2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links
[04/08, 3:08 pm] Rakesh Biswas Sir HOD Med: Today's update of her pain? @Nikhileshwar K
What analgesic is she getting?
[04/08, 3:21 pm] Nikhileshwar K: Sir she is on tramadol
[04/08, 3:24 pm] Rakesh Biswas Sir HOD Med: Dose?
[04/08, 3:25 pm] Nikhileshwar K: 1 amp in 100ml ns sir
[04/08, 3:33 pm] Rakesh Biswas Sir HOD Med: How many times given yesterday?
[04/08, 3:41 pm] Nikhileshwar K: Twice sir
[04/08, 4:01 pm] Rakesh Biswas Sir HOD Med: Start Tab Ultracet half qds
[04/08, 4:08 pm] Nikhileshwar K: Ok sir
[04/08, 5:33 pm] Nikhileshwar K: Ortho department is planning for L1-L4 Posterior screw fixation and L3-L4 vertebral body biopsy in 3 days Sir
[23/09, 9:55 am] Nikhileshwar K: SOAP NOTES -
23/9/2023
Ward : AMC
Unit : 6
DOA : 14/9/23
S:
Pain in the right lower limb
O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema
Bp- 100/60mmHg
Pr- 68bpm
Temperature - 98.9F
Rr- 16 cpm
Cvs - s1s2 heard
Cns - NFND
P/A - soft non tender
Rs - bae intact
A:
sepsis with MODS with DIC secondary to right lower limb cellulitis with bilateral transudative pleural effusion with right lower lobe consolidation with hypokalemia
P:
- IV FLUIDS NS AND RL @ 75 ML/hr
- INJ OPTINEURON 1 AMPOULE IN 500 ML NS/ IV/ TID
- INJ. PIPTAZ 2.25 G/ IV/TID
- INJ METROGYL 500 MG/ IV/ TID
- INJ ZOFER 4 MG/ IV/ TID
- INJ PAN 40 MG IV/ OD
- TAB CHYMEROL FORTE PO/BD
- TAB PCM 650 MG PO/TID
- NEB WITH IPRAVENT 6TH HRLY AND BUDECORT 12 HRLY
- STRICT IO CHARTING
- VITALS MONITORING
[25/09, 9:08 am] Nikhileshwar K: SOAP NOTES -
25/9/2023
Ward : SICU
Unit : 6
DOA : 14/9/23
S:
Pain in the right lower limb
O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema
Bp- 100/60mmHg
Pr- 68bpm
Temperature - 98.9F
Rr- 16 cpm
Cvs - s1s2 heard
Cns - NFND
P/A - soft non tender
Rs - bae intact
A:
sepsis with MODS with DIC secondary to right lower limb cellulitis with bilateral transudative pleural effusion with right lower lobe consolidation with hypokalemia
P:
- IV FLUIDS NS AND RL @ U5 ML/hr
- INJ OPTINEURON 1 AMPOULE IN 500 ML NS/ IV/ TID
- INJ. PIPTAZ 2.25 G/ IV/TID
- INJ METROGYL 500 MG/ IV/ TID
- INJ ZOFER 4 MG/ IV/ TID
- INJ PAN 40 MG IV/ OD
- TAB CHYMEROL FORTE PO/BD
- TAB PCM 650 MG PO/TID
- NEB WITH IPRAVENT 6TH HRLY AND BUDECORT 12 HRLY
- STRICT IO CHARTING
- VITALS MONITORING
[25/09, 9:38 am] Rakesh Biswas Sir HOD Med: Share the pleural tap values asap
[25/09, 10:37 am] Nikhileshwar K: Ok sir
[25/09, 11:20 am] Nikhileshwar K: Pleural Sugar - 129 mg/dl
Pleural protein - 1.11 g/dl
Serum LDH - 376 IU/L
pleural LDH - 208 IU/L
based upon these values and using light's criteria, it is a transudative pleural effusion sir
[25/09, 10:42 pm] Rakesh Biswas Sir HOD Med: Serum protein?
Share the ratios
[26/09, 10:36 am] Nikhileshwar K: SOAP NOTES -
26/9/2023
Ward : SICU
Unit : 6
DOA : 14/9/23
S:
Pain in the right lower limb
O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema
Bp- 100/60mmHg
Pr- 73bpm
Temperature - 98.9F
Rr- 18 cpm
Cvs - s1s2 heard
Cns - NFND
P/A - soft non tender
Rs - bae intact
A:
sepsis with MODS with DIC secondary to right lower limb cellulitis with bilateral transudative pleural effusion with right lower lobe consolidation with hypokalemia
P:
- IV FLUIDS NS AND RL @ 75 ML/hr
- T. AMOXYLLAV 625 MG PO/BD
- T. PAN 40 MG IV/ OD
- TAB CHYMEROL FORTE PO/BD
- TAB PCM 650 MG PO/SOS
- NEB WITH IPRAVENT 6TH HRLY AND BUDECORT 12 HRLY
- L.L DRESSING AND ELEVATION
- STRICT IO CHARTING
- VITALS MONITORING
[26/09, 10:37 am] Nikhileshwar K: Serum protein is 2.58 sir
Pleural LDH/ serum LDH = 208/376 = 0.55 (<0.6)
Pleural protein/ pleural protein = 1.11/2.58 = 0.43 (<0.5)
Hence transudative sir
[27/09, 2:49 pm] Nikhileshwar K: SOAP NOTES -
27/9/2023
Ward : SICU
Unit : 6
DOA : 14/9/23
S:
Pain in the right lower limb
O:
Pt is conscious,coherent and cooperative
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema
Bp- 100/60mmHg
Pr- 83bpm
Temperature - 98.3F
Rr- 20cpm
Cvs - s1s2 heard
Cns - NFND
P/A - soft non tender
Rs - bae intact
A:
sepsis with MODS with DIC(resolving) secondary to right lower limb cellulitis with bilateral transudative pleural effusion with right lower lobe consolidation with hypokalemia
P:
- T. AMOXYLLAV 625 MG PO/BD
- T. PAN 40 MG IV/ OD
- TAB CHYMEROL FORTE PO/BD
- TAB PCM 650 MG PO/SOS
- NEB WITH IPRAVENT 6TH HRLY AND BUDECORT 12 HRLY
- L.L DRESSING AND ELEVATION
- STRICT IO CHARTING
- VITALS MONITORING
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