mmHg 

On noradrenaline 0.16mg/ml at 5 ml/hr

PR: 115 BPM

RR: 15cpm

Spo2- 96%

Grbs- 173mg/dl

Temperature - 97.5 F

I/O- 2300ml/750 ml

CVS: S1 and S2 heard,no murmurs.

RS: BAE, b/l basal crepts +

P/A: soft ,non tender

CNS- NF ND

A: Sepsis with mods secondary to b/l lowerlimb necrotosing fascitis and fourniers gangrene with renal aki with anemia secondary to blood loss. With 

6 sessions of hemodialysis

P: 

1) Inj. NORADRENALINE(0.16mg/ml)at 10 ml/hr increase or decrease to maintain MAP>65mmHg

2) Inj. Augmentin 1.2gm IV/BD

3) Inj. PAN 40mg IV/OD

4) Inj. NEOMOL 1gm IV/SOS

5) Tab. OROFER -XT PO/OD

6) INTERMITTENT CPAP

7) REGULAR ASEPTIC DRESSING

8) MONITOR VITALS AND INFORM SOS

[24/08/23, 12:17:52 PM] Rakesh Biswas Sir GM HOD: ICU bed number?

[24/08/23, 12:19:08 PM] Sampath Kasarabadha: ICU Bed 6 sir

[24/08/23, 2:41:51 PM] Kims Himaja Mam GM PG1: 2:00 PM

BP: 70/40mmhg on NORAD 20ml/hr

PR: 116bpm

RR:26cpm

GRBS :158mg/dl

Ventilatior settings

RR :14

Fio2: 100

PEEP:5

Infusions

25D-10 ml/hr

DOBUT- 10 ml/hr

Medaz+Fentanyl- 5 ml/hr

Case 6:

Blog: https://kasarabadhasampathrollno71.blogspot.com/2023/09/this-is-online-e-log-book-to-discuss.html

PaJR: https://chat.whatsapp.com/BQKGEjuPKzW5Oh5GVXhIaY

[20/09/23, 8:11:28 PM] Rakesh Biswas Sir GM HOD: Keep the history here too as the description box information can be accidentally deleted by anyone

[20/09/23, 8:12:00 PM] Sampath Kasarabadha: Okay sir

[20/09/23, 8:13:12 PM] Kims Himaja Mam GM PG1: What should be treatment for evolved MI sir? Can we keep her on anti coagulants to prevent another one or are we putting her at risk for internal bleeding

[20/09/23, 8:13:41 PM] Sampath Kasarabadha: A 66 year old  female who is home maker came to  opd for general checkup.

HOPI:

Patient was apparently asymptomatic 10 years back then she was diagnosed as Hypertensive   During her general health check up 10 years back. She is on Amlodipine 2.5 mg  once daily.

Few days back, as a part of general checkup ECG Showed MI changes.

No C/o chest pain, palpitations,SOB,sweating.

Past history:

Known case of Hypertension since 10 years on amlodipine 2.5 mg.

Not a known case of DM,TB,Epilepsy ,CVA,CAD,Asthma.

Daily Routine:

She is a House wife, she wakes ups at 5AM in the morning, she engages in some spiritual activities (prayers) from 5AM to 7 AM .Then she does her daily household work and she has breakfast at 8:30 AM . She usually has upma ,Idilli,Dosa, for her breakfast. she then gets engaged with household works like washing clothes,preparing lunch and she has lunch at 1PM(Rice item),then she takes rest till 5:00PM .In the evenings she usually has tea then she goes for walking from 5:30PM to 6:30 PM and comes home and prepares dinner and has dinner at around 8:00PM along with her family. she usually has Roti  and rice for  her dinner.She goes to sleeps around  9:30 PM.

Personal History:

Diet: Mixed

Appetite:Normal

Sleep: adequate 

Bowel and bladder: regular.

No addictions 

Vitals:

BP:140/90 mm hg

PR: 82 bpm

RR :17 cpm

Temp:afebrile.

[20/09/23, 8:41:04 PM] Sampath Kasarabadha: Initial treatment patterns were similar among patients with EMI and MI in the SYNERGY trial. Patients with EMI had lower rates of death or re-infarction at 30 days compared with patients presenting with positive troponin results.

https://pubmed.ncbi.nlm.nih.gov/17405770/

[20/09/23, 9:05:40 PM] Rakesh Biswas Sir GM HOD: Any evidence anticoagulants prevent MI?

[20/09/23, 9:08:35 PM] Rakesh Biswas Sir GM HOD: Which question is this article answering?

[20/09/23, 9:48:57 PM] Kims Himaja Mam GM PG1: https://pubmed.ncbi.nlm.nih.gov/8104243/

Myocardial infarction and strokes can be prevented by refraining from smoking and maintaining appropriate blood pressure levels and a favourable balance of lipids. Following a myocardial infarction, further drug treatment should include aspirin, thrombolytic therapy (in acute myocardial infarction), beta-blockers, ACE inhibitors (in patients with a low ejection fraction) and perhaps anticoagulants

[20/09/23, 10:02:59 PM] Rakesh Biswas Sir GM HOD: This is opinion 

Evidence consists only of RCTs 

Any RCTs of anticoagulants to prevent MI?

[21/09/23, 9:43:55 AM] Rakesh Biswas Sir GM HOD: Hope you don't leave the patient or this group even after your medicine posting is over

[21/09/23, 9:51:43 AM] Sampath Kasarabadha: Okay sir

[21/09/23, 8:52:56 PM] Rakesh Biswas Sir GM HOD: More vegetables and less rice would be desirable

[21/09/23, 8:55:20 PM] Sampath Kasarabadha: Okay sir I will counsel them sir

[21/09/23, 8:55:53 PM] Rakesh Biswas Sir GM HOD: మన శరీర బరువు పెరగకుండా మరియు మన పొట్టపొడవు 80 సెం.మీ కంటే తక్కువగా ఉండేలా మన ఆహారం ఉండాలి. ఏమి తినకూడదు? చక్కెర మరియు పిండితోకూడిన ఆహారం పూర్తిగా నిలిపివేయబడింది. బిస్కెట్లు మరియు బ్రెడ్ పిండితో తయారు చేస్తారు, కాబట్టి బిస్కెట్లుమరియు బ్రెడ్ తినడం మానేయండి. నెలకు 500 గ్రాముల కంటే ఎక్కువ నూనె వినియోగించరాదు. ఏమి తినాలి ఫుడ్ప్లేట్‌లో 40% వివిధ ఆకుపచ్చ కూరగాయలు మరియు 10% వివిధ రంగుల పండ్లు. మిగిలిన సగంలో బియ్యం, గోధుమలు మొదలైన తెల్లటి గింజలు మరియు దుంపలు (బంగాళదుంపలు) ఉంటాయి.

Mana śarīra baruvu peragakuṇḍā mariyu mana poṭṭa poḍavu 80 seṁ.Mī kaṇṭē takkuvagā uṇḍēlā mana āhāraṁ uṇḍāli. Ēmi tinakūḍadu? Cakkera mariyu piṇḍitō kūḍina āhāraṁ pūrtigā nilipivēyabaḍindi. Biskeṭlu mariyu breḍ piṇḍitō tayāru cēstāru, kābaṭṭi biskeṭlu mariyu breḍ tinaḍaṁ mānēyaṇḍi. Nelaku 500 grāmula kaṇṭē ekkuva nūne viniyōgin̄carādu. Ēmi tināli phuḍ plēṭ‌lō 40% vividha ākupacca kūragāyalu mariyu 10% vividha raṅgula paṇḍlu. Migilina saganlō biyyaṁ, gōdhumalu modalaina tellaṭi gin̄jalu mariyu dumpalu (baṅgāḷadumpalu) uṇṭāyi.

https://www.hsph.harvard.edu/nutritionsource/healthy-eating-plate/

Thank you.