Comprehensive Study Notes: Jinnah Post-Graduate Medical Centre Case (Raheesa)

Admission and Patient Details

  • Name: Raheesa Wlo M. Asghar
  • Age/Gender: 51-year-old female
  • Address: Korangi, Karachi
  • Hospital: Jinnah Post-Graduate Medical Centre (JPMC)
  • Registration/Admission details:
    • Hospital Admission No.: 01/8/25
    • Ward No.: 05 | Bed No.: 36
    • Admitted under the care of: Prof. Dr Aball
    • Time and Date of Admission: 01/08/25 7:15 PM
    • Mode of Admission: Referred/Emergency (ER)
    • Next of Kin to be informed: Shahib (0315-6817390)
  • Disposition: Not clearly marked as discharged or died in the initial sheet; note shows possible discharge decisions later in records
  • Final Diagnosis (as per page 1):
    • Primary Diagnosis: Left against advice (likely LAMA)
    • Associated Diagnosis/Pathology: Not clearly stated in the excerpt
    • Operation: None listed
  • Disposals/Notes: Several progress notes reference ongoing management and referrals; discharge planning noted later in ED notes
  • Summary statement: Document set comprises admission form and sequential progress notes with vitals, investigations, treatments, nutrition planning, and rehab/physiotherapy notes; several entries include “Scanned with CamScanner” indicating scanned originals

Presenting History and Clinical Course (History)

  • Patient background:
    • 51-year-old female, married, resident of Korangi, Karachi
    • Known history of hypertension (HTN)
  • Presenting problem:
    • Acute altered level of consciousness (ALOC) with vomiting for about 1 day prior to ER admission; attendants reported gradual loss of responsiveness and irritability; by yesterday, patient was unresponsive
    • No fever, cough, shortness of breath (SOB), diarrhea, or constipation reported in the notes; vomiting described as 3 episodes prior to ALOC, watery, small amounts, with food particles; no blood in vomitus
  • Past medical history:
    • K/C of HTN
  • Surgical history: None reported
  • Personal history: Non-smoker, no addictive substances reported
  • Family history: HTN
  • Socioeconomic status: Lower class

Initial Vitals and Neurological Status (Early Admission)

  • Page 3: Initial vitals (likely at ER intake)
    • Blood Pressure (BP): around hypertensive crisis values (e.g., 180–200 systolic / 90–100 diastolic ranges reported in various entries)
    • Pulse: around 92 bpm (ranges 64–94 in subsequent notes)
    • Respiratory Rate (RR): around 23 breaths/min
    • Temperature: Af (afebrile) recorded in several entries
    • SpO2: around 94–98%
    • Random Blood Sugar (RBS): 144 mg/dL
  • Neurological status:
    • GCS not consistently documented in the earliest entry; later notes show GCS 9/15 to 10/15 range during progression
  • Other observations:
    • Blunted initial exam details but later entries show signs of HTN crisis and potential CNS involvement

Vitals and Observations During Hospital Stay (Trends)

  • Page 4 (02/08/2025):
    • BP: 140/90 mmHg
    • Pulse: 72 bpm
    • RBS: not clearly stated in this extract
    • SpO2: not clearly stated
    • CNS: GCS 10/15
    • Chest: Clear; CVS: 81+52 (likely heart rate/cardiac exam notated); Abdomen: non-tender
    • Interventions: Physiotherapy noted; IV fluids and monitoring ongoing; potassium replacement mentioned later (K+ af replacing)
  • Page 5: Ongoing vitals in bed 36 with fluctuating hypertensive readings (e.g., 200/100, 180/100, 120/100, etc.); RR and SpO2 values fluctuated within normal to mildly abnormal ranges; afebrile status continued
  • Page 7: Serial vitals with wide BP swings including hypertensive peaks (e.g., 200/140); HR around 64–76 bpm; RR around 20–24; SpO2 around mid-90s; time-stamped BP and input/output logs noted
  • Page 9: Reiterates ALOC with vomiting; vitals show BP 180/100, pulse 78, RR ~18, SpO2 99%; GCS noted as 9/15 or 10/15; abdomen soft and non-tender; plan includes investigations and management for hypertensive crisis and possible intracranial pathology
  • Page 12–13: Repeated vital signs with BP often elevated (e.g., 220/100; 180/90; 130/90; 200/140 in some entries), indicating ongoing BP management challenges
  • Page 16: Documentation of several call notes by on-duty doctors and ward staff; confirms admitted status in ward 36 and ongoing management; includes plans for consent and discharge on treatment

Investigations Ordered (Investigations/Imaging)

  • Investigations ordered (as listed on page 10):
    • Complete Blood Count (CBC)
    • Urea/Creatinine (UCE)
    • Liver Function Tests (LFTs)
    • Prothrombin Time/INR (PT/INR)
    • Dye studies/Drugs: D/R (likely drug screen or discharge records)
    • Chest X-Ray (CXR, PA view)
    • Computed Tomography Brain (CT Brain)
  • Point-of-care data:
    • RBS 144 mg/dl (as noted at presentation)
  • Imaging/Neuro considerations:
    • CT Brain performed or planned to assess for intracranial pathology given ALOC and HTN crisis; results not provided in the transcript

Differential Diagnosis (Impressions) and Final Diagnoses

  • Hypertensive encephalopathy / hypertensive emergency given repeatedly elevated BP readings with ALOC
  • Acute vomiting with possible intracranial or CNS involvement (necessitating imaging)
  • Uncontrolled HTN with potential prior hospital admissions for HTN (as per later progress notes)
  • LAMA (Left Against Medical Advice) noted in the initial admission note, though subsequently care continued under hospital monitoring

Treatments Delivered in the Emergency Department and Ward

  • Antihypertensive therapy:
    • Labetalol IV given (as per ED notes: “Labetalol zong y” with prior entries; details show 50 mg IV bolus in one entry)
    • Mannitol IV used (for cerebral edema/hypertensive encephalopathy considerations; dosing described as 250 mg stat then 150 mg q?; exact dosing not consistently clear)
  • Antibiotics:
    • Ceftriaxone 2 g IV (given as IV antibiotic; timing noted as 3/8/09 AM in page 8 notes; likely continued as a prophylactic/empiric therapy in infection workup)
  • Renal/Neuro/Fluid management:
    • Mannitol administration to reduce intracranial pressure if indicated
    • Foley catheterization performed (Pass Folley’s catheter) and NG tube placement (nasogastric tube) as part of GI decompression and monitoring
    • IV fluids with input/output charting documented; 200 mL input entries noted; specific fluid types not consistently detailed
  • Neurological/Neurosurgical consults:
    • Referred to Neuro Surgery as seen in page 15
  • Oxygen therapy and monitoring:
    • Vital monitors used; oxygen saturation monitored; no explicit high-flow oxygen requirement documented in the given excerpts
  • Supportive care:
    • Physiotherapy considered (PROM of bilateral upper/lower limbs; ankle pumps; chest physiotherapy noted on Page 6)
    • Nutrition support initiated through NG feeding plan and later enteral nutrition guidance
  • Disposition decisions:
    • Patient counselled about critical condition; discharge on treatment planned with multiple department involvement (General Medicine, Chest Medicine, Neuro Medicine, Neuro Surgery, etc.)

Nutrition and Diet Therapy (Caloric and Protein Calculations)

  • Nutritional assessment and plan (Pages 17–18):
    • Weight: 50 kg; BMI: 36 (based on records in page 17–18 section)
    • Caloric requirement calculation (Basal Energy Expenditure, BEE):
    • BEE = $25 ext{ kcal/kg} imes ext{weight (kg)}$
      • For weight 50 kg: extBEE=25imes50=1250extkcal/dayext{BEE} = 25 imes 50 = 1250 ext{ kcal/day}
    • Activity Factor (AF):
    • Confined to bed: AF = 1.2 (notes on page 17)
    • Injury Factor (IF):
    • The table lists several categories (Infection, Trauma, Skeletal, Blunt Head Injury, Minor, Major, etc.) with factors ranging roughly 1.1–1.8; the page uses IF = 1.2 for the calculation shown
    • For this patient, used IF = 1.2
    • Total Caloric Requirement:
    • extTotalCalories=extBEEimesextAFimesextIF=1250imes1.2imes1.2=1800extkcal/dayext{Total Calories} = ext{BEE} imes ext{AF} imes ext{IF} = 1250 imes 1.2 imes 1.2 = 1800 ext{ kcal/day}
    • This matches the stated total caloric requirement shown in the notes: 1800 kcal/day
  • Protein requirements (Pages 17–18):
    • General recommendation: 0.8 g protein per kg body weight per day for normal conditions
    • For 50 kg: 0.8 rac{ ext{g}}{ ext{kg}} imes 50 ext{ kg} = 40 ext{ g/day}
    • Stressed/ill patient adjustments (as per table in notes): mild, moderate, severe catabolism recommendations range roughly from 0.8 to 2.0 g/kg depending on severity (normal 0.8 g/kg; mild 0.8–1.0; moderate 1.0–1.5; severe 1.5–2.0). In practice, target protein would be adjusted based on clinical status
  • Enteral feeding plan (NG feeding):
    • “Ensure powder” (brand: Ensure) given as 3 scoops in 120 mL water every 4 hours
    • Enteral feeding schedule summarized as feeding every 4 hours with EN formula to meet the calculated caloric and protein targets
  • Example calculation from itemized food table (Page 17–18):
    • CEREAL AND CEREAL PRODUCTS (sample values):
    • Corn Flakes (Makai): 100 g → 375 kcal
    • Rice Polished (Boiled): 100 g → 345 kcal
    • Wheat Bread (Nan): 100 g → 369 kcal
    • Selected items and serving sizes contribute to the overall 1250 kcal baseline used for BEE/AF/IF calculation; the table is intended to guide dietitian planning for macro/micronutrient balance
  • Summary nutrition plan for this patient:
    • Caloric target: 1800 kcal/day
    • Protein target: approximately 40 g/day (minimum baseline for a 50 kg individual; higher targets may be used given stress/illness)
    • Route: NG feeding with fortified formula (Ensure) as per schedule; monitor tolerance and GI function
    • Monitoring: daily weight, intake/output, blood sugars, electrolytes, renal and hepatic function as part of ongoing management

Physiotherapy and Rehabilitation

  • Page 4–6 notes indicate:
    • Physiotherapy initiation and ongoing sessions (PROM for bilaterals; ankle pumps; chest physiotherapy, especially post-acute care)
    • Pelvic and gait-related rehabilitation not detailed; focus on limb mobility and chest clearance
  • Goals:
    • Maintain joint mobility, prevent deconditioning, improve airway clearance, and support overall functional recovery during HTN-related illness and ICU/ward stay

Nursing Care, Documentation, and Disposition

  • Nursing documentation includes:
    • Hour-by-hour vitals (BP, pulse, RR, Temp, SpO2, RBS)
    • I/O charts, fluid administration records, and ongoing monitoring of neurological status
    • Catheter and NG tube management; documentation of intake/output and device care
  • Disposition considerations and plan (Page 15–16):
    • ED discharge planning notes indicate consultation with multiple specialties (General Medicine, Chest Medicine, Gyn/Obs, Neuro Medicine, Neuro Surgery)
    • Patient counselled about condition and prognosis; call handling and follow-up guidance documented
    • Signature by physicians and care team required for progress notes and discharge orders
  • Social and ethical aspects:
    • The patient initially left against medical advice (LAMA) per primary diagnosis entry, but subsequent notes reflect continued inpatient management and multidisciplinary involvement, indicating a transition from LAMA to continued hospital care under medical supervision

Key Investigations and Clinical Data Summary (Selected Items)

  • Investigations ordered: CBC, UCE, LFTs, PT/INR, D/R, CXR (PA view), CT Brain
  • Vital trends emphasize hypertensive physiology with intermittent high BP readings (e.g., 180–200 systolic with diastolic around 90–100 in several entries) and GCS variations around 9–10/15 during the admission
  • Neuroimaging: CT Brain planned/ordered to assess intracranial pathology in the context of ALOC and HTN crisis; results not included in the available pages
  • Blood sugar fluctuated around 144 mg/dL (RBS)

Timeline Highlights (Selected Dates/Events)

  • 01/08/2025 7:15 PM: Admission to Ward 05, Bed 36; emergency evaluation; HTN crisis suspected; ALOC and vomiting noted; initial plan included IV therapies and investigations
  • 02/08/2025: Several vitals show BP stabilization attempts (e.g., BP 140/90); GCS 10/15; persistent HTN episodes noted; interventions included IV antihypertensives, diuretics or osmotics (Mannitol), and antibiotics (Ceftriaxone)
  • 03/08/2025: Ongoing management with serial vitals (BP around 180–210 systolic during spikes); electrolyte and renal function monitoring implied by I/O and IV fluid management
  • 04/08/2025: Physiotherapy and PROM exercises; nutrition planning formalized; continued NG feeding and monitoring documented
  • 22/08/2025 onward: Multiple progress notes reflect multidisciplinary management and discharge planning; CCs include HTN management and possible referral to subspecialties as needed

Formulas and Calculations (LaTeX)

  • Basal Energy Expenditure (BEE):
    • ext{BEE} = 25 rac{ ext{kcal}}{ ext{kg}} imes ext{weight (kg)}
    • For weight = 50 kg: extBEE=25imes50=1250extkcal/dayext{BEE} = 25 imes 50 = 1250 ext{ kcal/day}
  • Total Caloric Requirement (using AF and IF):
    • extTotalCalories=extBEEimesAFimesIFext{Total Calories} = ext{BEE} imes AF imes IF
    • With AF = 1.2 (bed-bound) and IF = 1.2 (as used in the notes):
    • 1250imes1.2imes1.2=1800extkcal/day1250 imes 1.2 imes 1.2 = 1800 ext{ kcal/day}
  • Protein requirements (example):
    • Normal: 0.8 rac{ ext{g}}{ ext{kg}} imes 50 ext{ kg} = 40 ext{ g/day}
    • Mild to moderate catabolic states typically range from 0.8 ext{ to } 1.5 rac{ ext{g}}{ ext{kg}} depending on severity

Important References from the Transcript (Key Points to Remember)

  • HTN and ALOC management with empirical therapy (Labetalol, Mannitol) and imaging workup (CT Brain)
  • GI decompression and urinary management with NG tube and Foley catheter
  • Empiric antibiotics (Ceftriaxone) in the context of suspected infection or sepsis workup
  • Multidisciplinary involvement (General Medicine, Neuro Medicine, Neuro Surgery, Chest Medicine, Gyn/Obs)
  • Nutritional plan emphasizes caloric and protein targets based on body weight and stress level, with explicit NG feeding regimen and an itemized diet table for planning
  • Physiotherapy and early mobilization efforts to prevent deconditioning during critical illness

Summary Takeaways for Exam Preparation

  • Recognize the presentation of hypertensive emergency with ALOC and vomiting, and the initial management steps (BP control, osmotic agents, antibiotics, imaging)
  • Understand the structure and purpose of hospital nutrition planning for an acutely ill patient: BEE, AF, IF, and practical enteral feeding strategies
  • Be able to interpret common clinical documentation elements: vitals trends, ICU/ward progression notes, nursing I/O charts, and multidisciplinary discharge planning
  • Recall typical investigations for ALOC with hypertension: CBC, LFTs, U&E, PT/INR, CXR, and CT Brain
  • Appreciate the role of rehabilitation and physiotherapy early in hospitalization to maintain function during acute illness