MY JOURNEY AS AN INTERN IN GENERAL MEDICINE

  

Myself REDDISHETTI LISHITHA posted in GENERAL MEDICINE DEPARTMENT from 1/12/23 TO 31/1/24

I thank DR RAKESH BISWAS SIR HOD GM

1/12/23 - 15/12/23 : Peripherals

16/12/23 - 31/12/23: Psychiatry

1/1/24 - 31/1/24 : Unit

Lead by DR SHASHIKALA MAAM, DR VENKAT SAI SIR, DR LOHITH VARMA SIR, DR RAVI KUMAR SIR

1) Self reflective writing on their medical student career :

“Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.”

my sincere gratitude to the faculty, mentors, colleagues, and patients who have been integral to my medical journey. Their guidance, support, and shared experiences have been invaluable pillars, shaping not only my professional identity but also my personal growth

The first case which attracted me as medical students was a case of 12 yr old girl brought to causality at around 3:00am with h/o 5-6 episodes of vomiting and in a drowsy and arousal state, obeying commands 

On examination her 

Bp was 110/90mmhg

Hr 93bpm

Rr 15cpm

Grbs 558mg/dl

Her urine for ketone bodies was positive

On taking history the patient was diagnosed with diabetes 3 months ago and was kept on insulin since 3 months

Pt used to miss her insulin dose in order to go to school early 

As she missed her insulin dose on the day she was brought to casualty in drowsy state

The link for tha above case is below

https://reddishettilishitha135.blogspot.com/2022/10/12-yr-old-girl-with-vomiting-and.html

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

Case 1

https://reddishettilishitha135.blogspot.com/2024/01/a-44-yr-old-male-co-bl-pedal-oedema.html

YouTube link of the video

https://youtube.com/shorts/a8o-PbkIxfc?si=N0h9bbD2XUrR9FSs

Technique i used is z technique

Diagnostic tap was done after taking consent

And samples were sent to pathology laboratory for ascitic fluid pathology and cytology

Biochemistry laboratory for

Ascitic fluid analysis, ascitic fluid LDH, SAAG

Microbiology laboratory for culture and sensitivity

Diagnosis of ascites

Reference link

https://www.ncbi.nlm.nih.gov/books/NBK435998/

Case 2

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/49m-ccf-pulmonary-edema-anemia-2-weeks.html

PaJR link

https://chat.whatsapp.com/DHs0e7ogFxjBQspjX4aCVX

Learning points

Daily monitoring for haemoglobin and total leucocytes count

Causes of anaemia

https://www.medicalnewstoday.com/articles/188770#Iron-deficiency-anemia

Nutritional and dietary causes of iron-deficiency anemia include:

not consuming enough iron

not consuming enough vitamin C

having a condition that prevents the body from sufficiently absorbing nutrients

Treatment for anaemia

https://www.nhlbi.nih.gov/health/anemia/treatment

[05/01, 6:16 PM] Rakesh Biswas Sir Gm Hod: ⁩ How would you differentiate if this patient's pulmonary edema is cardiogenic or non cardiogenic? 

While he has ample evidence to suspect it's cardiogenic are their any other data to suggest that it could even be non cardiogenic as in a covid like state?

[05/01, 6:48 PM] : It is most likely cardiogenic pulmonary edema as his history and symptoms fit in and also his chest x ray shows cardiomegaly too sir.

[05/01, 6:52 PM] +: Noncardiogenic pulmonary edema shows the classic “batwing” pattern of pulmonary opacities radiating centrifugally from the hila with air bronchogram. and cardiomegaly is also not seen

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408723/#:~:text=Noncardiogenic%20pulmonary%20edema%20is%20caused,to%20elevated%20pulmonary%20venous%20pressure

Case 3 

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/is-online-e-log-book-to-discuss-our.html

PaJR link

https://chat.whatsapp.com/IrcLPYVftrvFzrpB0TvjxE

Out come

[18/01, 8:16 PM] Rakesh Biswas Sir Gm Hod: Sample :

https://chat.whatsapp.com/IrcLPYVftrvFzrpB0TvjxE

patient impact key indicators :

Daily intern and PaJR team driven inpatient persistent clinical encounters enabled sharing of his daily energy inputs and outputs to adjust the dose of medications and exercise related activities

We couldn't have done this without the intern's team help

[18/01, 8:31 PM] Rakesh Biswas Sir Gm Hod: 👆

Work flow

[10/01, 11:28 AM] Reddishetti Lishitha: 70 yr old male c/o urinary retention, urinary hesitation, urinary urgency since 1 month

C/o b/l knee pain since 2013

C/o left ear hearing loss since 2008

Both eyes blurring of vision since 1 year

 History of presenting illness

Patience was apparently asymptomatic 1month ago and then he developed urinary retention since one month, unable to urinatr and severe discomfort with bladder fullness and associated with urinary hesitation since one month as patient is unable to urinate with difficulty in starting and maintaining urinary stream associated with urgent urination (urinary urgency) since one month with sudden need ti urinate  with discomfort in bladder associated with nocturia with 3 to 4 times at night only since one month

B/l knee pain since 2013,insidious onset progressively increasing and aggrevating on walking, climbing staires associated with hearing loss left side since 2008 and blurring of vision since 1 yr of both eyes

H/0 similar complaints of urinary retention 40 yrs back(1972) 

K/c/o DM II since 4 yrs and on tab glimeperide 1mg +tab metformin 1000mg po od

H/0 obsessive compulsive disorder and on medication tab clomipramine hcl

H/0 depression and on tab olanzapine 5mg+ fluoxetine 20 mg, and tab clomipramine hcl

[10/01, 11:29 AM] Reddishetti Lishitha: Urology referal done sir

[10/01, 11:41 AM] Reddishetti Lishitha: Urology sir adviced for paroste specific antigen test sir

[10/01, 11:53 AM] Reddishetti Lishitha: Ophthalmology referal done sir

[10/01, 12:45 PM] Reddishetti Lishitha: Ecg

[10/01, 1:19 PM] Rakesh Biswas Sir Gm Hod: Are the patient's advocates added here @⁨Reddishetti Lishitha?

[10/01, 1:20 PM] Sanidha KIMS: Yes sir

[10/01, 1:20 PM] Rakesh Biswas Sir Gm Hod: Please tag them and ask them to be careful not to use any patient identifiers during communication here

[10/01, 1:22 PM] Rakesh Biswas Sir Gm Hod: Ask them to share their questions about the current patient requirements addressed and those pending without giving away the patient's identity and or if they are related, then not give away their relation to the patient

[10/01, 1:27 PM] Sanidha KIMS: @pt ⁨advocate

We have explained everything regarding de-identifying the patient and also to feel free to ask about any patient related queries in the group in any language they are comfortable in.

@⁨Reddishetti Lishitha⁩ has taken all the consents.

[10/01, 1:45 PM]Pt advocate: Okk

[10/01, 1:48 PM] pt ⁨advocate: @⁨Reddishetti Lishitha⁩ apne bola khane se pehele inform kornekeliye.lekin edhar koivi nehi he

[10/01, 1:55 PM] Reddishetti Lishitha: Sister will check Grbs check before eating lunch

[10/01, 1:57 PM] Reddishetti Lishitha: Glucometer is not available in super specialty ward sir

[10/01, 2:20 PM] Reddishetti Lishitha: We checked with pts glucometer sir

[10/01, 2:20 PM] Rakesh Biswas Sir Gm Hod: Does the patient have his own glucometer?

Let's get his Fbs and two hour ppbs after every meal. 

Please ask them to share the image of the current medicines he is talking also mentioning the time

[10/01, 2:21 PM] Rakesh Biswas Sir Gm Hod: We may not need to see it before meals

[10/01, 2:28 PM] Reddishetti Lishitha: Yes sir pt has his own glucometer

I will inform them sir

[10/01, 2:28 PM] Reddishetti Lishitha: Ok sir

[10/01, 2:33 PM] Rakesh Biswas Sir Gm Hod: They haven't suggested turp? Only medical management? 

Please discuss with the Urologists again and share your assessment of the patient's LUTS symptoms and if when would you think he would need turp 

What did his last urologist say? He may have made this long distance trip only to get a turp done?

[10/01, 2:48 PM] Reddishetti Lishitha: They adviced to do prostate specific antigen test and review with reports to urology department sir

[10/01, 2:50 PM] Reddishetti Lishitha: Psa test is not done here sir so sample will be sent to khl today sir

[10/01, 2:54 PM] Reddishetti Lishitha: Till the PSA report come pt should use the medication sir

[10/01, 3:05 PM] Reddishetti Lishitha: Ent referal

Adviced for PTA

 and dental opinion i/v/o dental caries

[10/01, 3:05 PM] Reddishetti Lishitha: PTA is not working in our hospital so they adviced to get it done from out side

[10/01, 3:06 PM] Reddishetti Lishitha: And review to ent op with PTA report

[10/01, 3:58 PM] Reddishetti Lishitha: Ortho referal

[10/01, 6:47 PM] Rakesh Biswas Sir Gm Hod: 👆@⁨Pg1⁩

[10/01, 6:48 PM] Rakesh Biswas Sir Gm Hod: Outside as in Nalgonda? Ask MS and Dr Ranga Rao to provide vehicle tomorrow 

[10/01, 8:23 PM]  Pt advocate: Poha khaya 8 pm ko

[10/01, 9:51 PM] Bengal Pt: Random

[10/01, 9:55 PM] Pt advocate: Khane se pehele medicine

[10/01, 9:59 PM] Rakesh Biswas Sir Gm Hod: Khawar du ghonta baade ebong kalker fasting tao share korben 

Sokale koto mg Glimeperide newa hoi?

[10/01, 10:00 PM]  Pt advocate: Rice and sambbar

[10/01, 10:02 PM]  Pt advocate: 1 mg sir

[10/01, 10:02 PM] Pt advocate: Okk sir

[10/01, 10:03 PM] Pt advocate: Sokale 1 mg ebong rate khowar age 1 mg

[10/01, 10:22 PM]Pt advocate: Baki nicher 3 te regular khan

[10/01, 10:22 PM] Pt Advocate: Eta urologist ajke diyechen rate khowar por khete

[10/01, 10:26 PM] Rakesh Biswas Sir Gm Hod: 👍

[11/01, 12:04 AM] Pt Advocate: Khowar 2 ghonta pore

[11/01, 7:13 AM] Pt Advocate: Fasting sir

[11/01, 7:15 AM] Rakesh Biswas Sir Gm Hod: Duto Glimeperide er dose 1 mg theKe bariye 1.5 mg Kore Din aajke theke

[11/01, 7:15 AM] Pt Advocate: Okk sir

[11/01, 7:17 AM] Rakesh Biswas Sir Gm Hod: @⁨Sanidha KIMS⁩ @⁨Reddishetti Lishitha⁩ Please share the report of his serum creatinine

[11/01, 7:34 AM] Reddishetti Lishitha: Ok sir

[11/01, 8:44 AM] Pt Advocate: Sugarer osudh

[11/01, 8:44 AM] Pt Advocate: Chire r sosa breakfast

[11/01, 8:45 AM] Pt Advocate: Glimeperide 1.5 mg sir

[11/01, 8:48 AM] Pt Advocate: Glycomet 1gm

[11/01, 9:10 AM] Lohit Sir Gm Pg: @⁨Tushara Maam Gm Pg1⁩ is accompanying the patient to Nalgonda for PTA sir

[11/01, 10:46 AM] Pt Advocate: Khowar 2 ghonta pore

[11/01, 11:28 AM] Tushara Maam Gm Pg1: After taking all the permissions and arranging a vehicle now both patient and patient attenders are not willing to go sir @⁨Rakesh Biswas Sir Gm Hod⁩

[11/01, 11:41 AM] Pt Advocate: @⁨Rakesh Biswas Sir Gm Hod⁩ sir apnar sathe samna samni patient ebong amara kotha bolte chai

[11/01, 11:45 AM] Pt Advocate: Sir patient er ekhan loose motion hoche...

[11/01, 11:47 AM] Lohit Sir Gm Pg: When were these loose stools episode? 

Because patient did not say  about loose stools in the morning? 

Okay, we will come and see now

[11/01, 12:04 PM] Pt Advocate: Ok sir

[11/01, 12:56 PM] Pt Advocate: Sir Random

[11/01, 2:03 PM] Rakesh Biswas Sir Gm Hod: Post breakfast or pre lunch?

[11/01, 2:04 PM] Pt Advocate: Pre lunch

[11/01, 2:05 PM] Pt Advocate: Sir eta lunch er khowa at 2 pm

[11/01, 4:13 PM] Pt Advocate: Post lunch

[11/01, 8:19 PM] Pt Advocate: Eta patient er glucomiter e dekhachhe sir

[11/01, 8:19 PM] Pt Advocate: Just now

[11/01, 8:20 PM] Lohit Sir Gm Pg: Just readings are pre- dinner or after much time after dinner?

[11/01, 8:20 PM] Pt Advocate: Pre dinner sir

[11/01, 8:44 PM] Rakesh Biswas Sir Gm Hod: Please repeat this tomorrow

[11/01, 8:46 PM] Ravi Sir Gm Pg1: Sir informed patient to take 

Glimiperide 1.5mg and metformin 1000mg

[11/01, 8:46 PM] Rakesh Biswas Sir Gm Hod: The increased creatinine and his progressively increasing sugars suggest that he would be better managed with injection Insulin!

[11/01, 8:47 PM] Rakesh Biswas Sir Gm Hod: Alright let's recheck his creatinine tomorrow and also his sugars with the increased dose of Glimeperide

[11/01, 8:53 PM] Rakesh Biswas Sir Gm Hod: Khawar du ghonta baader tao janaben. Kalke jodi creatinine ta beshi dekhai tahole insulin shuru korte hote pare

[11/01, 8:55 PM] Pt Advocate: Ok sir

[11/01, 8:57 PM] Pt Advocate: Dhosa and boiled egg

[11/01, 8:57 PM] Pt Advocate: Chapati or pulka nehi mila

[11/01, 8:59 PM] Reddishetti Lishitha: Sir the reporter said that when pt takes this  medicine along with his regular diabetic medication his sugar levels were in control

[11/01, 9:29 PM] Rakesh Biswas Sir Gm Hod: Why did he stop?

[11/01, 9:35 PM] Sanidha KIMS: He hasn’t sir.

He just wanted to ask you whether he can continue with his homeopathic medicines.

He actually feels that when he was taking it his sugar levels were under normal range.

[11/01, 9:38 PM] Reddishetti Lishitha: He was using this for past one yr 

He takes 10 drops only if his plbs is high and for next 5 to 7 days blood sugar levels will be in control 

He stopped taking it from past 7 days as he wanted to ask you sir about this medication

[11/01, 11:01 PM] Pt Advocate: Khowar 2 hours pore

[11/01, 11:11 PM] Pt Advocate: Khana khane ke bad dabai

[12/01, 7:15 AM] Pt Advocate: Fasting

[12/01, 8:26 AM] Rakesh Biswas Sir Gm Hod: He can. Why would he need to discontinue?

[12/01, 8:26 AM] Rakesh Biswas Sir Gm Hod: He could have texted and asked

[12/01, 8:27 AM] Rakesh Biswas Sir Gm Hod: This is the reason for his diabetes @ Gmpg2⁩

[12/01, 8:28 AM] Rakesh Biswas Sir Gm Hod: Better avoid this medicine. Given by ENT?

[12/01, 8:29 AM] Rakesh Biswas Sir Gm Hod: The night dose of 1.5 mg is working well

[12/01, 8:38 AM] Reddishetti Lishitha: He uses this medication for depression sir

[12/01, 8:41 AM] Rakesh Biswas Sir Gm Hod: All right 

Get a psychiatry review today to optimize his medications 

Prof Viswak is going to chair your session on this patient @⁨ Gmpg2⁩

[12/01, 9:48 AM] Reddishetti Lishitha: Prostate specific antigen

[12/01, 10:19 AM] Lohit Sir Gm Pg: Take urologist opinion now @⁨Reddishetti Lishitha⁩

[12/01, 10:36 AM] Reddishetti Lishitha: Ok sir

[12/01, 10:40 AM] Reddishetti Lishitha: Sir urology sir are in ot after 2  they will see

[12/01, 12:07 PM] Rakesh Biswas Sir Gm Hod: Fix his OT date

[12/01, 12:10 PM] Lohit Sir Gm Pg: Sir urologist said - If their HOD sir will come on Tuesday , they will do the OT on Tuesday 

Otherwise they will do it on Wednesday for sure. 

They asked to get the pre- anaesthetic check up (PAC)done for him by tomorrow sir

[12/01, 12:36 PM] Reddishetti Lishitha: Repeat rft sir

[12/01, 12:38 PM] Rakesh Biswas Sir Gm Hod: Why not PAC today?

[12/01, 12:38 PM] Reddishetti Lishitha: Sir pac timings are from morning 9 am to 12 pm

[12/01, 12:39 PM] Reddishetti Lishitha: And surgical profile is not done sir

[12/01, 12:39 PM] Rakesh Biswas Sir Gm Hod: Relieved to see the creatinine at 1.1

We can continue incremental dose titration of Glimeperide

[12/01, 12:40 PM] Rakesh Biswas Sir Gm Hod: Okay tomorrow then

[12/01, 12:40 PM] Reddishetti Lishitha: Ok sir

[12/01, 12:42 PM] Reddishetti Lishitha: Sir we are sending surgical profile today and tomorrow morning we will take him to pac sir

[12/01, 6:49 PM] Lohit Sir Gm Pg: @⁨Rakesh Biswas Sir Gm Hod⁩ 

Sir, for the PAC clearance, as the anaesthetics also want the blood sugars to be under control before surgery 

Should we increase the dose to Glimperide 2mg tonight or should we continue 1.5mg and see sir?

[12/01, 6:54 PM] Lohit Sir Gm Pg: Hii..Please try to make sure that name of the hospital or patients name or identity gets revealed in the images you upload in this group.

[12/01, 7:50 PM] Pt Advocate: Ektu Age ei Test eta Sir

[12/01, 7:50 PM] Pt Advocate: Pre dinner

[12/01, 7:55 PM] Rakesh Biswas Sir Gm Hod: 👆1.5 mg is acting reasonably well on fasting 

Although there's room for more reductionism of fasting to ideal control 

Can make it 2mg tonight and see the fasting

[12/01, 7:56 PM] Rakesh Biswas Sir Gm Hod: It should be "...doesn't get revealed"

[12/01, 7:58 PM] Rakesh Biswas Sir Gm Hod: What time was the Glimeperide 2 mg taken in the morning today?

[12/01, 8:10 PM] Lohit Sir Gm Pg: I think only 1.5mg was taken sir

[12/01, 8:12 PM] Lohit Sir Gm Pg: @⁨Pt Advocate⁩ ask the patient to take Glimiperide 2mg before dinner today

@⁨Ravi Sir Gm Pg1⁩ explain the patient

[12/01, 8:44 PM] Pt Advocate: Ok sir

[12/01, 8:57 PM] Ravi Sir Gm Pg1: We explained to patient to take glimiperide 2mg sir.

[12/01, 9:03 PM] Pt Advocate: Glimiperide 2 mg liya sir

[12/01, 9:05 PM] Pt Advocate: Before dinner

[12/01, 11:17 PM] Pt Advocate: Dinner korar 2 hours por

[13/01, 9:01 AM] Pt Advocate: Before breakfast

[13/01, 9:18 AM] Rakesh Biswas Sir Gm Hod: Yesterday before dinner taken 1 mg?

[13/01, 9:23 AM] Lohit Sir Gm Pg: He has  taken glimiperide 2mg sir

[13/01, 9:25 AM] Pt Advocate: Before dinner taken 2mg sir

[13/01, 3:52 PM] Pt Advocate: Aftar Launch

[13/01, 4:42 PM] Lohit Sir Gm Pg: PAC form

[13/01, 4:44 PM] Lohit Sir Gm Pg: Sir PAC clearence was not done today 

They asked to review again when  the Blood sugar levels and blood pressure levels are under control 

BP was 160/90mmhg at 11am when the anaesthetics checked sir 

Everyday morning it is usually 130/80mmhg sir when we check

[13/01, 4:44 PM] Lohit Sir Gm Pg: At 2pm BP is 160/9mmhg 

At 4pm BP is 140/90mmhg sir

[13/01, 4:45 PM] Lohit Sir Gm Pg: I think he is ?Denovo hypertensive sir

[13/01, 4:46 PM] Lohit Sir Gm Pg: We are checking his BP 2nd hourly sir

[13/01, 5:06 PM] Rakesh Biswas Sir Gm Hod: HFpEF

[13/01, 5:07 PM] Rakesh Biswas Sir Gm Hod: Left axis and poor progressing of r 

Can be taken under moderate cardiac risk

[13/01, 5:09 PM] Lohit Sir Gm Pg: Okay sir

[13/01, 5:54 PM] Ravi Sir Gm Pg1: Good evening sir 

Now bp is 150/90mmhg

[13/01, 7:01 PM] Lohit Sir Gm Pg: Sir shall we start him on Tab. Amlodipine 5mg? 

Shall we ask him to take now? As the readings are consistently high

[13/01, 8:15 PM] Ravi Sir Gm Pg1: 8pm bp is 

160/70mmhg

[13/01, 9:28 PM] Lohit Sir Gm Pg: Sir BP is 160/80mmhg 

Asked the patient to take 

tab. Amlodipine 5mg PO STAT now

And shall we continue same tomorrow morning 8am sir?

[13/01, 9:29 PM] Rakesh Biswas Sir Gm Hod: Alright

[13/01, 9:29 PM] Rakesh Biswas Sir Gm Hod: Yes

[13/01, 9:30 PM] Lohit Sir Gm Pg: Okay sir

[13/01, 9:42 PM] Pt Advocate: Amlodipine 1 ta khelo sir, Dinner er age

[13/01, 9:45 PM] Pt Advocate: Sir, canteen me rice ke elava kuch nehi he

[13/01, 9:45 PM] Pt Advocate: Patient rice meals kha sakta he keya sir?

[13/01, 10:20 PM] Lohit Sir Gm Pg: Sir patient post meal GRBS was 274mg/dl yesterday night 

As patient is not able to take diabetic diet in our hospital and as the surgery is on Tuesday/ Wednesday 

Sir shall we give insulin  to control the blood sugars levels with insulin till the  surgery sir 

Now he wants to eat rice meals 

Sir we are asking the patient to 

take Inj. Human actrapid insulin 14 units  Subcutaneously before food now sir

[13/01, 10:29 PM] Rakesh Biswas Sir Gm Hod: That may not help the fasting

[13/01, 10:30 PM] Lohit Sir Gm Pg: Shall we add long acting Inj. NPH also sir

[13/01, 10:33 PM] Rakesh Biswas Sir Gm Hod: Starting and uptitrating insulin may take a lot more time now 

But alright 

We'll need to start with 

6U NPH 6U Actrapid before breakfast 

6U before lunch 

6U NPH 6U Actrapid before dinner 

And continue metformin 500 mg after dinner

[13/01, 10:33 PM] Rakesh Biswas Sir Gm Hod: 14U subcutaneously at the very first shot may cause hypoglycemia

[13/01, 10:34 PM] Lohit Sir Gm Pg: Okay sir 

Thank you

[14/01, 1:08 AM] Lohit Sir Gm Pg: @⁨Pt Advocate⁩ post meal GRBS

[14/01, 1:19 AM] Ravi Sir Gm Pg1: Bp at 1.19pm is 

150/80 sir

[14/01, 1:23 AM] Pt Advocate: Sir

[14/01, 1:24 AM] Pt Advocate: At 1.21am

[14/01, 7:19 AM] Rakesh Biswas Sir Gm Hod: How much Insulin taken?

[14/01, 7:26 AM] Pt Advocate: Fasting

[14/01, 7:27 AM] Pt Advocate: Sir

[14/01, 7:34 AM] Pt Advocate: Sir suger level to control e aschei na

[14/01, 7:40 AM] Lohit Sir Gm Pg: 6 U NPH and 6 U Actrapid sir

[14/01, 7:41 AM] Lohit Sir Gm Pg: Shall we  give 8U actrapid and 6U NPH now  sir

[14/01, 7:42 AM] Lohit Sir Gm Pg: 160/60 8:00pm

160/80 10:00pm

150/80.  1:00am

150/80.   4:00am

   150/60. 7:00am

[14/01, 7:54 AM] Lohit Sir Gm Pg: @⁨Pt Advocate⁩ what will patient eat now

[14/01, 7:55 AM] Lohit Sir Gm Pg: @⁨~Dr.shivakumar⁩ make sure unit/ward measures BP 4th hourly today

[14/01, 7:56 AM] Lohit Sir Gm Pg: Ask patient to take this tablet now also

[14/01, 8:09 AM] Pt Advocate: No sir, patient eat 9 am

[14/01, 8:17 AM] Pt Advocate: Sir, sister ne bola breakfast se pehele 9 baje insulin dena he,to isliye insulin dene ke bad hi patient kha sakta he sir

[14/01, 8:20 AM] Pt Advocate: Sir,keya kore bataiye

[14/01, 8:43 AM] Lohit Sir Gm Pg: 8U Actrapid + 6U NPH subcutaneously before breakfast

[14/01, 8:45 AM] Pt Advocate: Okk sir

[14/01, 9:05 AM] Rakesh Biswas Sir Gm Hod: Jehetu kalke theke notun treatment plan shuru hoyeche oi jonye

[14/01, 9:07 AM] Rakesh Biswas Sir Gm Hod: Breakfast jeta unar bhalo laage tai khete bolun. Tarpor ektu baire paichari koruk du ghonta baade abar sugar ta test korar aage

[14/01, 9:09 AM] Rakesh Biswas Sir Gm Hod: @⁨Lohit Sir Gm Pg⁩ This is after 6U of actrapid? Just imagine what would have happened with 14U!!

[14/01, 9:10 AM] Rakesh Biswas Sir Gm Hod: This fasting suggests he may require 8U of NPH tonight while the actrapid can remain 6U

[14/01, 9:10 AM] Rakesh Biswas Sir Gm Hod: 👆@⁨Lohit Sir Gm Pg⁩

[14/01, 9:57 AM] Lohit Sir Gm Pg: Okay sir

[14/01, 10:42 AM] Pt Advocate: Ok sir

[14/01, 12:06 PM] Pt Advocate: 150/70  12.05 pm

[14/01, 12:09 PM] Rakesh Biswas Sir Gm Hod: Two hours after morning 8U?

[14/01, 12:17 PM] Lohit Sir Gm Pg: What did he eat for breakfast?

[14/01, 12:22 PM] Rakesh Biswas Sir Gm Hod: They forgot to share that image

[14/01, 1:04 PM] Pt Advocate: Vada and sambbar

[14/01, 1:06 PM] Lohit Sir Gm Pg: @⁨Rakesh Biswas Sir Gm Hod⁩ 

Sir considering his post meals GRBS values being above 200 all the time 

Shall we go with 10 units Inj.HAI subcutaneously before lunch

[14/01, 1:12 PM] Rakesh Biswas Sir Gm Hod: Today just 8U 

We need to uptitrate very gently to avoid hypoglycemia such as avoiding yesterday's potential disaster

[14/01, 1:22 PM] Pt Advocate: Chapati and dal

[14/01, 4:48 PM] Lohit Sir Gm Pg: Post lunch GRBS?

[14/01, 5:58 PM] Ravi Sir Gm Pg1: Sir

1 pm 150/90

4 pm 140/90

[14/01, 6:06 PM] Pt Advocate: 233

[14/01, 6:13 PM] Rakesh Biswas Sir Gm Hod: With 8U watery insulin?

[14/01, 6:14 PM] Lohit Sir Gm Pg: With 10U actrapid sir

[14/01, 6:15 PM] Rakesh Biswas Sir Gm Hod: No salads?

[14/01, 6:16 PM] Pt Advocate: No salads sir

[14/01, 6:16 PM] Rakesh Biswas Sir Gm Hod: @⁨Tushara Maam Gm Pg1⁩ Dynamic e logged case report?

[14/01, 6:25 PM] Tushara Maam Gm Pg1: For this case sir?!

[14/01, 6:31 PM] Tushara Maam Gm Pg1: Ok sir

[14/01, 7:46 PM] Ravi Sir Gm Pg1: Sir

 Bp-160/80

Temp- 98.6

[14/01, 7:46 PM] Ravi Sir Gm Pg1: 7.45pm

[14/01, 7:55 PM] Lohit Sir Gm Pg: Sir asking the patient to take 

6 units Actrapid 

8 units NPH before dinner 

And tab metformin 500mg after dinner

[14/01, 7:57 PM] Lohit Sir Gm Pg: Sir do the readings suggest  we give tab. Among 10mg from tomorrow

[14/01, 8:21 PM] Rakesh Biswas Sir Gm Hod: No let's wait till evening tomorrow

[14/01, 8:22 PM] Rakesh Biswas Sir Gm Hod: Share all the readings in one text box

[14/01, 9:01 PM] Lohit Sir Gm Pg: Sir unfortunately our pharmacy doesn’t have NPH at present sir 

It was not available in outside pharmacy also 

We have Inj. Mixtard 

Inj Actrapid 30% 

Inj. NPH 70% 

How much dose shall we give sir? 

@⁨Rakesh Biswas Sir Gm Hod⁩

[14/01, 9:22 PM] Rakesh Biswas Sir Gm Hod: 10U of mixtard will contain 7U of NPH and 3U of actrapid 

We need to add 3U of actrapid to this mix for today's post dinner 

For tomorrow's fasting we can give 12U of mixtard

[14/01, 9:23 PM] Rakesh Biswas Sir Gm Hod: What he did he take in the morning before breakfast then!!?? 🧐😳

[14/01, 9:29 PM] Rakesh Biswas Sir Gm Hod: Was 6U of mixtard given instead of NPH here?

[14/01, 9:30 PM] Lohit Sir Gm Pg: No sir morning we borrowed NPH from our icu

[15/01, 12:07 AM] Pt Advocate: Rat ko chapati,dal,or sambar khaye

[15/01, 12:08 AM] Pt Advocate: Khane ke 2 hours bad

[15/01, 7:38 AM] Rakesh Biswas Sir Gm Hod: How much actrapid and mixtard did he take before yesterday's dinner? 

What's his fasting today?

[15/01, 8:18 AM] Pt Advocate: Today fasting

[15/01, 8:29 AM] Pt Advocate: Sir keye patient breakfast se pehele insulin le ga???

[15/01, 8:44 AM] Pt Advocate: Panner dosa, sammber and chatni breakfast

[15/01, 8:59 AM] Lohit Sir Gm Pg: Give Inj. Mixtard 12 Units now before breakfast

[15/01, 9:00 AM] Lohit Sir Gm Pg: Mixtard 10 units 

Actrapid 3 units sir

[15/01, 9:47 AM] Rakesh Biswas Sir Gm Hod: Only 3.6 units of actrapid to absorb this dosa! 

I would have preferred the same dose of actrapid as yesterday if not increased by +2

The low fasting is due to yesterday's NPH hike and has nothing to do with what's going to happen after two hours of his breakfast

[15/01, 11:01 AM] Pt Advocate: After breakfast

[15/01, 11:05 AM] Rakesh Biswas Sir Gm Hod: 👆@⁨Lohit Sir Gm Pg⁩ Correlation between intervention choices and outcomes?

[15/01, 11:06 AM] Rakesh Biswas Sir Gm Hod: Adding 4 more units of watery insulin to the morning mixtard would have produced a better result 

The blood sugars are nothing to worry about and can be easily optimized with judicious dose titrations of insulin

[15/01, 11:07 AM] Lohit Sir Gm Pg: Okay sir

[15/01, 1:55 PM] Pt Advocate: Roti and dal

[15/01, 1:55 PM] Pt Advocate: Guava and Orange

[15/01, 1:56 PM] Pt Advocate: Lunch

[15/01, 2:05 PM] Rakesh Biswas Sir Gm Hod: The Roti looks very gluten dense! 

Better have rice if one can't have multigrain rotis

[15/01, 2:09 PM] Pt Advocate: Ok sir

[15/01, 2:09 PM] Pt Advocate: Vater poriman kotokhani thakbe

[15/01, 2:09 PM] Pt Advocate: Sir?

[15/01, 2:58 PM] Rakesh Biswas Sir Gm Hod: One fourth of the plate

[15/01, 3:03 PM] Rakesh Biswas Sir Gm Hod: https://medicinedepartment.blogspot.com/2023/09/the-healthy-plate-diet-in-bengali-telegu.html?m=1

[15/01, 4:16 PM] Lohit Sir Gm Pg: After 12units of actrapid - post meal GRBS is 209mg/dl sir

[15/01, 4:23 PM] Rakesh Biswas Sir Gm Hod: How much actrapid did he taKe yesterday before lunch and what was the two post prandial after lunch yesterday?

[15/01, 4:25 PM] Lohit Sir Gm Pg: Yesterday it was 233mg/dl with 10units actrapid sir

[15/01, 4:26 PM] Rakesh Biswas Sir Gm Hod: Good. Then +2 today was the correct increment 👏👏

[15/01, 4:27 PM] Lohit Sir Gm Pg: Thank you sir

[15/01, 4:33 PM] Lohit Sir Gm Pg: BP recordings sir 

15/01/2024

8am-150/80

12pm- 150/70

4pm-140/90

8pm-160/90

16/01/2024

8am-150/90

12pm-140/80

4pm-160/90

[15/01, 8:36 PM] Pt Advocate: Rice,sammber,chiken,soyabin bitroot

[15/01, 8:36 PM] Pt Advocate: Dinner

[15/01, 8:38 PM] Rakesh Biswas Sir Gm Hod: How much insulin @⁨Lohit Sir Gm Pg⁩ ?

[15/01, 10:12 PM] Lohit Sir Gm Pg: 10 units Mixtard 

5 units actrapid was given sir

[15/01, 11:02 PM] Pt Advocate: After dinner

[16/01, 2:28 AM] Lohit Sir Gm Pg: BP recordings sir 

15/01/2024

8am-150/80

12pm- 150/70

4pm-140/90

8pm-160/90

16/01/2024

8am-150/90

12pm-140/80

4pm-160/90

8pm-160/90

2am-160/90mmhg sir

[16/01, 2:29 AM] Lohit Sir Gm Pg: Shall we increase the dose to tab. Amlong 10mg sir?

[16/01, 7:09 AM] Rakesh Biswas Sir Gm Hod: Alright

[16/01, 7:38 AM] Lohit Sir Gm Pg: Fasting GRBS at 7:30am is 199mg/dl sir

[16/01, 8:51 AM] Rakesh Biswas Sir Gm Hod: Effect of 7U of NPH yesterday

[16/01, 10:58 AM] Pt Advocate: After breakfast

[16/01, 11:28 AM] Lohit Sir Gm Pg: This is after 

14 units of Mixtard 

7 units of actrapid sir

[16/01, 12:32 PM] Rakesh Biswas Sir Gm Hod: Which is 11 units of actrapid and 9.8 units of NPH!

[16/01, 12:32 PM] Lohit Sir Gm Pg: Yes sir

[16/01, 12:34 PM] Rakesh Biswas Sir Gm Hod: If he needed 12U before lunch which could have been 14 he would have needed around 14U before breakfast today but I agree he took way above today from what he took yesterday before breakfast

[16/01, 12:35 PM] Reddishetti Lishitha: Bp

8:00 am 160/90 mmhg

12 :00pm 150/80 mmhg

[16/01, 12:36 PM] Lohit Sir Gm Pg: Yesterday before breakfast we gave him 12units of Mixtard and his post meal GRBS was 320mg/dl sir

[16/01, 12:37 PM] Lohit Sir Gm Pg: Should we go with 14 units actrapid now before lunch sir?

[16/01, 12:55 PM] Nithin Gm Pg1: Sir viswak sir told 

Patients depression with psychotic symptoms are in resolving phase

But ocd is still active 

And all the drugs doses are glycemic protective their is no need for tapering 

All the above is discussion with pg 3 sir and sir

[16/01, 12:58 PM] Reddishetti Lishitha: Grbs pre lunch 267mg/dl

[16/01, 1:00 PM] Rakesh Biswas Sir Gm Hod: Can we discuss what are the components of his global diagnosis in detail with the uncertainties? 

How are the medications helping his OCD? How have we evaluated his outcomes around these as well as the other comorbidities?

[16/01, 1:01 PM] Pt Advocate: Before lunch

[16/01, 1:04 PM] Rakesh Biswas Sir Gm Hod: We just need the values 2 hours after insulin and meals and one fasting in the morning. Only 4 pricks in 24 hours

[16/01, 1:07 PM] Reddishetti Lishitha: Ok sir

[16/01, 1:19 PM] Pt Advocate: Chapati,sambbar,dal and curd

[16/01, 1:19 PM] Pt Advocate: Lunch

Grbs monitoring

[16/01, 3:33 PM] Pt Advocate: After lunch

[16/01, 3:44 PM] Rakesh Biswas Sir Gm Hod: This sambar contains a lot of sugar and should be avoided!

[16/01, 3:46 PM] Rakesh Biswas Sir Gm Hod: 👆Yesterday no sambar sugar. 

Just trying to explain why his insulin requirements before lunch increased today

[16/01, 3:49 PM] Nithin Gm Pg1: Yes sir its already proved with our surgical high sugars pts sir 

After stopping sambar idly in his breakfast sugars came down to normal

[16/01, 3:50 PM] Nithin Gm Pg1: Only after sambar idly he use to have that 3oo plus sugars sir

[16/01, 4:16 PM] Reddishetti Lishitha: 4 00pm bp 160/ 90mmhg

[16/01, 7:23 PM] Pt Advocate: Sugar less red tea

[16/01, 7:30 PM] Rakesh Biswas Sir Gm Hod: Probably the sugary sambar and not the idli that was responsible

[16/01, 8:47 PM] Pt Advocate: Chapati,dal and salad

[16/01, 10:43 PM] Rakesh Biswas Sir Gm Hod: The cough syrup can increase the blood sugars!

[16/01, 11:09 PM] Pt Advocate: Sir cough syrup ajj lunch ke bad suru huya.

[16/01, 11:16 PM] Rakesh Biswas Sir Gm Hod: Bondho Kore Din

[17/01, 7:45 AM] Pt Advocate: Ok

[17/01, 7:46 AM] Pt Advocate: Fasting

[17/01, 7:59 AM] Rakesh Biswas Sir Gm Hod: Insulin numbers before dinner @⁨Lohit Sir Gm Pg⁩ ?

[17/01, 8:08 AM] Lohit Sir Gm Pg: 12units Mixtard 

7 units actrapid sir

[17/01, 8:11 AM] Lohit Sir Gm Pg: Yesterday for breakfast we gave

14 units Mixtard 

7 units actrapid sir 

And post meal GRBS was 315mg/dl 

Shall we go with same dose sir considering he is not having sambar today

[17/01, 8:31 AM] Pt Advocate: Pesarattu, breakfast

[17/01, 10:44 AM] Pt Advocate: After breakfast

[17/01, 11:46 AM] Lohit Sir Gm Pg: With 14 units actrapid - post lunch GRBS was 243 mg/dl sir 

Shall we go with 16 units actrapid before lunch today sir

[17/01, 12:14 PM] Hrudaii Kims: Bp recording 

12 00 pm 150/90

[17/01, 1:35 PM] Pt Advocate: Pre lunch

[17/01, 1:52 PM] Pt Advocate: Chapati and dal

[17/01, 2:03 PM] Pt Advocate: Lunch ke bad 1 goli

[17/01, 4:06 PM] Pt Advocate: After lunch

[17/01, 4:18 PM] Rakesh Biswas Sir Gm Hod: After 16 U of actrapid @Lohith?

[17/01, 4:18 PM] Lohit Sir Gm Pg: 12units actrapid sir

[17/01, 4:18 PM] Rakesh Biswas Sir Gm Hod: Before 16U of actrapid @⁨Lohit Sir Gm Pg⁩ ?

[17/01, 4:19 PM] Lohit Sir Gm Pg: We gave only 12 units actrapid sir 

Pre meal- 91mg/dl 

Post meal -281mg/dl sir

[17/01, 4:19 PM] Rakesh Biswas Sir Gm Hod: Why because of the pre meal? That's the reason we don't get it done?

[17/01, 4:20 PM] Lohit Sir Gm Pg: Yes sir, we clearly informed the ward sister and the patient attendants to not check pre meal GRBS and but they checked it again sir

[17/01, 4:20 PM] Rakesh Biswas Sir Gm Hod: If it was 16U how much do you think it would have been after two hours?

[17/01, 4:20 PM] Lohit Sir Gm Pg: 200mg/dl sir

[17/01, 4:20 PM] Rakesh Biswas Sir Gm Hod: Maybe slightly lesser than that too

[17/01, 4:20 PM] Lohit Sir Gm Pg: Yes sir

[17/01, 4:21 PM] Lohit Sir Gm Pg: This is a learning experience for me sir

[17/01, 4:21 PM] Lohit Sir Gm Pg: To not follow pre-meal GRBS

[17/01, 4:23 PM] Rakesh Biswas Sir Gm Hod: No it's not about not following but about the utility of estimating and adjusting insulin dose for the post meal based on the pre meal. 

Part of Narasimha and Govardhini's thesis which they may not be doing!

[17/01, 4:24 PM] Lohit Sir Gm Pg: Okay sir

[17/01, 4:24 PM] Hrudaii Kims: Bp recording 

12 00 pm 140/ 90

[17/01, 4:26 PM] Hrudaii Kims: About the surgery 

sir told they will confirm tomorrow

[17/01, 5:04 PM] Reddishetti Lishitha: Patient is saying he is hungry and wants to eat food sir

[17/01, 5:05 PM] Rakesh Biswas Sir Gm Hod: Why not? Isn't this his tea time anyway

[17/01, 5:06 PM] Rakesh Biswas Sir Gm Hod: Always ensure a balanced diet with fruits and vegetables

[17/01, 5:08 PM] Reddishetti Lishitha: Sir patient wants to have food like vada

[17/01, 6:25 PM] Rakesh Biswas Sir Gm Hod: Can with some fruits and salads. Let them buy some fresh fruits and salads from Narketpally market

[17/01, 6:25 PM] Rakesh Biswas Sir Gm Hod: Those that can be eaten raw

[17/01, 6:30 PM] Reddishetti Lishitha: Ok sir

Usg abdomen

[17/01, 7:30 PM] Rakesh Biswas Sir Gm Hod: Case report link?

[17/01, 7:32 PM] Lohit Sir Gm Pg: 12units Mixtard 

7 units actrapid 

Was given yesterday for dinner sir 

Post meal GRBS was -247

Fasting GRBS was -199 

Shall we go with 14 units Mixtard 

And 7 units actrapid now?

[17/01, 7:48 PM] Reddishetti Lishitha: https://reddishettilishitha135.blogspot.com/2024/01/is-online-e-log-book-to-discuss-our.html

[17/01, 7:54 PM] Pt Advocate: Suger less red tea

[17/01, 7:55 PM] Lohit Sir Gm Pg: What did he have for dinner?

[17/01, 7:56 PM] Lohit Sir Gm Pg: Or will have for dinner?

[17/01, 7:57 PM] Lohit Sir Gm Pg: BP-160/90mmhg

[17/01, 8:00 PM] Pt Advocate: No sir, dinner me 2 chapati or dal khayenge

[17/01, 9:01 PM] Pt Advocate: Chapati,dal and salad

[17/01, 11:32 PM] Pt Advocate: Post dinner

[18/01, 7:39 AM] Pt Advocate: Fasting

[18/01, 8:10 AM] Lohit Sir Gm Pg: Sir shall we go with 14 units Mixtard 

9 units actrapid now sir

[18/01, 8:37 AM] Pt Advocate: Upma,pesarattu

[18/01, 9:17 AM] Reddishetti Lishitha: BP recordings sir 

15/01/2024

8am-150/80

12pm- 150/70

4pm-140/90

8pm-160/90

16/01/2024

8am-150/90

12pm-140/80

4pm-160/90

8pm-160/90

2am-160/90mmhg sir

17/1/24

8 am 160/90

12 pm 150/90

4pm 140/90

8pm 160/90

[18/01, 9:24 AM] Ravi Sir Gm Pg1: Sir as urology sir came for morning rounds and said patient can be discharged as patient is not willing for surgery sir.

Urology sir told to continue tablets for 3months sir.

[18/01, 9:25 AM] Ravi Sir Gm Pg1: Today bp at 9am is 130/70mmhg sir

[18/01, 10:58 AM] Pt Advocate: After breakfast  189

[18/01, 1:44 PM] Pt Advocate: Lunch.....Chapati,dal and salad

[18/01, 1:45 PM] Pt Advocate: Khane se pehele actrapid 14 units diya

[18/01, 4:02 PM] pt advocate : 2 hours after lunch

[18/01, 4:58 PM] Rakesh Biswas Sir Gm Hod: @⁨Reddishetti Lishitha⁩ What happened to the opd patient you took to Dermatology?

[18/01, 5:27 PM] Reddishetti Lishitha: Sir dermatology people said it is truncal acne and seborrheic captitis with post inflammatory Hyperpigmentation 

And secondary to? Nummular eczema over left leg 

@⁨Rakesh Biswas Sir Gm Hod⁩ sir

[18/01, 5:27 PM] Reddishetti Lishitha: Multiple well defined erythematous monophasic scaly papules

[18/01, 7:23 PM] Rakesh Biswas Sir Gm Hod: This post inflammatory hyperpigmentation over the skin of his arm is due to acne?

[18/01, 8:39 PM] Pt Advocate: 2 mg glimepiride... Khane se pehele

[18/01, 8:49 PM] Pt Advocate: Chapati,dal,salad

[18/01, 11:05 PM] Pt Advocate: After dinner

[18/01, 11:06 PM] Pt Advocate: Dinner ke bad metformin 500 liye the

[19/01, 8:29 AM] Rakesh Biswas Sir Gm Hod: Fasting?

[19/01, 8:32 AM] Rakesh Biswas Sir Gm Hod: @⁨Reddishetti Lishitha⁩ @⁨Ravi Sir Gm Pg1⁩ @⁨Lohit Sir Gm Pg⁩ Share his deidentified discharge summary by pasting it in the case report link here before you get my signature on it today👇

https://reddishettilishitha135.blogspot.com/2024/01/is-online-e-log-book-to-discuss-our.html

[19/01, 9:02 AM] Pt Advocate: Fasting 136

[19/01, 9:29 AM] Reddishetti Lishitha: Ok sir

[19/01, 10:09 AM] Rakesh Biswas Sir Gm Hod: When?

[19/01, 12:18 PM] Pt Advocate: After breakfast

[19/01, 1:01 PM] Rakesh Biswas Sir Gm Hod: Share it in the editable text format in your case report link and release the patient asap

[19/01, 1:19 PM] Reddishetti Lishitha: Sir @⁨Rakesh Biswas Sir Gm Hod⁩  we need your signature on discharge summary for long distance patient discharge

[19/01, 1:19 PM] Pt Advocate: Chapati and dal

[19/01, 1:25 PM] Rakesh Biswas Sir Gm Hod: Ask the SR to sign

[19/01, 1:26 PM] Reddishetti Lishitha: Ok sir

[19/01, 3:45 PM] Pt Advocate: After lunch

[19/01, 3:47 PM]Gm Pg: Should we increase the dose glimiperide 2mg to 2.5 BD sir? 

And should add on oral hypoglycaemic drug for afternoon also?

[19/01, 4:55 PM] Rakesh Biswas Sir Gm Hod: No afternoon just metformin after lunch 

Let's recheck on Sunday his fasting and two hour post meal values and then decide about any need for dose increments

[19/01, 10:46 PM] Gm Pg: Okay sir

[20/01, 9:39 PM] Pt Advocate: Khane se pehele glimepiride 2 mg

[26/01, 1:34 PM] pt advocate: Fasting 151

Before breakfast 

Pan 40 

Glimepiride 2mg

[26/01, 1:34 PM] pt advocate: Breakfast milk and cornflakes

[26/01, 1:35 PM] pt advocate: After 2 hour   ~ 285

[26/01, 4:02 PM] Rakesh Biswas Sir Gm Hod: 👍

Case 4

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/35f-opd-vomiting-sob-and-abdominal.html

Pajr link

https://chat.whatsapp.com/INvI0zLWZ6kLDgwD4TlCmj

Case 5

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/38f-co-facial-puffiness-weight-gain-and.html

PaJR link

https://chat.whatsapp.com/IeTTfmrAjD437PJBZCTlLM

What is cushings syndrome and clinical features 

Classification of cushings

Effects of cushings on body

How to diagnose cushings disease?

Case 6

Blog link

https://reddishettilishitha135.blogspot.com/2023/12/27-m-co-asymptomatic-skin-lesions.html

Left leg: single well defined hyperpigmented macule notes over lower 1/3 rd of leg just above medial malleolus

Multiple, well defined, monomorphic erythematous papules with scaling notes over bilateral arms

[18/01, 4:58 PM] Rakesh Biswas Sir Gm Hod: @⁨Reddishetti Lishitha⁩ What happened to the opd patient you took to Dermatology?

[18/01, 5:27 PM] Reddishetti Lishitha: Sir dermatology people said it is truncal acne and seborrheic captitis with post inflammatory Hyperpigmentation 

And secondary to? Nummular eczema over left leg 

@⁨Rakesh Biswas Sir Gm Hod⁩ sir

[18/01, 5:27 PM] Reddishetti Lishitha: Multiple well defined erythematous monophasic scaly papule

[18/01, 7:23 PM] Rakesh Biswas Sir Gm Hod: This post inflammatory hyperpigmentation over the skin of his arm is due to acne?

[18/01, 7:33 PM] Reddishetti Lishitha: yes sir it is due acne  post inflammatory hyperpigmentation occurred sir

And it takes time to resolve as it is due to age factor to sir

[18/01, 8:45 PM] Rakesh Biswas Sir Gm Hod: Does the arm hyperpigmentation have any relationship to his leg eczema?

[18/01, 9:16 PM] Reddishetti Lishitha:  sir their is no relationship between arm hyperpigmentation and leg eczema both are two different diagnosis

Case 7

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/14y-f-vsd.html

1. Types of vsd

https://www.cdc.gov/ncbddd/heartdefects/ventricularseptaldefect.html

An infant with a ventricular septal defect can have one or more holes in different places of the septum. There are several names for these holes. Some common locations and names are (see figure):

1. Conoventricular Ventricular Septal Defect
   In general, this is a hole where portions of the ventricular septum should meet just below the pulmonary and aortic valves.
2. Perimembranous Ventricular Septal Defect
   This is a hole in the upper section of the ventricular septum.
3. Inlet Ventricular Septal Defect
   This is a hole in the septum near to where the blood enters the ventricles through the tricuspid and mitral valves. This type of ventricular septal defect also might be part of another heart defect called an atrioventricular septal defect (AVSD).
4. Muscular Ventricular Septal Defect
   This is a hole in the lower, muscular part of the ventricular septum and is the most common type of ventricular septal defect.

2.Clincal findings in vsd

https://www.cdc.gov/ncbddd/heartdefects/ventricularseptaldefect.html

 ventricular septal defect usually is diagnosed after a baby is born.

The size of the ventricular septal defect will influence what symptoms, if any, are present, and whether a doctor hears a heart murmur during a physical examination. Signs of a ventricular septal defect might be present at birth or might not appear until well after birth. If the hole is small, it usually will close on its own and the baby might not show any signs of the defect. However, if the hole is large, the baby might have symptoms, including:

• Shortness of breath,
• Fast or heavy breathing,
• Sweating,
• Tiredness while feeding, or
• Poor weight gain.

During a physical examination the doctor might hear a distinct whooshing sound, called a heart murmur. If the doctor hears a heart murmur or other signs are present, the doctor can request one or more tests to confirm the diagnosis. The most common test is an echocardiogram, which is an ultrasound of the heart that can show problems with the structure of the heart, show how large the hole is, and show how much blood is flowing through the hole

3.Treatment

https://www.cdc.gov/ncbddd/heartdefects/ventricularseptaldefect.html

Treatments for a ventricular septal defect depend on the size of the hole and the problems it might cause. Many ventricular septal defects are small and close on their own; if the hole is small and not causing any symptoms, the doctor will check the infant regularly to ensure there are no signs of heart failure and that the hole closes on its own. If the hole does not close on its own or if it is large, further actions might need to be taken.

Depending on the size of the hole, symptoms, and general health of the child, the doctor might recommend either cardiac catheterization or open-heart surgery to close the hole and restore normal blood flow. After surgery, the doctor will set up regular follow-up visits to make sure that the ventricular septal defect remains closed. Most children who have a ventricular septal defect that closes (either on its own or with surgery) live healthy lives.

Medicines

Some children will need medicines to help strengthen the heart muscle, lower their blood pressure, and help the body get rid of extra fluid.

Nutrition

Some babies with a ventricular septal defect become tired while feeding and do not eat enough to gain weight. To make sure babies have a healthy weight gain, a special high-calorie formula might be prescribed. Some babies become extremely tired while feeding and might need to be fed through a feeding tube.

PSYCHIATRY

Cases seen in psychiatry

-Anxiety

-dissociation

-somnambulism

-adjustment issues

-somatoformdisorder

-deliberare selfharm _impulsive type

-panic disorder with anxious personality

-F20

-depression

3) Anecdotal self reflections on their internship learning with some video  evidence of procedures performed

ABG : 31

Interpretation and osce

https://reddishettilishitha135.blogspot.com/2024/01/abg-interpretation.html

Central line   total 6

Assisted 4 and Suturing done

Foly's 19

-Silicon urine catheter 14 fr insertion after dilating urethra with urethra dilators  from 8 fr to 16 fr and through guide wire

Intubation 4

Dialysis and monitoring

Blood transfusion and monitoring 4

https://youtu.be/sMtjAiif_PE?si=EdTC_SbUcSO3-wpe

Capnography

Ryles tube insertion and checking for position 5

Canulation  and sample collection 15

Excision of sebaceous cyst 

Cpr  3

Ward duty i monitored patients bp

Ecg

2d echo

4)Case based OSCE along with Bloom's learning levels achieved

https://reddishettilishitha135.blogspot.com/2024/01/measuring-and-mixing-urine-before.html

I was asked to go to the biochemistry laboratory and learn about the process by which UPCR is calculatedcalculated for my patient

PaJR link

https://chat.whatsapp.com/J73wQ60iSov7c30Xhi7hRV

Blog link

https://reddishettilishitha135.blogspot.com/2024/01/50m-hypoalbuminemia-viral.html

24 HR URINE PROTEIN CREATININE RATIO

MEASURING AND MIXING URINE BEFORE TAKING TEST SAMPLE FOR 24HR UPCR

YouTube link

https://youtu.be/9fVE5WLrIu8?si=FA3njXRTS7WKz2I8

Thymol crystals one pinch used as preservative are added to urine can before giving

It has pungent smell

How to collect 24 hr urine for 24 hr upcr? 

24 hr urine sample collected after discarding the first sample at 6:00 am and  urine is collected from next sample till next day morning first sample

Urine samples as given by attenders

Measuring cylinder 1 lt

Measuring urine volume using  measuring cylinder

Urine measured=2300 ml

Mixing of urine

Video link for mixing of urine

https://youtube.com/shorts/2TvGq1E43Lo?si=LMW8Blgc9Wga5a99

After mixing both urine samples 3 ml test sample is taken and centrifuge slowely to saparate sediment and supernatant

Took 3 test tubes labeled as test, standard and blank, 

Add 2ml of sulphosalicylic acid to each test tube

Sulphosalicylic acid

-Add 0.5 ml urine sample to test tube marked T

-Add 0.5 ml standard protein to standard tube marked S

Standard protein

-Nothing should be added to blank tube

Wait for 10 minutes

       Comparison between blank and test

I could appreciate Cloudy appearance in test sample test tube

I kept blank in calorimeter and made zero cal

Blank

Reading 0.00 cal

Following this standard solution is placed in calorimeter

Reading  0.44 cal

Following this the test sample is placed

Reading 0.22 cal

All readings are notes

Calculating protein values

Calculating spot urine protein

=calorimeter test value x concentration of standard solution/ calorimeter standard value

[Concentration of standard solution =60mg]

=0.22 x 60/0.44

= 30 mg/dl

Spot urine protein = 30mg/dl

 Calculating 24 hr protein 

= spot protein x 24 hr urine volume/100

=30 x 2300/100

= 690mg/dl

24 hr urine protein  is 690mg/dl

Calculating urinary creatinine

The test sample is diluted with distal water in ratio 1:10

100 u test sample + 900 u diatal water = dilution

This is done in BS 390 auto analyser

BS 390 auto analyser

The value obtained for 1 :10 dilution= 1.96

Calculating spot urinary creatine

= value obtained x 10

[10 is constant-linearity range for Creatinine]

= 1.96 x 10 = 19.6 mg/dl

 spot urinary creatine = 19.6 mg/dl

24hr urinary creatinine=

Calculated value x 24 hr urinary volume /100

=19.6 x 2300/100 = 450.8 mg/dl

Converting to gms = 0.45 gm/dl

24hr urinary creatinine= 450.8 mg/dl

24 hr Urinary protein creatinine ratio 1.5

[24/01, 6:43 PM] Reddishetti Lishitha: 

https://reddishettilishitha135.blogspot.com/2024/01/measuring-and-mixing-urine-before.html

Video link

https://youtu.be/9fVE5WLrIu8?si=33kynxy1ix2atJ2E

Pajr link

https://chat.whatsapp.com/J73wQ60iSov7c30Xhi7hRV

[24/01, 8:08 PM] Rakesh Biswas Sir Gm Hod: Wow 👏👏👏