Music and Medicine ProJR

 Sunday, March 15, 2026

Music and Medicine ProJR: Integrative precision medicine rehab of any illness state through "n of 1" musical interventions.

Summary:

The text below explores the hypothesis that music can serve as a potent form of integrative precision medicine, particularly for rehabilitation and palliative care. It uses the real-world example of Pandit Vivek Joshi, a Sarod maestro who practices "Vibration Therapy" in medical settings, as a springboard for a deeper neurobiological and physiological discussion.

The core argument is that music is not just psychologically soothing; it actively interfaces with the nervous system. By providing predictable patterns, rhythms, and tones, music helps synchronize temporal lobe oscillatory networks, reduces neurological "prediction errors," and shifts the autonomic nervous system from a defensive state of vigilance to a regulated state of safety (aligned with Polyvagal theory). Because every nervous system is different, the text advocates for "n-of-1" trials—highly individualized therapeutic approaches where specific musical vibrations are prescribed to match an individual's unique auditory and neurological processing needs.

30F DM 1 yr, HTN mths foot ulcer Telangana PaJR

12-03-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

 [11:25 pm, 12/03/2026] PPM 3: Good day sir ma patient ki 3years back b12 problem vacchindhi sir valu appudu 30 vunde hyd yashoda hospital lo Rajashekar reddy sir ni consult ayyamu sir thanu inapur 5mg tablets b ta forced tablets iccharu sir after 1 year back sugar attack ayyindhi sir sugar  chala uncontrolled vuntundhi sir ippudu e tablets vesukunna thala thippadam naralu chala lagadam avuthunnai sir thinna thinakunna 400above sugar chupisthundhi ma patient problem ki solutions cheppandi sir

[11:25 pm, 12/03/2026] PPM 3: @PA  edey na Meru cheppalanukunnadi.

[11:32 pm, 12/03/2026] PPM 3: As this patient advocate (hu2) I saw her first time with non healing ulcers with poorly controlled sugars on OHA. 

She underwent debridement and insulin optimisation with actrapid  and Lantus. 

She also been diagnosed with hypertension few months back, since then she is using Telmisartan + hydrochlorthiazide and metaprolol. 

She had palpitations, persistent tachycardia and occasional episodes of weakness followed by giddiness. At such episodes her sugars and BP normal.

[11:33 pm, 12/03/2026] PA: E koncham ekkuva dose tablets or insulin kuda ameki padatam ledu sir bp kuda ekkuvagavundhi  bp ki tablets vaduthundhi sir

[11:34 pm, 12/03/2026] PPM 3: Recently she was added with prazopress XL 2.5mg night by her primary physician at her village.

[11:35 pm, 12/03/2026] PPM 3: @PA Ippudu bp inka sugar Ela undi..?

[11:36 pm, 12/03/2026] PA: Bp 150 or160 sugar 310

[11:36 pm, 12/03/2026] PPM 2: 3 years back anni bagane undey na? B12 problem appudu em symptoms vocchai patient ki?

[11:37 pm, 12/03/2026] PA: Bp ekkuvaga ayyindhi sir thalathippdam

[11:38 pm, 12/03/2026] PPM 2: Okay. Appudu BP entha undey?

Mee patient em chestharu? Roju em panulu cheskuntaro every hour describe cheyyandi. Problems modalaina taravatha ee panulu cheskontam lo ibbandi ela ayindi

[11:40 pm, 12/03/2026] PA: Appudu bp 180 vunde sir   aproblem vacchindu ontariga koncham dhuramkuda nadavaledu eppudu thalathipputhuvundhi ani cheppevaru

[11:41 pm, 12/03/2026] PA: Thodulenide ekkada vellaledu

[11:42 pm, 12/03/2026] PPM 2: Acha okay. @PPM3 can you ask the advocate to share AP and lateral views of the patient and also all previous medical records in a strictly deidentified manner.

[11:42 pm, 12/03/2026] PPM 2: Dhuramga nadavekapovadam, antey dammu kuda vosthundey na?

[11:43 pm, 12/03/2026] PA: Ledu sir dammu ledu heart ki sambandhinchi anni testlu kuda normal vunnai sir

[11:44 pm, 12/03/2026] PA: Yashoda hospital chepincharu anni ok vunnai annaru

[11:45 pm, 12/03/2026] PA: But thanaku nadi vyavastha koncham week ga vundhi annaru

[11:46 pm, 12/03/2026] PA: Andhuke bp ki metxl 50mg tablets iccharu

[9:24 am, 13/03/2026] PPM 1: Please ask him not to share any names of doctors or hospitals to protect the privacy confidentiality of his patient and also to represent his patient in a way that her privacy is always protected.

[9:24 am, 13/03/2026] PPM 1: But thanaku nadi vyavastha koncham week ga vundhi annaru

@CR I'm unable to get the exact translation of this.

[9:25 am, 13/03/2026] PPM 1; @CR can we ask the patient's advocate to share her current BP recordings and four point sugar profile along with the timing and names of the medicines similar to how the other PaJR patients are sharing?

[9:28 am, 13/03/2026] CR: Pulse rate was weak.

[9:29 am, 13/03/2026] PPM 1: How did they come to know it was weak?

[9:30 am, 13/03/2026] CR: When they consulted the doctor at Yashoda hospital

[9:30 am, 13/03/2026] PA: Pulse 80 or 90 sir

[9:37 am, 13/03/2026] PPM 1: The problem is we want to know what the patient felt at that time to understand the event properly and the patient's advocate puts more emphasis on what the doctors told them (which we don't want to hear)!

[9:42 am, 13/03/2026] CR: Spoke to her and she will update by afternoon

[9.45 am, 13/03/2026] PPM 1: Can use this template?👇

రోగి న్యాయవాది కోసం ప్రశ్నలు;

దయచేసి మీ రోగి యొక్క ప్రస్తుత సమస్యలకు దారితీసిన సంఘటనల క్రమాన్ని వివరించండి. దయచేసి మీ పేషెంట్‌కు ఎటువంటి సమస్యలు లేకపోయినా సంఘటనల క్రమాన్ని ప్రారంభించండి. 

దయచేసి 24 గంటల పాటు మీ రోగి సరిగ్గా ఉన్నప్పుడు అతని గంటా దినచర్యను వివరించండి 

తర్వాత, వ్యాధి అతని జీవితాన్ని పట్టుకున్న తర్వాత, అతని గంటా 24 గంటల దినచర్యకు ఏమి జరిగిందో దయచేసి వివరించండి 

దయచేసి రోగి యొక్క గంట దినచర్యలో ఏ భాగం అంతరాయం కలిగిందో ప్రత్యేకంగా పేర్కొనండి 

రోగికి మన నుండి ప్రస్తుత అవసరాలు ఎలా ఉన్నాయి, మనం అతనికి ఒకే ఔషధం ఇవ్వవలసి వస్తే, వారు ఏ సమస్యను పరిష్కరించడానికి ఇష్టపడతారు?

దయచేసి ఇక్కడ చిత్రంలో క్రింద ప్రదర్శించిన విధంగా ఉదరం మరియు చేయి కండరాల రోగి యొక్క క్లినికల్ ఫోటోను పోస్ట్ చేయండి:

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[10:02 am, 13/03/2026] PPM 3: @PA  ikkada me patients personal details leda doctors / hospital names em pettakandi. Meku emina ala doubt untey nak personal message pettandi.

[10:02 am, 13/03/2026] PPM 3: Ela unnaru..? Eppudu BP and sugar entha undi..?

[10:19 am, 13/03/2026] PA: Fasting 306, Bp140 pulse 96

[10:22 am, 13/03/2026] PPM 2: Tablets inka insulin vadthunnavi photo pettandi clear ga kanapadey laga

[10:37 am, 13/03/2026] PPM 1: Yes we need to know what was her night dose that led to this high fasting

[10:38 am, 13/03/2026] PA: Memu intiki vacche sariki 10pm aindhi sir

[10:40 am, 13/03/2026] PA: Late nt aindhi sir

[10:41 am, 13/03/2026] PA: Nt needura ledu tension ki

[10:43 am, 13/03/2026] PA: Food kuda ekkuva thinadu kani fasting ekkuva chupisthundhi but time neglect bagavundhi

[10:48 am, 13/03/2026] PA: Thanaku 7months back surgery ainde kalu velu ki gaju mukka thegi velu infection aindhe koncham velu thisaru sir

[10:53 am, 13/03/2026] PA: Appudu insulin padindhi sir ippudu ade insulin padatam leduu  g

[11:10 am, 13/03/2026] PPM 2: Okay got it.

[11:10 am, 13/03/2026] PPM 2: Adey em em teeskuntunaro, time and dose tho saha pettandi

[11:39 am, 13/03/2026] PPM 3: T. Glimiperide 2mg twice daily 

T. Sitagliptin 50mg twice daily 

T. Pioglitazone 15mg once daily 

T. Met xl 50 mg twice daily 

T. Telma H once daily morning 

T. Prazopress XL 2.5mg night. 

Currently not taking Lantus since 1 week to 10 days

[11:39 am, 13/03/2026] PPM 3: @PA  inka me patient emina vadthunnara..?

[11:40 am, 13/03/2026] PPM 2: Thanks. Isn't she type 1? Why not taking insulin?

[1:57 pm, 13/03/2026] PPM 3: Yes she was earlier on insulin actrapid and Lantus. 

She developed giddiness and weakness (her sugars at event was 302) 

Physcian near her village advised to stop insulin and started on OHAs. 

@PA me patient insulin enduku stop chesaru..?

[2:11 pm, 13/03/2026] PPM 2: Her not having a DKA (I presume) and having poor diabetes should make us consider non Type 1 causes. Particularly FCPD induced Type 3C and Type 5 are first contenders.

[2:12 pm, 13/03/2026] PPM 2: @PA @PPM3 please ask them to share AP and lateral views of the patient habitus, without identifiers obviously

@PaJR Health can you help translate the message to telugu

[2:12 pm, 13/03/2026] PaJR Health: *TELUGU TRANSLATION*

దయచేసి రోగి యొక్క శరీరాకృతి (habitus) కనిపించేలా ముందు నుండి (AP view) మరియు పక్క నుండి (Lateral view) తీసిన ఫోటోలను పంపండి. ఫోటోలలో రోగి ముఖం లేదా ఇతర గుర్తింపు వివరాలు (identifiers) లేకుండా జాగ్రత్త వహించండి.

*CLINICAL NOTE*

The absence of DKA despite poor glycemic control suggests we should investigate non-Type 1 etiologies. Fibrocalculous Pancreatic Diabetes (FCPD) leading to Type 3c or Type 5 diabetes are primary considerations. The habitus views will help assess for clinical markers of these conditions.

[2:15 pm, 13/03/2026] PPM 2:  Which chronic pancreatitis etiologies first present with endocrine abnormalities over exocrine abnormalities?

[2:15 pm, 13/03/2026] PaJR Health: *ETIOLOGICAL DIFFERENTIATION*

While exocrine insufficiency (steatorrhea, malabsorption) typically precedes endocrine dysfunction in most forms of chronic pancreatitis (CP), specific etiologies can present with diabetes as the sentinel or dominant feature:

1. *Fibrocalculous Pancreatic Diabetes (FCPD):* 

   - A unique form of tropical CP where *diabetes (endocrine)* is often the presenting symptom, frequently occurring in young, lean individuals. 

   - Unlike alcoholic CP, exocrine symptoms like steatorrhea are often mild or clinically silent initially, despite extensive pancreatic calcification.

2. *Type 3c Diabetes (Pancreatogenic):* 

   - In cases of *Early-stage Chronic Pancreatitis* or *Autoimmune Pancreatitis (AIP)*, glucose intolerance can manifest before overt exocrine failure. AIP, in particular, may present with sudden-onset diabetes or obstructive jaundice rather than malabsorption.

3. *Genetic/Hereditary Pancreatitis (PRSS1, SPINK1):* 

   - While these usually present with recurrent acute pain, the progression to endocrine failure can sometimes outpace clinically apparent exocrine insufficiency, depending on the specific mutation and environmental triggers.

4. *Idiopathic Senile Chronic Pancreatitis:* 

   - In elderly patients, "painless" pancreatitis may present primarily with new-onset diabetes due to progressive atrophy and fibrosis, with exocrine symptoms being less prominent.

*CLINICAL NOTE*

In the current patient (30F, lean, poorly controlled sugars >400 mg/dL, history of "weak pulse" and giddiness), the presentation of severe diabetes without a history of chronic diarrhea or steatorrhea strongly points toward *FCPD* or *Type 3c diabetes*. The requested AP/Lateral habitus photos are critical to look for the "lean" phenotype and abdominal distension typical of FCPD.

[2:26 pm, 13/03/2026] PPM 3: She has urine ketones 1 positive. 

Added Lantus yesterday again 

Added PaJR yesterday to track her.

[2:54 pm, 13/03/2026] PPM 1: We need to know her four point (at least) sugars with or without insulin

[2:57 pm, 13/03/2026] PPM 2: Wouldn't really consider that as significant here

[3:39 pm, 13/03/2026] PPM 2: Do you have a ketone meter at the place you work? If yes can check

[6:06 pm, 13/03/2026] PPM 3: Yes but patient has to travel 60 kms. This ketones was done 2 days earlier

[6:06 pm, 13/03/2026] PPM 3: I can ask her to get urine ketones done near her home.

[6:49 pm, 13/03/2026] PPM 2: Not needed. Body morphology more important

[6:49 pm, 13/03/2026] PPM 2: History of weight loss? Osmotic symptoms?

[8:08 pm, 13/03/2026] PPM 3: History of weight loss? Osmotic symptoms?

@PA me patient weight loss emina iyyara..?

[10:06 am, 14/03/2026] PPM 3: @PA  me patient ela unnaru..?

[12:24 pm, 14/03/2026] PPM 1: @PA Meru me patient gurinchi ilkada cheppandi 

me patient ki eppati nundi em problem undi, anni oka serial events laga cheppandi.

Didn't realise this but as per new DPDP rules we gather this DPDP compliant signed informed consent before we can even create a PaJR group for any patient.

Please ask them to take the next step ASAP 👇

: తదుపరి దశ, ఈ ఫారమ్‌ను డౌన్‌లోడ్ చేసి:https://userdrivenhealthcare.blogspot.com/2025/11/pajr-telugu-consent-form-dpdp-compliant.html?m=1, దానిని చదివి, సంతకం చేయండి.

ఫారమ్‌లో ఈ క్రింది వివరాలను పూరించండి:

వయస్సు

లింగం

పూర్తి చిరునామా

సమస్య యొక్క సంక్షిప్త వివరణ

ఈ రోజు తేదీ

వాట్సాప్ (WhatsApp) మొబైల్ నంబర్

సంతకం చేసే వ్యక్తి అన్ని పేరాగ్రాఫ్‌లను చదివారని ధృవీకరిస్తూ అన్ని బాక్సులపై టిక్ (Tick) చేయండి.

ఆ తర్వాత, ఫారమ్‌ను స్కాన్ చేసి మా టీమ్ కోఆర్డినేటర్ మరియు ఆర్కైవిస్ట్  గారికి పంపండి.

అనంతరం, ఆమె రోగి కోసం ఒక PaJR గ్రూప్‌ను క్రియేట్ చేస్తారు. అప్పుడు రోగి సమస్యలకు సంబంధించి సాధ్యమైనంత ఉత్తమమైన సాక్ష్యాధారిత (evidence-based) పరిష్కారాన్ని కనుగొనడానికి మేము ఇతర బృంద సభ్యులతో చర్చలు ప్రారంభిస్తాము. అలాగే, రోగి యొక్క వ్యక్తిగత వివరాలను వెల్లడించకుండా (deidentified data), సమాచారాన్ని ఈ ఓపెన్ యాక్సెస్ కేస్ రిపోజిటరీలో భద్రపరుస్తాము:

 https://pajrcasereporter.blogspot.com/?m=1

గోప్యత కోసం ముఖ్య సూచనలు:

రోగి లేదా వారి బంధువులు తమ గుర్తింపును ఎవరికీ వెల్లడించవద్దని కోరడమైనది.

రోగి యొక్క గోప్యతను మరియు రహస్యాలను కాపాడటం కోసం, వారు కేవలం తమను తాము 'రోగి యొక్క ప్రతినిధి' (Patient’s Representative) గా మాత్రమే పరిచయం చేసుకోవాలని కోరండి.

Tadupari dasha, ee form-nu download chesi:

https://userdrivenhealthcare.blogspot.com/2025/11/pajr-telugu-consent-form-dpdp-compliant.html?m=1,danini chadivi, santakam cheyandi.

Form-lo ee krindi vivaralanu poorinchandi:

Vayassu (Age)

Lingam (Gender)

Poorti chirunama (Full address)

Samasya yokka sankshipta vivarana (Brief description of the problem)

Ee roju tedi (Today’s date)

WhatsApp mobile number

Santakam chese vyakti anni paragraph-lanu chadivayani dhruveekaristu anni box-lapai tick cheyandi.

Aa taruvata, form-nu scan chesi maa team coordinator mariyu archivist gariki pampandi.

Anantaram, aame rogi kosam oka PaJR group-nu create chestaru. Appudu rogi samasyalaku sambandhinchi sadhyamainanta uttamamaina sakshya-dharita (evidence-based) parishkaranni kanugonadaniki memu itara brunda sabhyulato charchalu prarambhistaamu. Alage, rogi yokka vyaktigata vivaralanu velladinchakunda (deidentified data), samacharanni ee open access case repository-lo bhadraparustamu: https://pajrcasereporter.blogspot.com/?m=1

Gopyata kosam mukhya suchanalu:

Rogi leda vaari bandhuvulu tama gurtimpunu evariki velladinchavaddani koradamainadi.

Rogi yokka gopyatanu mariyu rahasyalanu kapadatam kosam, vaaru kevalam tamanu taamu 'Rogi yokka pratinidhi' (Patient’s Representative) ga matrame parichayam chesukovalani korandi.

[9.59 am, 15/03/2026] PPM 3: Gud mrng sir today fasting sugar120 bp112/70 pulse 77 sir

[12.52 pm, 15/03/2026] PPM 1: And post prandial after breakfast, after lunch, after dinner with what dose of medications would be very useful to know

70M DIABETES MELLITUS, Recent GIDDINESS, Cerebellar Ataxia Telangana PaJR

 

12-03-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[12.53 pm, 12/03/2026] PA: 

                                         

                                       
[1.22 pm, 12/03/2026] PPM 1: @PA  idi mundu glimiperide 1 mg teeskuntunnara?

[4.41 pm, 12/03/2026] PA: Post Lunch Sugar Result Timing 4:10 pm

[8:32 am, 13/03/2026] PPM 1: I'm guessing he's only on glimiperide 1 mg and metformin but still need to confirm how many times in a day

[8:33 am, 13/03/2026] PPM 1: The fasting suggests he may be taking glimiperide 1mg at night as well.

I wonder how he was surviving on all these medications along with 20U of soluble insulin twice a day as he had supposedly claimed in the OPD!

[8:37 am, 13/03/2026] PPM 1: 

Apparently he had been adviced by our PG's to stop the tablets and continue soluble insulin alone 6 months back when he was admitted.

@CR we need to ask the patient advocate to pm us the discharge summary which we can convert to text and share in his case report using LLMs

[8:41 am, 13/03/2026] PPM 1: Clearly he hasn't grasped the import of data deidentification!

[8:42 am, 13/03/2026] PPM 1: He mistook the OPD ticket data to be a discharge summary?

[8:59 am, 13/03/2026] PPM 1: No but can the patient advocate ask our clerk to identify it by name from our computer. I shall pm you the clerk's number as he too does a lot of our work by retrieving the EMR summaries from the closed LAN, which we then deidentify

[9:00 am, 13/03/2026] CR: If okay I myself will talk to him.

[9:16 am, 13/03/2026] PPM 1: I'll inform our clerk about you and to expect your call. Sharing his number with you in pm

[9:40 am, 13/03/2026] CR: Currently they want to know the medication dosage as the patient has not taken any medicine for today.

[9:43 am, 13/03/2026] PPM 1: But he hasn't confirmed what medication dose he was taking before he got the blood sugar values done

[9:48 am, 13/03/2026] CR: He will update now.

[10:03 am, 13/03/2026] PA: Taking Early Morning 6:00AM without breakfast 👆

[10:06 am, 13/03/2026] PA: In the evening, take the same tablets at 6 pm before eating.

[10:09 am, 13/03/2026] PA: He takes this tablet at 8:30 pm around after dinner.

[10:15 am, 13/03/2026] PA: All these tablets were used on the day of the sugar test as prescribed by PPM1 sir

[10:20 am, 13/03/2026] PA: This Patient's Food Schedule

1.Early Morning at 6:00 am Bread &Milk (buffalo milk)

2.10:00 AM Sorghum hull (జొన్న గట్కా)

3.2:00 Pm Rice (Little bit)

4.7:00 Millet bread (జొన్న రొట్టె)

He used to take 20 mg insulin injection early in the morning and these three tablets twice daily at 6 Am And again at 6 pm.                                 He takes these two tablets at night at 8:30 pm after eating.      

 

[10:34 am, 13/03/2026] PPM 1: So he needs to continue on glimiperide 1mg twice daily before meals and tablet metformin thrice daily after meals as this is providing fair control without insulin and we can repeat the four point sugar profile after one week to decide if we need to change the dose

[10:34 am, 13/03/2026] PA: This patient has been using the above two medications regularly for the past five months.

[10:37 am, 13/03/2026] PPM 1: Please share his serum creatinine done from the OPD two days back

[10:39 am, 13/03/2026] PaJR Health: ⚠️ *PRIVACY ALERT*

PIIs (Personally Identifiable Information) were detected in the image you just shared. To protect your privacy, this image file has been rejected and was NOT saved to our clinical database.

VIOLATIONS FOUND - FLAG_PII_VIOLATION Patient name visible on lab report.

🔹 *ACTION REQUIRED:* Please delete the image from this chat for your own safety and reshare a de-identified version (blur out names, faces, or IDs).

Thank you for helping us maintain your privacy.

[10:39 am, 13/03/2026] PaJR Health: ⚠️ *PRIVACY ALERT*

PIIs (Personally Identifiable Information) were detected in the image you just shared. To protect your privacy, this image file has been rejected and was NOT saved to our clinical database.

VIOLATIONS FOUND - FLAG_PII_VIOLATION Patient name, Barcode No, Visit ID, UHID, and Hospital/Clinic letterhead are visible.

🔹 *ACTION REQUIRED:* Please delete the image from this chat for your own safety and reshare a de-identified version (blur out names, faces, or IDs).

Thank you for helping us maintain your privacy.

[10:39 am, 13/03/2026] PaJR Health: ⚠️ *PRIVACY ALERT*

PIIs (Personally Identifiable Information) were detected in the image you just shared. To protect your privacy, this image file has been rejected and was NOT saved to our clinical database.

VIOLATIONS FOUND - FLAG_PII_VIOLATION Patient name visible on lab report (MrD SATHAIAH), Patient Barcode No (10122180), Patient Visit ID (KDL54940/OP), Patient UHID (20260313975).

🔹 *ACTION REQUIRED:* Please delete the image from this chat for your own safety and reshare a de-identified version (blur out names, faces, or IDs).

Thank you for helping us maintain your privacy.

[10:39 am, 13/03/2026] PaJR Health: ⚠️ *PRIVACY ALERT*

PIIs (Personally Identifiable Information) were detected in the image you just shared. To protect your privacy, this image file has been rejected and was NOT saved to our clinical database.

VIOLATIONS FOUND - FLAG_PII_VIOLATION - Patient name visible on lab report, Hospital/Clinic letterhead visible.

🔹 *ACTION REQUIRED:* Please delete the image from this chat for your own safety and reshare a de-identified version (blur out names, faces, or IDs).

Thank you for helping us maintain your privacy.

[11:19 am, 13/03/2026] PPM 1: Thanks. This is very suggestive of his cardiac problem

Please share a deidentified version of his chest X-ray

[11:19 am, 13/03/2026] PPM 1: His serum creatinine is 1.20 for the record before I delete with the identifiers

[11.54 pm, 13/03/2026] PaJR Health: ⚠️ *PRIVACY ALERT*

PIIs (Personally Identifiable Information) were detected in the image you just shared. To protect your privacy, this image file has been rejected and was NOT saved to our clinical database.

VIOLATIONS FOUND - FLAG_PII_VIOLATION: Patient name visible on medical scan.

🔹 *ACTION REQUIRED:* Please delete the image from this chat for your own safety and reshare a de-identified version (blur out names, faces, or IDs).

Thank you for helping us maintain your privacy.

[2.55 pm, 13/03/2026] PPM 1: 

20M Ankle TB residual pain WB PaJR

 UNDERSTANDING CASES IN GENERAL MEDICINE

Hi I am Riddhi Bhalla, a medical student in India. This blog is a collection of cases reviewed by me under the guidance of my seniors. This blog aims to elaborate on cases, their treatments and increase our understanding of patient care at the undergraduate level. Happy reading:)

September 09, 2022

20 YEAR OLD MALE WITH TUBERCULOSIS OSTEOMYELITIS

** This is an ongoing case. I am in the process of updating and editing this BLOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence-based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedback are most welcome through the comments box provided at the very end.

 I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE SHEET

Chief complaint: Pain in the right ankle causing difficulty in walking.

History of presenting illness:  Patient was apparently asymptomatic 8 months ago. 

8 months back he was working in the farm and suddenly started getting pain in the right ankle. 

Pain was of low intensity and subsided on taking painkillers. 

The pain was continuous and recurred everyday as the effect of the medication wore off. 

For 5 months patient would take a painkiller tablet everyday and pain would subside 

He went to an RMP where Xray and blood tests were done and everything was apparently normal. Patient continued taking painkillers. 

Gradually the pain increased and swelling with pus developed over dorsum of the right foot.                                                                                           

He then again visited a doctor, MRI was done which showed infection and lytic lesions. 

Patient got admitted on the 22nd of June 2022 for surgery (ANKLE ARTHROTOMY) under local anesthesia and pus was drained by excision. 

Upon removal of sutures after 2 weeks biopsy was done which was suggestive of bone tuberculosis. 

This was followed by an MRI which confirmed TB. 

Treatment for TB started on the 18th of July 2022.

Patient is on ATT regimen and is regular with medication

Now patient also complains of pain over the left hip and lower back on lifting leg while sitting and also on walking after a long time of rest. 

Previously, before the surgery patient's pain was over the swelling in dorsum and is now on over the lateral malleolus

History of past illness:  Not a known case if Diabetes, hypertension, epilepsy, asthma

Diagnosed with Bone TB after biopsy report following surgical drainage of pus. 

Drug history:   

8 months back when pain was of low intensity and subsided on taking medication patient was taking one painkiller tablet every day for 5 months

On first visit to RMP no other medication was given and patient continued use of painkillers

After surgery patient was prescribed the following medications, following which he reported swelling of the entire right lower limb:

1.Dalacin C

2. Limcee tab

3. Gemcal

4. Deksel nano syrup

Patient is currently on HRZE since 18th July 2022 and will commence HRE regimen from 13th September. 

Personal history:    

Mixed diet

Normal appetite

Bowel movement normal

Normal micturition

Patient does not report difficulty in sleeping

No addictions

Drug allergy? 

Family history:  No relevant family history

General examination:                                                    Pallor: present

                  

                                                                       Icterus: Absent
                                          

                                                                        Cyanosis: Absent

                                          

                                                                      Clubbing: Absent

     

Koilonychia: Absent

Lymphadenopathy: Absent

Edema: Absent

Vitals:

Temperature:  afebrile

Respiratory rate:  14cpm

Pulse: 82bpm

Blood pressure: 126/90 mm of Hg

CVS examination:  S1, S2 heard. No murmurs. 

Respiratory system examination: Trachea central, no vesicular breath sounds, no wheeze

CNS examination: 

Higher functions: Patient is conscious and coherent, well oriented to time, place and person. He is able to recollect past events in orderly fashion and doesn't show any deficits. 

Speech: Normal and coherent

Motor system examination: 

Attitude and position: Normal

Bulk: Right lower limb shows wasting over the calf. 

Tone: Normal

Power: 5

Reflexes: Normal

Gait: Limping due to pain in the right ankle

Demonstrated by the following videos:

Video 1

Video 2

Sensory System examination: 

Normal

Signs of meningeal irritation are absent. 

Cranial nerves: Intact and normal

IMAGING:

MRI: done previously before admitting into our ward

Before surgery:

                                      

                                                                    After surgery

                                       

XRAY on 9th September 2022:

                             

                                       
Biopsy reports:( before admission into our hospital done at time of removal of sutures post arthrotomy) 

Provisional Diagnosis:   

Tubercular Arthritis of right ankle with severe bony erosions of talus and navicular 

Biopsy suggestive of tubercular pathology

Treatment:

Day1

Referral to orthopedic

Treatment suggested:

1. Continue ATT

2. Tab Hifenac BD

3. Tab Pantop 40 mg OF

4. Tab Benadone Forte 20mg OD

Updated on 13/9:

1. Ultracet 1/2 tab Qid for 3 days

2. Naproxicin 1 Tab OD for 3 days a week

3. Continue ATT regimen and Benadone Forte OD

             FOLLOW UP

April

Patient completed ATT regimen in early january and has tested negative for Tuberculosis twice, once in January and once in February. 

He complains of mild pain which is maximum on starting activity after a period of rest and reduces on continuing work but aggravates again on extensive labour. 

No tenderness or local rise of temperature is noted. 
16th April

                                                        

                                                    CASE DISCUSSION

Response time in tuberculous osteomyelitis patients in ATT regimen: 

Taken from the article: TUBERCULOUS OSTEOMYELITIS

RAJEEV VOHRA, HARINDER S. KANG, SAMEER DOGRA, RADHA R. SAGGAR, RAJAN SHARMA

From Mohan Dai Oswal Cancer Treatment and Research Foundation, Ludhiana, India

Relevant excerpt:  The mean follow-up was 41 months (13 to 96). All patients were relieved of pain within six months of the initiation of treatment and sinuses healed within 14 weeks. In 20 patients the ESR returned to normal within six months of the beginning of treatment. Demineralisation of the affected region persisted for a maximum of five months. During healing, we noticed increased radiodensity in all cases. By the end of treatment for nine months 23 patients had regained full range of painless movements of the adjacent joints; only two had slight limitation.

Sural nerve damage following arthrotomy

[7:51 pm, 11/03/2026] PPM 1: Today's update from the patient advocate after one and a half years!

[11/03, 18:40] 20M Patient Advocate Ankle Tuberculosis Pain: unar paye baatha  hoy sokale gum theke otar pr , kichukhon hata hati korle abar thik hoy, ar kichukhon rest korar por uthleo baatha kore

[11/03, 18:42] 20M Patient Advocate Ankle Tuberculosis Pain: Ai baathata prothom theke uni bhebechilen thik hoye jabe kintu aekhono aeki  rokom

[11/03, 18:42] 20M Patient Advocate Ankle Tuberculosis Pain: 

Etar jono ki kono medicine nite hbe , na jete hobe?

[11/03, 18:43] 20M Patient Advocate Ankle Tuberculosis Pain: Please reply 

@PaJR Health can you go through his case report in the link below and share your insights and further plan for his current pain?

https://riddhibhalla25.blogspot.com/2022/09/20-year-old-male-with-ankle-pain-and.html

[7:51 pm, 11/03/2026] PaJR Health: *CLINICAL REVIEW: CHRONIC ANKLE PAIN POST-TUBERCULOUS OSTEOMYELITIS*

Based on the historical record and the current update, here is the clinical analysis of the patient's persistent symptoms.

*PATIENT STATUS SUMMARY*

🔹 *Diagnosis:* Tuberculous Osteomyelitis (Right Ankle) with severe bony erosions (Talus/Navicular).

🔹 *Treatment History:* Completed ATT (Anti-Tubercular Treatment) in January 2023; tested negative twice.

🔹 *Current Complaint:* Pain upon waking or after rest (first-step pain), which improves with movement but recurs after rest.

*CLINICAL INSIGHTS*

1. *Mechanical vs. Inflammatory Pain:* The description of pain being worst after rest (morning stiffness) that improves with walking is characteristic of "start-up pain." In a post-TB ankle with known bony erosions of the talus and navicular, this is highly suggestive of *Secondary Osteoarthritis* or joint stiffness due to previous structural damage, rather than active infection.

2. *Structural Damage:* The 2022 MRI and X-rays confirmed significant bony destruction. Even with the infection cleared, the joint surface is no longer smooth, leading to mechanical pain.

3. *Sural Nerve Involvement:* The record previously noted potential sural nerve damage post-arthrotomy, which can contribute to chronic regional pain or altered sensation.

*RECOMMENDED ACTION PLAN*

1. *Imaging:* A new X-ray (Weight-bearing AP/Lateral) of the right ankle is necessary to assess the current state of joint space narrowing and bone healing/remodeling since 2023.

2. *Inflammatory Markers:* Check ESR and CRP to definitively rule out a late recurrence, though unlikely given previous negative tests.

3. *Physical Therapy:* Focus on gentle range-of-motion exercises and calf stretching to reduce "start-up" stiffness.

4. *Footwear:* Use of medial arch supports or cushioned footwear may reduce the load on the eroded navicular/talus bones.

💡 *CLINICAL NOTE*

The patient's symptoms (pain after rest improving with activity) are classic for post-infectious joint degeneration. If the pain becomes constant or local swelling/warmth returns, urgent re-evaluation for recurrence is mandatory.

📋 *Case Record:* [20 year old male with Tuberculous Osteomyelitis](https://riddhibhalla25.blogspot.com/2022/09/20-year-old-male-with-ankle-pain-and.html)

[7:54 pm, 11/03/2026] PPM 1: Please share a Bengali translation for the benefit of our patient advocate 

[8:47 pm, 11/03/2026] PPM 1: Please translate this to Bengali

[8:47 pm, 11/03/2026] PaJR Health: *ক্লিনিক্যাল রিভিউ: টিবি পরবর্তী গোড়ালির দীর্ঘস্থায়ী ব্যথা (CHRONIC ANKLE PAIN)*

পুরানো রেকর্ড এবং বর্তমান আপডেটের ভিত্তিতে রোগীর বর্তমান সমস্যার ক্লিনিক্যাল বিশ্লেষণ নিচে দেওয়া হলো:

*রোগীর বর্তমান অবস্থার সারসংক্ষেপ*

🔹 *রোগ নির্ণয়:* ডান গোড়ালির হাড়ের টিবি (Tuberculous Osteomyelitis) এবং তালুস/নাভিকুলার হাড়ের ক্ষয়।

🔹 *চিকিৎসার ইতিহাস:* জানুয়ারি ২০২৩-এ টিবির পূর্ণাঙ্গ কোর্স (ATT) শেষ হয়েছে; দুইবার পরীক্ষার ফলাফল নেগেটিভ এসেছে।

🔹 *বর্তমান সমস্যা:* ঘুম থেকে ওঠার পর বা বিশ্রামের পর ব্যথা (প্রথম পদক্ষেপ নিতে কষ্ট), যা হাঁটাচলা করলে কমে কিন্তু আবার বিশ্রাম নিলে ফিরে আসে।

*ক্লিনিক্যাল পর্যবেক্ষণ (CLINICAL INSIGHTS)*

১. *যান্ত্রিক বনাম প্রদাহজনিত ব্যথা:* বিশ্রামের পর ব্যথা বেশি হওয়া (সকালের জড়তা) যা হাঁটলে কমে, একে "স্টার্ট-আপ পেইন" বলা হয়। হাড়ের ক্ষয়ের ইতিহাস থাকলে এটি সক্রিয় ইনফেকশনের চেয়ে *সেকেন্ডারি অস্টিওআর্থ্রাইটিস* বা হাড়ের কাঠামোগত ক্ষতির কারণে হওয়া জয়েন্টের জড়তার লক্ষণ হওয়ার সম্ভাবনা বেশি।

২. *হাড়ের কাঠামোগত ক্ষতি:* ২০২২ সালের এমআরআই এবং এক্স-রে অনুযায়ী হাড়ের উল্লেখযোগ্য ক্ষতি হয়েছিল। ইনফেকশন সেরে গেলেও হাড়ের উপরিভাগ মসৃণ না থাকায় চলাফেরার সময় যান্ত্রিক ঘর্ষণে ব্যথা হতে পারে।

৩. *স্নায়ুর সমস্যা:* আগের রেকর্ডে অস্ত্রোপচারের পর সুরাল নার্ভ (Sural Nerve) ক্ষতিগ্রস্ত হওয়ার সম্ভাবনা উল্লেখ ছিল, যা দীর্ঘস্থায়ী ব্যথা বা অনুভূতির পরিবর্তনের কারণ হতে পারে।

*প্রস্তাবিত কর্মপরিকল্পনা*

১. *ইমেজিং:* ২০২৩ সালের পর হাড়ের বর্তমান অবস্থা এবং হাড়ের জোড়ার ফাঁকা অংশ (joint space) দেখার জন্য ডান গোড়ালির একটি নতুন এক্স-রে (Weight-bearing AP/Lateral) করা প্রয়োজন।

২. *রক্ত পরীক্ষা:* ইনফেকশন আবার ফিরে আসার কোনো সম্ভাবনা আছে কি না তা নিশ্চিত করতে ESR এবং CRP পরীক্ষা করা যেতে পারে (যদিও আগের রিপোর্ট নেগেটিভ থাকায় এর সম্ভাবনা কম)।

৩. *ফিজিওথেরাপি:* গোড়ালির জড়তা কমাতে হালকা ব্যায়াম এবং কাফ মাসল (calf muscle) স্ট্রেচিংয়ের ওপর জোর দিতে হবে।

৪. *জুতো:* হাড়ের ওপর চাপ কমাতে নরম কুশনযুক্ত জুতো বা আর্চ সাপোর্ট ব্যবহার করা যেতে পারে।

💡 *ক্লিনিক্যাল নোট*

বিশ্রামের পর ব্যথা হওয়া এবং চলাফেরায় তা কমে যাওয়া—এটি জয়েন্টের ক্ষয়জনিত সমস্যার একটি সাধারণ লক্ষণ। তবে যদি ব্যথা ক্রমাগত বাড়তে থাকে বা গোড়ালি ফুলে গরম হয়ে যায়, তবে দ্রুত ডাক্তার দেখিয়ে পুনরায় পরীক্ষা করা জরুরি।

📋 *কেস রেকর্ড:* [20 year old male with Tuberculous Osteomyelitis](https://riddhibhalla25.blogspot.com/2022/09/20-year-old-male-with-ankle-pain-and.html)                          

[9:04 pm, 11/03/2026] PA: সমস্যা শুধু সকালে উঠে ব্যাথা করে আর হাঁটাচলা করলে ঠিক হয়ে যায়, এক ঘন্টা বসে থাকা বা রেপ করার পর ব্যাথা করে আবার হাঁটাচলা করতে করতে ঠিক হয় .

[9:20 pm, 11/03/2026] PPM 1: Ligament er byatha. Bhoyer kichu nei

24M Right Hemiparesis and hemiatrophy 23 yrs (1yr age) SEIZURES 10yrs Telangana PaJR

 

11-03-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[4.19 pm, 07/03/2026] PPM 1: History shared by @PPM3 on 24/2/26

24 years old male pt 

2nd child of non consanguious marriage spontaneous conception 

with normal vaginal delivery 

with nill peri natal events 

had fever at 1 year of age for that they went to local hospital and treated with intravenous injections/ fluids to Right upper arm 

after that rt upper limb developed weakness which is insidious in onset gradually progressive (some local dr told it as polio) 

initially he able to do some work with it like eating food combing till the age of 10 yrs. 

At the age of 10 yrs he had generalised tonic clonic seizures with uprolling of eyeballs deviation of mouth 

frothing from mouth and irrelevant talk. 

seizures lasting for 5 to 10 mins resolves spontaneously 

pt is advised Valproate 300 mg once daily

pt is continuously having seizures with that once in 2 to 3 days 

last episode last night.

[4.22 pm, 07/03/2026] PPM 1: He signed the consent form with his left hand

                                                

75M Severe Hyponatremia Telangana PaJR

 

09-03-2026

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[8.42 pm, 09/03/2026] PPM 1: @PPM3 can you share this patient's history?

I vaguely recall he had many episodes of vomiting just before the day he was brought to hospital for ? Vomiting? 

And then we simply got fascinated by his Hyponatremia post admission as documented here: https://medicinedepartment.blogspot.com/2026/03/hyponatremia-projr-march-2026-afternoon.html?m=1

Discussion around this patient's Hyponatremia data available in the above link. 👆

And here: https://pajrcasereporter.blogspot.com/2026/03/hyponatremia-projr.html?m=1
[8.46 pm, 09/03/2026] PPM 1: Looks like there may have been some altered sensorium following the vomiting that necessitated his admission before we found the sodium to be 108!

[8.54 pm, 09/03/2026] PPM 1: There's a lot of fluid in his left suprapatellar bursa that may need tapping although it's likely OA with hypervolemia.

Currently patient appears to be hypervolemic SIADH as per his urinary sodium calculations (are they valid, did the local team use 24 hour Urinary sodium) or was he having hypovolemic Hyponatremia

[3.44 pm, 11/03/2026] PPM 1: Update:

Was discharged today.

Reviewing the events from the file                                                    Ward notes

                                       
                                                                   The labs

                                      
[3.52 pm, 11/03/2026] PPM 1: I needed to get his detailed history of the left synovitis event @PPM3 @PPM4
[11.41 am, 16/03/2026] PPM 1: Reviewing him right now in OPD

[1:16 pm, 16/03/2026] PPM 1: @PaJR Health now on reviewing the history it appears that he's been having gradual weight loss and cachexia since 2 months before he presented to us with tachypnoea and then we found the Hyponatremia of 108 and his left knee arthritis.

Do you think this could all fit into a para neoplastic syndrome after going through his case report here: https://pajrcasereporter.blogspot.com/2026/03/75m-severe-hyponatremia-telangana-pajr.html?m=1

[1:16 pm, 16/03/2026] PaJR Health: The constellation of *gradual weight loss, **cachexia, **severe hyponatremia (108 mEq/L), and **joint involvement* (synovitis/arthritis) in a 75-year-old male is highly suspicious for a paraneoplastic process.

*CLINICAL CORRELATION*

1. *SIADH & Malignancy:* The patient's labs (Serum Osmolality 221.7, Urine Osmolality 449.4, and high Urine Na+ 195 mEq/L) are classic for SIADH. In a patient with significant weight loss and tachypnea, Small Cell Lung Cancer (SCLC) is the primary suspect, as it is the most common cause of paraneoplastic SIADH.

2. *Cachexia & Weight Loss:* Two months of progressive wasting prior to the acute presentation of hyponatremia suggests a chronic underlying systemic disease, often seen in advanced solid tumors.

3. *Paraneoplastic Arthritis:* While the record mentions "Septic Arthritis" and "Baker's Cyst," if the synovial fluid culture was negative or the "Chronic Granulomatous Infection" remains unconfirmed, consider *Paraneoplastic Polyarthritis* or *Hypertrophic Osteoarthropathy (HOA)*. HOA is specifically associated with lung adenocarcinoma and presents with joint pain and swelling.

4. *Tachypnea:* This could represent the primary site (lung mass/pleural effusion) or a secondary complication like lymphangitic carcinomatosis.

*📋 CASE RECORDS*

1. [75M Severe Hyponatremia Telangana PaJR] (https://pajrcasereporter.blogspot.com/2026/03/75m-severe-hyponatremia-telangana-pajr.html?m=1)

*💡 CLINICAL NOTE*

The "diffuse hyperpigmentation" noted in the physical exam logs is a critical finding. While it can occur in chronic illness, it also raises the possibility of paraneoplastic *ACTH secretion* (Cushing's Syndrome), which can cause both hyperpigmentation and profound electrolyte disturbances, though usually hypokalemia rather than hyponatremia.

*NEXT STEPS*

*   *Imaging:* Urgent HRCT Chest (as previously ordered) to look for a primary lung lesion or hilar lymphadenopathy.

*   *Biopsy:* If the "Chronic Granulomatous Infection" in the knee was based on histology, it could mimic or coexist with malignancy (e.g., TB in an immunocompromised cancer state).

*   *Tumor Markers:* Consider CEA, NSE, or LDH depending on imaging findings.

[1:28 pm, 16/03/2026] PPM 2: Has he been taking steroids for his knee pain sir?