This is an Online E Log Book to discuss our patient's de-identified health data shard 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.
This is the case of a 44yr old female patient from West Bengal who 4 - 5 yrs back initially had problem with her wisdom teeth and when she consulted a dentist she was treated with proper medication. Later she had infection in the treated area of the wisdom teeth with some particles stuck in between the teeth and had itching and was prescribed antibiotics.
When she was on medication of antibiotics regularly she experienced fatigue and weakness. She was advised to check her diabetes and was found to be diabetic with PP 202mg/dl. The patient was given medication for controlling sugar levels and was advised to recheck her sugar values which came down to 174mg/dl. She also suffered with cramps in the abdomen.
Since August 2024 she lost apetite and experienced weakness. She couldn't eat much and whatever little food she consumed, she was full. Slowly her health deteriorated and she experienced sour taste in the mouth. With medication and normal reports the patient still had no apetite. In October her spo2 was 72 and was done angiography. Her heart rate was more. Had problem in the gall bladder too. Since one month she is having temperature of 99-100 for every 2 to 3 days. Within last 2 months she lost 10kgs of weight.
Severe intermittent right hypochondrial pain since August 2024 every day.
Hospitalized once and also found to have intermittent hypoxia on SpO2 monitor and later developed intermittent palpitations along with hypoxia
Attached HIDA scan and all other numerous ultrasound abdomens and CT angiographies within normal limits.
Murphy's sign positive with a distinct catch in the patient's breath during deep inspiration.
Also diabetic since 5 years. On glimiperide 1 mg before breakfast and metformin 850mg after dinner.
When she was admitted in some nursing home in West Bengal she was prescribed with the following medicines.
Ondam.
PA - I am from West Bengal waiting for your answer Sir..What should I do pl tell me .Gateman told me to inform you.
Waiting at OPD hall.
PPM 1 - Come to room 78.
PA - Yes sir.
PPM 1 - @PPM 4 discussed with Prof Sir and adviced for CT abdomen tomorrow morning. Please prepare the patient accordingly and share his consultation notes here.
PPM 1 - She will need oral contrast to look for gastric and duodenal diverticulum.
PPM 1 - Discuss with the radiology and surgery teams.
Share the deidentified surgery notes here.
Deidentified CT abdomen images if they are done.
PPM 3 - Cect Abdomen Done sir. Will share.
PA - Pl tell me, after taking contrast liquid starting loose motion nd nausea and feeling very weak ...can the patient take any biscuit this time? With dry mouth and feeling tasteless.
@PPM3 please check her blood sugar and let me know.
Oral contrast with mannitol was given and then ct done sir.
Radiology hod sir said there is no need for iv contrast and it seems to be normal and
This has been discussed with brig sir also sir.
PPM 3 - The patient is in her room.
PPM 3 - Yes sir. She also wants to meet you. Will bring her to ICU
Today's CT abdomen. Gall bladder looks alright while the pancreas looks mildly bulky but likely normal.
Normal gall bladder. Slightly bulky pancreas. @PPM3 please check if any serum lipase or amylase done earlier.
PPM 1 - Let's get her 2 hour post prandial blood sugars after every meal.
And serum amylase and lipase.
PPM 3 - Will check sir.
PPM 1 - @PPM5 I had to delete the reports you shared to protect the patient's privacy as the patient identifiers were visible there
PA -
PPM 1 - 👍
PA - Both menus r alright?
PPM 1 - Yes
PA - After taking little amount of nuts and sprouts the patient is feeling abdomen cramp and indigestion..why?
PPM 1 - It's image wasn't shared?
You mean your patient is feeling abdominal cramps after she took nuts and sprouts?
PA - Yes after taking nuts and sprouts the patient is feeling abdominal cramps.
Should the patient skip eating nuts and sprouts? She is totally vegetarian that's why she want to know that.
Pl give the patient a diet chart according to her diagnosis for breakfast, lunch and dinner separately.
PPM 1 - Ask your patient to share the image of all her food plates before she takes
What time did she take the nuts and sprouts?
PA - In the morning.
This is the diet plan👆
PPM 1 - Time?
PA - 8.30am. Alternate of biscuits.
PPM 1 - 👍
Since what time did she start getting the symptoms?
PA - After 30 mints starts pain and feeling fullness of belly.
PPM 1- The rice plate was eaten at 11.30am? By that time the 9 am pain had subsided?
PA - No it was 11 am for lunch.
PPM 1 - Is this the first time noted in your patient?
Please don't make your patient identifiable.
PA - Our patient completed her dinner at 7 pm
PPM 1 - 👍The proportion of grains is more than fruits and vegetables in this plate?
PA - Little amount of peas, carrot and tomato are there than rice and pulses.
PPM 1 - 👍
Yes that amount needs to be equal to the proportion of cereals and pulses in the plate.
PA - Okay.
05-01-202
PA - Lunch at 11 am.
PA - Our patient took puffed rice with boiled carrot and chole..
PPM 1 - 👍
PA - Dinner at 8.38pm.
PPM 1 - 👍
06-01-2025
PPM 1 - 👍
PA - Vegetable curry, Roti, Salad and Guava for breakfast.
PPM 1 - 👍
Pulses or any other protein?
PA - Oh,no sir patient didn't take it today.
07-01-2025
PA - Morning tea with sprouts.
PA - Patient took lunch at 10.30 am with boiled rice, masoor dal, mixed veggies...
PPM 1 - 👍
PA - Since 2 days feeling both side upper abdomen pain after taking food and moving. Pain stays for a long time. Please advise which can help reduce pain or discomfort.
PPM 1 - Please mention the exact time patient felt the pain and how long did it last.
PA - The patient is feeling the pain after taking food. It starts after 15-20 minutes and continues for about 3 hrs minimum.
The patient doesn't feel pain on empty stomach.
PPM 1 - This indicates the intestinal movement after food is taking time around three hours to move because the current in the intestinal circuit is not flowing properly
The only solution to this is to take smaller amounts every time and maintain the time of intake.
PA - The patient had dinner Daliya kichidi by 7.10pm.
08-01-2025
PA - Good morning. Tea and soaked kabuli chana at 8.30am.
PPM 1 - Are we sure that the proportion of lentils and Dalia (broken wheat) are in a proportion of 25+25 and the fruits and vegetables are 25+25 in this plate?
PA - Yes, we sure that Lentils, Dalia and vegetables are in equal quantity but there are no fruits.
Can the patients take fruits at night?
PPM 1 - Can mix dry fruits in the mix.
PA - Ok
In the day time fresh fruit and at night mix fruit . right?
PPM 1 - Can.
PA - Lunch at 11.15am
PA -At 2.30 pm the patient took methi roti with mixed veg salad.
Fried Rice of Brown Rice for dinner at 8.30pm.
PPM 1 - 👍
09-01-2025
PA - The patient took lunch with Brown Rice, daal and salad at 10.30 am.
PA - At 14.18 the patient had roti, curry and salad.
At 19.16pm the patient took roti, mixed vegetable, dal and roasted papad for dinner.
10-01-2025
PA - Morning tea with chia seeds and roasted chana.
PPM 1 - 👍
What were her activities yesterday and what time did she experience the pain?
PA - At 11am the patient had rice, dal, and vegetable curries.
PA - The patient had Oats dosa and vegetables curd chutney. at 14.50hrs
PPM 1 - 👍
PA - Today our patient takes only half cup veg soup in dinner. After taking breakfast she feels very uneasiness in abdomen, vomiting tendency, acidity and indigestion. she also wants to know that can take Dompan or any others?
PPM 1 - Better to take a walk for the abdominal uneasiness.
PA - Okay.
11-01-2025
PA - The patient had a cup of tea and roasted chana in the morning.
She had cucumber for breakfast. At 11am she had lunch with rice dal and veg curry.
PPM 1 -👍
PA - At 3 pm the patient had roti and veg curry.
At 7.54pm dinner with rice and dal.
PPM 1 - 👍
12-01-2025
PA - At 10.42, The patient had Kichidi for lunch. Since yesterday evening she suffered with vomitings even after dinner.
PPM 1 - How's she feeling now?
PPM 1 - 👍
PA - Dinner.
13-01-2025
PPM 1 - Thanks
Better to share the entire plate image for us to estimate the quantity
Also can keep a small plastic scale nearby while taking the image as that will also help us to guage the quantity.
PA - Morning tea with ragi and oats biscuit (without maida and sugar)
PPM 1 - 👍
PPM 1 - Home made ragi biscuit?
Ragi biscuits available in shops are largely maida.
PA - No .sir. This is purely homemade made by the patient and followed by dr.'s advice. There is no maida and atta, sugar.
PPM 1 - 👏👏
If only home made food could be sold but that's just not possible. Every home has to prepare their own home made food and the homes with the healthiest food have the best outcomes.
PPM 1 - 👍.
PA - At 3 pm 2 chapathis and orange.
PPM 1 - What are the components in this chapati?
PA - Ragi flour, oats and little bit salt.
For dinner peas rice and salad.
PPM 1 - 👍
14-01-2025
PA - Morning tea with ragi biscuit.
PPM 1 - 👍
PA - Lunch at 2.14pm
PA - Rice dal and sabji for dinner. at 8 pm.
PPM 1 - 👍
15-01-2025
PA - At 7 am the patient had a cup of black tea and puffed rice.
At 11 am the patient had lunch with rice vegetable curry and soup.
PPM 1 - 👍
PA - At 2.35pm the patient had quinoa kichidi and roasted papad and apple.
Dinner with brown rice dal and sabji at 8.28pm.
PPM 1 - 👍
16-01-2025
PA - Lunch at 11.25pm with brown rice, sajina phool and dumur
At 3.15pm puffed rice bhel and chole.
PA - The patient had dinner at 6.30pm with rice and mixed veg curry.
PPM 1 - 👍
17-01-2025
PPM 1 - Other hourly activities and pain?
PA - Lunch at 10.21 am with rice and vegetable curry.
PPM 1 - 👍.
PA - At 3.38pm the patient had dosa, chutney and an apple.
PA - The patient had dinner with rice, oats, dosa and soup.
PPM 1 - 👍
This Sunday we will look forward to this patient's fasting and post two hour sugars after every meal.
Also her hourly BP for ten readings on the same day.
PA - Pl tell me how it is possible?
PPM 1- The same way as it was shown while this patient was admitted with us in the ward.
18-01-2025
PA - Morning Tea with Hazel nut at 7.18am
At 10.51am lunch with rice, vegetables and dal.
PPM 1 - 👍
PA - At 7.41pm Kichidi and veg curry.
PPM 1 - 👍
Tomorrow sugar and BP review using home glucometer and Home electronic BP monitor:
Fasting
Two hours after breakfast
Two hours after lunch
Two hours after dinner
Mention timings along with timings of medicine taken with name and dose
BP readings randomly hourly covering the entire waking hours of the day.
19-01-2025
PA - 7 Am BP. _106/66.
Fasting _118.
PPM 1 - 👍
PA - 9Am _BP----157/89
Our patient took Glimiperide 1before lunch nd after 2 hours sugar level is 141 (PP).
BP 124/52. . Pulse 59
PA - The patient is feeling very weak and headache.
PA - At 2.50pm vegetables and puffed rice.
PPM 1 - What were her hourly activities till the headache started?
PA - Nothing different,as usual in normal daily routine.
PPM 1 - What time did the headache start and what was the patient doing at that time?
PA - After 12 pm starts headache,that time she was in the room and it continues...
PPM 1 - How long did it continue?
After tiffin break at 3 pm she took 1/2 tab metformin nd 2 hours sugar level is 130.
PPM 1 - 👍
PA - 8.45 pm BP___105/48
What should we do?
PPM 1- It's alright.
Is she taking the tablet bisoprolol half?
At 7.45 pm__105/60
Our patient completed her dinner veg rice with curry at 7.45 pm and took metformin 1/2 after dinner.
PPM 1 - 👍
PA - She feels very uneasiness, dizziness and eyes feeling dark..
That time Patient was ironing. In her room.
PPM 1 - For how long?
PA - The patient took metformin 1/2 tablet and in the morning took concor 2.5.
2 hours after dinner at 9.45pm sugar level is 142..
PPM 1 - Can also make the concor half from now on.
PA - At present she feels very dizziness and... headache
Continuously feels from starting...
PPM 1 - Started when?
PA - After 2pm ...
20-01-2025
PA - At 7am black tea with hazlenut. BP is 101/59. The patient is experiencing dizziness and headache since yesterday.
PPM 1 - For dizziness she can take tablet phenargan 25 mg every 8 hours and for the headache she can take paracetamol 650 every 6 hours for 1 day depending on how her symptoms are relieved.
PA - At 3.25pm the patient had steamed dhokla made of rice, dal, coconut and Dhaniya paste.
PPM 1 - 👍
21-01-2025
PA - At 7.22am Black tea with roasted chana.
At tiffin break. 👇
Lunch 👇
Dinner 👇
PPM 1 - What are the ingredients in the chapati?
PA - Ragi atta, oats and isobgul.
PA - BP readings 117/76, PR89
109/66, PR 80
103/51, PR 84
103/40, PR 86
22-01-2025
PA At 7am tea with chana
PPM 1 - 👍
PA - Lunch at 11.05am. 👇
PA - At tiffin break.
PA - Pulka, mixed veg curry and cutlet for dinner at 21.21
23-01-2025
PA - Tea with roasted chana at 9 am
Millet roti, mixed veg curry and fruits. for breakfast.
Lunch with rice, dal, veg curries and papad.
Dinner at 7pm with rice and veg curry.
24-01-2025
PA Tea with boiled kabuli chana at 7.25am
At 10.30 rice with dal, mixed veg curry and chutney.
PPM 1 - 👍
PA - Dhaliya upma at 14.49
Dinner with roti and beatroot curry.
25-01-2025
PA - Lunch.
PPM 1 - 👍
PA - Breakfast.
PPM 1 - 👍
PA - Dinner
26-01-2025
PA - Today At 7 Am. Fasting -125
PPM 1 - 👍
PA - Breakfast 👆
Post breakfast sugar value is 77mg/dl.
PA - Lunch.
Post lunch sugar value is 148
PPM 1 - What medication and dose did she take before breakfast?
77mg/dl at what time?
PA - 2 hours after breakfast at 10.30am
PA - Before breakfast she took Glimiperide 1mg nd after breakfast she took metformin 500 of 1/2tab.
After 2 hours dinner taking metformin 200 (half tablet) sugar level 158mg/dl.
27-01-2025
PA - Tea at 8.11am
Lunch.
PA - At 3pm veg salad with roti.
PPM 1 - 👍
PA - At 18.55 dinner with rice and dal.
PPM 1 - 👍
28-01-2025
PA - tea with roasted chana at 7am.
PA - At 10.57am lunch with rice, dal, veg curry and chutney.
PA - At 13.14 ragi dosa with chutney and one orange.
The patient had dinner with rice and mixed veg curry at 19.58.
PPM 1 - 👍
29-01-2025
PA - Tea with puffed rice at 7.33am
Lunch with rice and veg curries at 10.09am
One roti, boiled peas and apple at 14.10.
At 19.56 dinner with brown rice, brinjal and mushroom veggies.
PPM 1- 👍
30-01-2025
PA - Morning tea with soaked chana.
Lunch with brown rice and veg curries at 10.30am.
Ragi and oats chilka with vegetables stuffing.
Dinner with rice and potato and mixed veg curry.
31-01-2025
PA - Tea with puffed rice at 10.16am.
At 11am rice with beatroot curry and dal.
PPM 1 - 👍
PA - The patient became unconscious for few seconds due to vertigo and experienced uneasiness, slight headache and weakness.
Now her BP is 169/99 at 14.42
What should we do?
PPM 1 - This was resolved in pm with further BP and other symptoms monitoring.
PA - Okay.
At 15.19 her BP is 112/72, PR 90
The patient had dinner with rice, mixed veg curry and sprouts.
01-02-2025
PA - The patient had lunch with rice, dal and mixed veg curry at 10.30am
Chana, peas and noodles and one orange at 14.55.
PPM 1 - 👍Hope she's feeling well today?
PA - Yes she is better but headache continuing.
PA - At 18.43 dinner with brown rice, brinjal curry and chutney.
PPM 1 - 👍
02-02-2025
PA - At 8am BP 85/59, PR 94. The patient is feeling very weak.
Fasting blood sugar 123.
Lunch with one roti, sweet potato curry.
PPM 1 - 👍
In such occasions it would be very important to also know the BP after 3 minutes of standing or immediately after standing or sitting.
Hope she's feeling better now?
PA - BP 114/67, PR 104 at 2pm.
PPM 1 - 👍
PA - After 3mints of standing BP was 80/50
Before breakfast she took Glimiperide 1mg nd after breakfast she took 1/2 tab of metformin 500 and after 2 hours of breakfast sugar level was 128.
PPM 1 - 👍
Sugars are very well controlled till after breakfast.
PA - Lunch at 3pm with rice raw banana curry, sprouts, and mixd vegetables.
2 hours after lunch the patient took 1/2tab of metformin 500 nd sugar level was 92.
PPM 1 - 👍
Patient took metformin immediately after lunch or two hours after lunch?
PA - After lunch.
After lunch the patient took 1/2 tab metformin nd then 2 hours after sugar level was 104.
PPM 1 - 👍
Her sugars are very well controlled.
03-02-2025
PA - "I can't understand one thing, the patient says that when riding in a car, auto, or bike, it feels like everything inside the stomach is shaking, and there's a feeling of dizziness. This didn't happen before, and even during yoga, there's a lot of pressure. Why is this happening?"
PPM 1 - How long?
PA - "My patient feels very weak, has no energy, and when the blood pressure is low, they notice their vision goes completely dark, and they feel dizzy. Why is this happening? And sometimes they mention feeling a lot of pressure in the chest."
"I didn't understand what you meant by 'how long.' Whenever there's jerking on the road, there's a feeling of dizziness."
PPM 1 - "Does it mean as long as the jerking happens?
PA - Yes.
PPM 1 - How far can the patient travel?
We always suggest that if it's a long distance, they should get off a few kilometers earlier and walk the rest to keep the body in good condition."
PA - Ragi roti and palak sabji at 11.08 am
At 15.28
04-02-2025
Lunch at 11am
At 15.54 above menu.
Dinner at 20.44
05-02-2025
PA - At 7.33am Tea with Boiled chana.
Lunch at 11am.
PA - At 15.57 mixed veggies with nuts and black tea.
Dinner at 22.16 with one roti and veg curries.
06-02-2025
PA - At 7.27am tea with chana.
Lunch at 11.30am rice with dal and veg curry.
At lunch Bowl of daal and bell.
PPM 1 - 👍
PA - Dinner at 20.56 with 1 roti and veg curry.
PPM 1 - 👍
07-02-2025
PA - Morning tea with roasted chola at 7.18am
At 10.30am Rice with dal, vegeteable curry and chutney.
At 14.02 roti with sabji
PA - Tomorrow the patient will get done tests for BP and sugar?
The patient had a fever again since yesterday, between 99.4 and 100, and there's a bit of discomfort in the stomach again."
Otherwise okay.
PPM 1 - Please check the temperature every four hours.
Yes check BP and sugar.
PA - Okay
PA - "The muscles in the hand are quite painful and stiff."
09-02-2025
PA - Fasting blood sugar 112mg/dl.
BP 116/78mmHG
Morning--Black tea and roasted chana at 7.32am
At 10.47am rice with mixed veg curry and soup.
PPM 1 - Has the stiffness improved with activity now?
PA - Slightly
Before lunch the patient took Glimiperide 1mg and after metformin 500mg 1/2tab.After 2 hours of lunch sugar level is 121mg/dl
PPM 1 - 👍
PA - The patient had Puffed rice and potato bajji at 15.16
In between 10.30 to 11am the patient has her lunch and has snacks at 3-4pm
PPM 1 - 👆Alright so we can call this tiffin
Breakfast is a term for the first food of the day.
PA - Okay.
After tiffin the patient took metformin 500mg of 1/2 tablet, then 2 hrs after tiffin the sugar level is 112mg/dl at 17.02.
PPM 1 - 👍
PA - At 19.33 the patient had rice and veg curries for dinner. Taken metformin 5oomg 1/2 tab and post dinner value is 90mg/dl.
PPM 1 - 👍
She can reduce her glimiperide to 0.5mg from tomorrow and repeat the sugars similarly next week or earlier.
PA - Can she takes Glimiperide 0.5mg before breakfast?
PPM 1 - Yes.
10-02-2025
PA - Morning Tea with roasted chola.
Meal at 10.48am with rice, dal and broccoli.
PPM 1 - 👍
PA - Before meal the patient took 0.5mg of glimiperide and 250mg of metformin.
Yes, is it ok or need to take full tab of Glimiperide?
PPM 1 - It's ok if your patient is taking glimiperide 0.5 mg before food and after that she is taking metformin 500 mg after food. Whether we need to increase or decrease the dose further will depend on her blood sugar values after two hours of taking the tablet.
PA - Okay
At 3pm the patient had millets kichidi and roasted papad.
At 18.57 rice with mixed veg curry.
PPM 1 - 👍
11-02-2025
PA - Morning tea with roasted chola
Lunch at 11.37 with rice, veg curries and soup.
PA - Morning tea with roasted chola.
The patient is feeling weak. BP 90/60
PPM 1 - BP different in lying down and then taken again after standing for three minutes?
PA - Yes. after standing for 3 minutes it was 92/58
PPM 1 - 👍
13-02-2025
PA - Morning black tea with puffed rice.
At 9am BP is 101/61, PR 80.
After 3 minutes standing the BP is 86/64, PR 73
The head is feeling very dizzy, and the eyes are going dark.
PPM 1 - The BP response doesn't suggest a vascular problem.
More likely to be a vestibular activation either due to an otolith or due to other x factors
The patient may take tablet Avomine (promethazine theoclate) 25 mg for her giddiness sos
PA - What is otolith or other X factor means?
For quite a few days, I've been having trouble seeing, and the area above the eyes towards the forehead feels heavy almost throughout the day. I don't know if the corneal problem has worsened.
PPM 1 - This needs a local evaluation by the local Ophthal
@Meta AI what is the role of otolith and other x factors in vertigo and giddiness? Also please translate the answer into Bengali other than your english response.
Meta AI
I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.
PA - When corneal dystrophy was first detected, I used to have similar problems. During the day, I had severe headaches and couldn't go outside.
PPM 1 - 👍
@Meta AI what is the role of otolith and other x factors in vertigo and giddiness?
Meta AI
Otoliths play a crucial role in maintaining balance and equilibrium in the body. They are small calcium carbonate crystals located in the otolith organs (utricle and saccule) of the inner ear. Here's how they contribute to balance and what happens when they're affected:
# Role of Otoliths
1. Gravity detection: Otoliths help detect linear acceleration and gravity, allowing the body to maintain its position in space.
2. Balance and equilibrium: They work with the semicircular canals to detect rotational movements and maintain balance.
3. Vestibular-ocular reflex: Otoliths help trigger the vestibular-ocular reflex, which stabilizes the eyes during head movements.
# X Factors Contributing to Vertigo and Giddiness
1. Benign Paroxysmal Positional Vertigo (BPPV): Misplaced otoliths in the semicircular canals can cause brief, intense episodes of vertigo.
2. Vestibular migraine: Abnormalities in the vestibular system, including otolith function, can contribute to migraines and vertigo.
3. Inner ear infections: Infections like labyrinthitis or vestibular neuritis can damage the otolith organs and lead to vertigo.
4. Head trauma: Trauma to the head can dislodge otoliths, leading to balance problems and vertigo.
5. Age-related degeneration: As people age, the otolith organs can degenerate, leading to balance problems and increased risk of falls.
6. Other medical conditions: Certain conditions, such as Meniere's disease, otosclerosis, and acoustic neuroma, can affect the otolith organs and contribute to vertigo.
In summary, otoliths play a vital role in maintaining balance and equilibrium. When they're affected by various factors, it can lead to vertigo and giddiness. If you're experiencing persistent or severe vertigo, it's essential to consult a healthcare professional for proper diagnosis and treatment.
PPM 1 - @PA please share all the documents regarding your patient's corneal dystrophy here after deidentification or if you are unable to deidentify share it with @CR and myself in pm ASAP.
I'm unable to find the Ophthal notes here👇
regarding their evaluation of her corneal dystrophy while the patient was admitted with us
@PA can you share more about when did this patient first develop her visual symptoms and when was she first diagnosed with corneal dystrophy?
PA - The patient was detected with corneal dystrophy in both eyes for first time in 2018.
PPM 1 - What was her symptoms at that time.
Please share the deidentified documents from LV prasad from 2018.
PA - At that time she faced many problems. In the morning she couldn't open her eyes and had severe pain while opening her eyes.
PPM 1 - Alright pain while opening her eyes in the morning.
How long did the pain last during the morning?
What happened next?
After how many days did she visit her doctor for the same problem?
PA - Whole day it was very painful and couldn't go out during day time.
She felt itching, redness and sensitive to lights.
It lasts till now even after PTK.
PPM 1 - 😮
Every day?
PA - After that she was advised by the doctor to do PTK and to continue with eye drops daily 4-6 times.
Yes, if it is sunny, was very difficult to go outside.
Eyes couldn't tolerate light.
So the patient used blue coating UV protecting, photo chrome glasses. Without that she couldn't open eyes even for a single moment.
Before operation vision was blurred. Had continuous headache.
Patient had roti with sabji at 14.52.
PPM 1 - Since when was her vision blurred?
PA - From 2017 end the patient had the vision problem.
Actually she didn't know about the blurred vision and thought it was due to diabetes.
PPM 1 - You mean she's experiencing blurred vision since 2017?
Can you share what were the day to day difficulties she was facing due to this blurred vision since then?
PA - Almost.
14-02-2025
PPM 1 - Please share her documents for us to evaluate her vision serially in a timeline.👍
PA - In 2016 Oct she lost her father and was totally depressed.
She faced lot of problems with burning sensation in her eyes at daytime and when outside she couldn't read the letters on the sign boards and had water in eyes.
She had anxiety disorder and couldn't identify people with blurred vision.
Her vision was so poor that she couldn't see the road properly and stumbled upon uneven roads. Even at home she couldn't climb the stairs. She always needed support.
She felt relief when it was dark in her room and spent most of her time with lights off.
She was sensitive, open minded and self dependent woman with her own business of designing and tailoring products. At that time she had to depend on others and felt depressed. She lost confidence and later in 2018 of October she got operated with PTK for her eyes.
PPM 1- Thanks very well described symptoms.
Please share the deidentified details of her first and subsequent Ophthal evaluations.
PA - Deidentified details means?
Since childhood she had dry eyes problem.
Headache, migraine and vomiting tendency also there.
PPM 1 - 👍
Old opthal reports or any other reports previously taken, removing the patient's name from the reports and sharing in the group.
PA - Will try.
She used eye drops since she was 16 yrs old.
Another important problem was she had blood hemorrhage in her eyes when she had high fever.
PPM 1 - When was the first episode of what is probably medically called "subconjunctival hemorrhage," (which the patient is saying"blood hemorrhage in eyes)?
It's a common condition and nothing to worry about or unrelated to her vision problems but can she recall the approximate years when she noted her blood in the eyes?
PA - She first noticed at the age of 19.
PPM 1 - 👍
PA -
PA - The Patient's BP at 6.42am is 109/65, PR 89
Fasting sugar 105mg/dl.
Had tea with soaked chana in the morning.
Before lunch took Glimiperide 1mg of 1/2tab nd after 2 hours of lunch took metformin 500 1/2 tab.
After 2 hours sugar level is 111.
PPM 1 - So currently patient is only on 0.5mg of glimiperide once daily?
PA - Yes,since last Monday the patientis taking only.5mg of Glimiperide once daily.
Post dinner sugar level is 141mg/dl and taken Metformin 250mg.
PPM 1 - 👍
17-02-2025
PA - Morning tea with soaked chana.
Since last 2-3 days the patient feels pain with stiffness on her tennis elbow.
PPM 1 - With a natural history of between 10 and 18 months, it is common for lateral epicondylitis/epicondylolagia aka tennis elbow to resolve spontaneously. In the vast majority of individuals, the illness will eventually improve, and symptoms are typically well-controlled by non-operative treatments like activity modification and physiotherapy.
Added our expert Physiatrist @PPM3 to this group who also lives in Mumbai and the patient can perhaps get his appointment to meet him there for his suggestion regarding activity modification.
First @PA can the patient share if she has noticed any particular activity yesterday or earlier that may have aggravated her condition which started (how many?) months ago?
An overview on this
topic 👇
PA - Yes,sir the patient notice that when she cleans room, or carry any weight or cooks that time she gets pain.
She also noticed that if she takes rest in hand then automatically resolves.
If she uses Tennis elbow band then she finds relief.
PPM 1 - 👍
PPM 3 - 👍
PPM 1 - So the solution is also already available to the patient.
PPM 3 - Activity modifications need OT. AIIPMR near race course Haji Ali may be preferable. Our OT on long leave.
The principle is to use the hand with " palm up " always (for a couple of months)
If you search YouTube, you will get physiotherapy that will worsen the pain. Occupational Therapy is required at the outset. Physiotherapy to be added at a later stage.
PA - Patient can't understand.
PPM 1 - Jokhon hi kaaj korben etai khyal rakhben je apnar haather taalu ta uporer deeke face korbe.
PA - Hater talu opor dik kore kaj ki kore?
PPM 3 - Sobi kaaj.
PPM 1 - We need to show her a video of how one may do it. Can you fish out any such video? @PPM3
PPM 3 - Failed.
PPM 3 - Lengthy, could not find significant points.
PPM 1 - 👍
In this video the presenter shows some, where she keeps her palm above 👇
PPM 3 - No.
PA - The patient took millets and mushroom fry for dinner.
18-02-2025
PA - Glimiperide 500 is not available in our local market so had to take half tablet.
PPM 1 - Glimiperide 0.5 mg you mean? Yes
PA - Morning tea at 7am.
Er age 1st time 15 days almost saradin portam r terpor kajer somoytuku potam .ice pack ditam
Ei point e pain hoche. Ei band ta pora thik ache ki?porbo ?kotokhon r kokhon,?
19-02-2025
PA - BP 99/64, after 3 min BP is 90/60 at 9 am
Symptoms at that time was vertigo, black eyes...hand and neck pain.
PPM 1 - BP is fine. So the problem is neural. Nothing to worry.
23-02-2025
PA - Fasting sugar is 112mg/dl
BP is 115/70, PR 60
PPM 1 - 👍
PA - The patient completed her lunch at 11.5am and she took before lunch Glimiperide 1mg 1/2tab and after metformin 500 mg. After 2 hours of lunch sugar level is 119mg/dl
PPM 1 - 👍
PA - After tiffin the patient took metformin 500 in 1/2tb and 2 hours later sugar is 99mg/dl at 17.01hrs.
PPM 1 - 👍
PA - After dinner she took metformin 500 in 1/2tab nd after 2hours of dinner sugar level is 203.
PPM 1 - Tiffin was taken at what time?
PA - At 3.05pm
24-02-2025
PA - Morning tea with chole at 7.24am
Lunch at 10.12am with rice beans and veggies.
28-02-2025
PPM 1 - Feedback from our Ophthalmologist previously at LV Prasad:
The lvpei reports are very hazy. She was seen by Dr Somashiela murthy. Do you have any specific questions?
@PA do let us know if you have any specific questions about the patient's current Ophthal problems. Is she meeting Dr Murthy in Mumbai?
PA - She will meet on 31st March.
PPM 1 - And Dr Somashiela Murthy is currently practicing in Mumbai?
PA - Yes now she is in Mumbai.
Does the patient have any images of her corneal evaluation? If not now it would be nice if she can collect them during her March evaluation in Mumbai.
PA - Okay.
Yes, Now she is in Mumbai.
Lunch
PA - After bath she does puja, meditation and then she starts cooking and cutting vegetables.
12.30pm she is painting for her customer's order.
PPM 1 - Very nice👏👏
PA - At 14.44pm
PPM 1 - 👍
PA - Are any reports required for corneal related issues?
PPM 1 - Any images of the cornea in the reports?
PA - She will try to share the image of corneal dystrophy. Give some time.
At 4pm the patient went out by bike on business purpose.
PPM 1 - Patient drives her motor bike herself?
PA - No no.
Dinner with one roti and vegetables.
PPM 1 - 👍
01-03-2025
7 am Freshen up and taking tea with nuts.
PPM 1 - 👍
PA - Lunch
PPM 1 - 👍
PA - Cornea reports.
02-03-2025
PA - Morning Tea with chana.
Sugar monitor is not working properly, so the patient cannot check fasting sugar level.
PPM 1 - Let's hope it can be repaired quickly! How old is it? Is it in warranty period? Would the patient like to switch to CGM as in another PaJR patient here 👇
PA - The patient completed her tiffin at 2.30pm. then she took metformin 500 in 1/2tab.After2 hours sugar level is 234mg/dl.
The patient had dinner with ragi roti and dal at 7 pm.
PPM 1 - Let us know her sugar at 9PM and tomorrow fasting and then two hours after breakfast.
PA - The patient woke up in the morning 6.o clock. After freshen up she took tea with nuts.
8 Am -take bath then doing puja and meditation. 11.Am- lunch 11 .30Am_Engage her own work. 11.30 am __went outside for 40 mints (walking). 1.30 Pm _cook food 2.30pm tiffin break, 3pmTime pass with mobile 4-30 pm_blood test. 5.00p.mFull attention with roof gardening and watering the plants. 6 pm meditation and self healing practice. 6.45pm _ cook food. 7Pm__Dinner completed then engage with her shop..
PPM 1 - 👍
How many customers does she see daily on an average?
PA - On an average 7-8 customers.
PA - After 2 hours of dinner sugar level is 167mg/dl.
PPM 1 - 👍
03-03-2025
PA - The patient woke up at 6.30am and got freshed up. Fasting sugar level is 95mg/dl
PPM 1 - 👍
Not able to see the patient's lateral view of the arm and abdomen here 👇
https://pajrcasereporter.blogspot.com/2024/12/44f-diabetes-nud-ccf-wb-pajr.html?m=1
@PA can you share it here so that it can be added to her case report?
PA - What does the patient need to do in this group?
PPM 1 - The patient needs to share her deidentified images of the arm and abdomen that she may or may not have shared earlier in this group as it has not been uploaded in her case report. It's important to have these deidentified images in every case report as it describes the patient's phenotype.
PA - Patient had lunch with rice and cooked vegetables.
After lunch she took Metformin 500 1/2 tablet and post lunch sugar value is 126mg/dl.
PA - The patient had one puri, aloo sabji, one apple and lime at 14.02hrs.
2hrs after tiffin the sugar level is 172mg/dl.
PPM 1 - 👍
PA - Is it high?
PPM 1 - No. Nothing to worry about. Most of our other patients in other groups have sugars range between 300-400!
PA - Okay
PPM 1 - Is the lateral view in the DP that of the patient's?
PA - Yes
PPM 1 - If she can maintain this phenotype then her diabetes can be reversed easily.
PA - Which is indicated by lateral view?
PPM 1 - Yes the muscles in the arm and the abdominal fat.
PA - The patient had weight loss and is now 46kg. Upper waist 30" and middle portion 32"
PPM 1 - 👍
Weight loss is not always good because that can signify muscle loss too. What is good is Paet loss and from the image it looks that there has been some paet loss which is good.
PA - Paet loss means?
PPM 1 - Loss of abdominal fat.
PA - The patient had dinner with one roti and dal.
PPM 1 - 👍
Can you share the patient's previous lateral view photos so that the phenotypic improvement can be visually compared?
PA - Lateral view photos of the patient. 👇
End of July 2nd day of high fever.
PPM 1 - 👍
August last week
PPM 1 - 👍
Unless we can find images in the lateral view it could be difficult to compare although yes the changes are visible here too.
04-03-2025
PA - Morning tea with chana
PPM 1 - 👍
PA - The patient had roti and sabji at 14.49.
PPM 1 - 👍
PA - Dinner with roti and sabji.
05-03-2025
PA - Lunch with rice, dal, curry and soaked chana.
[05-03-2025 13:58] PA: In tiffin break sabji Puri
[05-03-2025 14:17] PPM 1: 👍
PA - Dinner sabji puri
06-03-2025
[06-03-2025 07:12] PA: Morning Tea with chole.
PPM 1 - 👍
[06-03-2025 14.49] PA: The patient took her tiffin with roti, stir fried veggies and mixed pickle.
[06-03-2025 17.18] PA: Today patient baked homemade biscuits and namkeen after tiffin. All are made
of ragi, jowar and millets flour, jeera ,saunf and little bit salt and jaggery.
[06-03-2025 18.16] PPM 1: 👏
[06-03-2025 19.37] PA: Dinner.
[07-03-2025 10:17] PA: The patient had lunch with rice veg curry and salad.
[07-03-2025 10:18] PA: After a gap of few weeks today the patient is having upper abdominal pain.
[07-03-2025 10:38] PA: There was a lot of discomfort and couldn't sleep, felt feverish, throat
completely choked and also abdominal pain.
[07-03-2025 10:43] PA: Couldn't sleep till midnight. Today she woke up at 6am. After freshening up she
takes black tea with sprouts. After that she cleans her bed then goes to bath and washes her clothes.
[07-03-2025 10:46] PA: After that she practices her regular puja, meditation, then she goes to school to
drop her daughter, then she returns home at 10.15 am and takes her lunch.
[07-03-2025 14:21] PPM 1: Hopefully feeling better now?
[07-03-2025 14:22] PA: Yes, now she is better.
[07-03-2025 19:31] PA: Dinner with roti and sabji at 6.45pm.
[08-03-2025 06:59] PA: Morning Tea.
[08-03-2025 07.03] PA: Sever cough has developed, along with stomach, chest and head pain. The nose
is blocked and there is congestion in the chest. Can you suggest any medicine or cough syrup? Haven't been able to sleep at all.
[08-03-2025 07:14] PPM 1: What time yesterday? This is for this 44F patient, right?
[08-03-2025 07:50] PA: After 10.30pm. Yes, this is 44F patient's condition.
[08-03-2025 07:52] PA: When she is in sitting posture it's ok but when lies on the bed it was very
difficult.
[08-03-2025 07:53] PA: Sweating is there
[08-03-2025 10:00] PPM 1: Given this information it appears due to gastro esophageal reflux.
Here are some simple preventive tactics:
Elevate the head of your bed. If you regularly experience heartburn while trying to sleep, place wood or cement blocks under the feet at the head end of your bed. Raise the head end by 6 to 9 inches. Raising your head with additional pillows isn't effective.
Start on your left side. When you go to bed, start by lying on your left side to help make it less likely to have reflux.
Don't lie down after a meal. Wait at least three hours after eating before lying down or going to bed.
Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up again once you have chewed and swallowed that bite.
Don't consume foods and drinks that trigger reflux. Common triggers include alcohol, chocolate, caffeine, fatty foods or peppermint.
Don't wear tight-fitting clothing. Clothes that fit tightly around the waist put pressure on the abdomen and the lower esophageal sphincter.
[08-03-2025 11.34] PA: BP 92/60, PR 92
100/59, PR 98, 3mints after standing.
[-8-03-2025 13.49] PA: In tiffin time Patient took tomato soup and cabbage paturi.
[08-03-2025 19:32] PA: The patient had dinner with brown rice and mixed veg curry.
[08-03-2025 19:57] PPM 1: 👍
[09-03-2025 06:51] PA: Fasting blood sugar 109mg/dl, BP 108/74, PR 90
[09-03-2025 07.37] PA: Fever has come down to 100 F along with body aches, headache and severe
cough. Should the patient take paracetamol? The cough is not subsiding, it feels stuck.
[09-03-2025 10:48] PA: The patient had her lunch with kichidi and curry at 10.30am
[09-03-2025 12:02] PPM 1: Yes can take six hourly
[09-03-2025 12:02] PPM 1: Also let us know at what time she is taking the BP medicine
[09-03-2025 12:03] PPM 1: Can take water vapor if it feels stuck.
[09-03-2025 12:22] PA: She takes BP medicine after lunch.
[09-03-2025 12:22] PA: Yes.
[09-03-2025 12:41] PA: Before lunch she takes 1/2Glimiperide 1mg and after 1/2 tab metformin. After
2 hours of lunch sugar level is 177
[09-03-2025 12:48] PPM 1: 10:30 AM? after lunch?
[09-03-2025 12:53] PA: Yes
[09-03-2025 17:23] PA: After having her tiffin with puffed rice she took metformin 500 in 1/2tab and 2
hours after meals sugar level is 119mg/dl and BP is 126/76, PR 96
[09-03-2025 17:27] PA: After lunch she took concorcor 2.5 around 10 am
[09-03-2025 21:27] PA: 2 hours after dinner sugar level is 120
[09-03-2025 22:20] PPM 1: 👍
[09-03-2025 22:21] PPM 1: Share the name and dose of the BP medicine taken once at 10:30 AM
[10-03-2025 00:22] PA: BP medicine concor cor 2.5 once daily at 10.30 am after lunch
[10-03-2025 11:17] PA: Lunch thali with rice and vegetables.
PPM 1 - 👍
[10-03-2025 13:02] PA: Patient concentrating on her work.
[10-03-2025 13:04] PA: She takes a cup of lemon water.
[10-03-2025 13:04] PA: No ice
[10-03-2025 13:04] PA: No sugar
[10-03-2025 14.52] PA: The patient had millet kichidi with some chips.
[10-03-2025 19.58] PA: Dinner completed at 7.30 with 1 bowl of boiled mutter.
PPM 1 - 👍
[11-03-2025 07:32] PA: Morning Tea with Ragi biscuit and chola.
[11-03-2025 10:46] PA: Her morning warm up session. 👆
[11-03-2025] PPM 1: 👏
[11-03-2025 14:09] PA: Roti with Jack fruit curry, mixed pickle and 2 dates
[11-03-2025] PPM 1: 👍
[11-03-2025 18:44] PA: Patient daily practices this type of exercise.
[11-03-2025 19.23] PA: Dinner with ragi roti and aloo sabji.
[12-03-2025 07.48] PA: Morning black tea with roasted chana
[12-03-2025 10.53] PA: Lunch rice dal and vegetables.
PPM 1 - 👍
[12-03-2025 15.10] PA: Patient had vegetable salad
[12-03-2025 19.11] PA: dinner rice with vegetables and pickle.
PPM 1 - 👍
[12-03-2025 21.50] PA: Patient's weight has come down to 45kg.
[12-03-2025 21.50] PPM 1: 👏
[13-03-2025 07.20] PA: Black tea and nuts.
[13-03-2025 09.54] PA: Lunch with brown rice, bitter gourd curry and salad.
[13-03-2025 09.55] PPM 1: 👍
[13-03-2025 14.11] PA: The patient had Curd rice with vegetables.
[14-03-2025 08:01] PA: Morning Tea with nuts
[14-03-2025 11:06] PA: At lunch, rice with vegetables and soup.
PPM 1 - 👍
[14-03-2025 15.01] PA: Idly and chutney.
[14-03-2025 18.09] PA: Black tea and samosa with tomato ketchup.
[14-03-2025 21.11] PA: Vegetable rice with aloo sabji
[15-03-2025 07:59] PA: Morning Tea with nuts
[15-03-2025 09:16] PPM 1: 👍
[15-03-2025 10.48] PA: Rice dal and vegetable stew.
[15-03-2025 22:24] PA: Since the patient had indigestion problem since morning, she has
eaten rice and vegetables. If the patient eat rice 3times, will her blood sugar increase if tested
tomorrow?
[15-03-2025 22:26] PPM 1: No.
It will depend on what she eats tomorrow
[15-03-2025 22:26] PA: Ok
[15-03-2025 22:27] PPM 1: Rice or any other cereal is not bad for diabetes if consumed in the correct
proportion
[15-03-2025 22:27] PA: What should she take tomorrow?
[15-03-2025 22:27] PA: Ok
[16-03-2025 07:35] PPM 1: The Harvard plate proportion at all times as shared earlier here 👇
[16-03-2025 08.15] PA: In the morning the patient checks her BP 89/57. When She feels very weak,
eyes are getting dark.
[16-03-2025 08:16] PA: After 3 min standing BP is 90/49.
[16-03-2025 08:17] PA: Does the patient takes her BP medicine after breakfast in this situation?
[16-03-2025 10:17] PPM 1: Need not
[16-03-2025 10.58] PPM 1: This is an important event in the patient's timeline today that gives us fresh
insights into her corneal issues.
[16/03, 09:48] pm: Eta dekhe mone hocche episcleritis
Aer aage koto bar hoyeche?
Here's the translation:
pm: It looks like episcleritis. How many times has this happened before
[16/03, 10:32] Patient Advocate Diabetes 44F WB: Bes onekber hoyeche .
It's happened quite a few times.
[16/03, 10:33] pm: Prothom jokhon chokkher somosya ta shuru hoyechilo taro aage?
Did this eye problem start before the first time?
[16/03, 10:37] Patient Advocate Diabetes 44F WB: Amr mone hoche eta allergic attack ,bcz 23 e meyer
madhyomik r por rishikesh ,gongotri,teheri r ferar pothe hardwar ekdin snan korar por din thekei same
problem start hoy ..sebr amr meyer kdin dhore khub hat e choto choto rash beriechilo .r itching o .18 th
last exam ,tai kal homeopathy dr .dekhieche bolechen allergy theke ..tai mone hoche amr o mone hoy
erokom kichu holo kina?
I think it's an allergic attack because after my daughter's exams on the 23rd, we went to Rishikesh,
Gangotri, and on the way back, after bathing in Haridwar, the same problem started. My daughter also
had small rashes on her hands and itching for a few days. The last exam was on the 18th, so we showed
a homeopathy doctor yesterday, who said it's due to an allergy. So, I think it might be something like
that.
[16/03, 10:38] Patient Advocate Diabetes 44F WB: Ha chokher problem bstart hober age thekei hoto
hathath hathath .chokher pressure bere jeto ,ba samanno lege gelei chokher moni chore jeto etc .
Yes, the eye problem used to happen suddenly before it started. The eye pressure would increase, or
even a slight touch would cause the eye to move, etc.
[16-03-2025 13:12] PA: Before lunch the patient takes Glimiperide 1mg in 1/2tab and after metformin
500mg 1/2tab. 2hours after lunch sugar level is 123
PPM 1 - 👏
[16-03-2025 13:13] PA: Today she doesn't take concor cor 2.5 after meal
PPM 1 - 👍
A few Ophthalmologist inputs:
AIIMS Delhi:
[16/03, 13:35] S: First pic.... more of episcleritis.... low dose steroids in form of eyedrop and lubricating drops may help.
Corneal dystrophy.... epithelial... PTK done to improve vision....
Immune mediated corneal haze mostly seen in viral keratitis....
[16/03, 14:17] cm : Was wondering if her corneal lesion (can we be sure the pathology is dystrophy) may have been due to immune inflammation manifesting as recurrent episcleritis and spreading through peri corneal routes?
[16/03, 15:08] S: The slit lamp photographs are important. The photos provided are quite blurry.
However corneal dystrophy is likely cause. These can manifest at any age group.
Immune reactions have diffuse margins. Corneal dystrophy are well demarcated deposits.
Immune reactions will improve with steroid drops...(given in post viral Immune reactions) . Corneal dystrophy shows no change with any medications.
PGI:
[16/03, 14:05] C: Recurrent corneal erosion syndrome may be.
Diabetes has a known association.
There is faulty adherence of epithelial cells to the basement membrane.
[16/03, 14:07] C: This may be either a case of diffuse episcleritis or allergic conjunctivitis. Nonspecific conjunctival and episcleral congestion.
[16/03, 14:09] cm : Can we relate it to her corneal dystrophy for which she had to undergo keratoplasty
[16/03, 14:11] C: Yes, anterior corneal dystrophies are associated with recurrent corneal erosion syndrome.
[16/03, 14:18] cm: So perhaps her recurrent episcleritis since age of 19 induced pericorneal inflammation leading to corneal dystrophy?
[16/03, 14:19] C: No
[16/03, 14:20] C: Recurrent episcleritis cannot cause corneal dystrophy.
They are congenital.
[16/03, 14:21] C: Maybe they are separate pathology.
'Allergy' and dystrophy
[16/03, 14:21] cm: We really don't know if the pathophysiology is dystrophy in this patient. It has been clinically labeled that way perhaps but the histopathology post keratoplasty may have revealed fibrosis?
[16/03, 14:26] C: When was the keratoplasty done?
[16/03, 15:06] C: Scleritis is sometimes associated with sclerosing keratitis and opacity.
So recurrent scleritis and sclerosing keratitis may be a theoretical possibility. Usually associated with connective tissue disorders.
LVPEI:
[16/03, 11:49] sm: Episcleritis is immune mediated. The pattern of congestion that we see in this corneal dystrophy is related to recurrent corneal erosion, it's circum corneal congestion. And associated with pain, watering photophobia.
The symptom of episcleritis is redness of eyes and only a mild discomfort.
[16/03, 11:50]sm: Are you suspecting an immune mediated mechanism for her diabetes as well?
What is epicondylolagia?
[16/03, 11:52]cm: 👆 looking at the congestion here it didn't occur to me that it is circumcorneal but even if so the congestion appears to have preceded her corneal dystrophy that still makes the etiology immune mediated?
[16/03, 11:52] sm: This is not circumcorneal
[16/03, 11:52]sm: This looks like episcleritis
[16/03, 11:52]cm: Exactly! That's what I thought too!
[16/03, 11:54]cm: Type 2 adiposity driven diabetes does also have adipokine driven immune antecedents leading to vasculopathy driving pancreatic damage?
Lateral epicondylolagia is a current term for her tennis elbow
[16-03-2025 17:31] PA: After tiffin she took metformin 500in 1/2Tab, 2hours after sugar level is 148
[16-03-2025 17:33] PPM 1: Tiffin at what time?
[16-03-2025 17:34] PA: Sorry 3.30pm.
[16-03-2025 21:11] PA: After dinner she took metformin 500 1/2tab and 2hours after dinner sugar level
is 142.
[17-03-2025 08:52] PA: Would u suggest any eye drop for relief? The patient feels heaviness and slight
pain with uneasiness to open eyes, her left eye, looking small in size than the other eye but now there
is no redness
[17-03-2025 08:54] PA: In the morning she takes black tea with chola
[17-03-2025 09:13] PA: Today can she takes BP medicine concor cor 2.5 after breakfast?
[17-03-2025 10:15] PPM 1: Can see serial BP recordings after stopping
[17-03-2025 10:16] PPM 1: Her current eye drop appears to be fine
[17-03-2025 10:20] PPM 1: Slight pain? Can she elaborate on that? Is it constant in her left eye?
Her eye needs to be examined by a local doctor asap.
[17-03-2025 12:08] PA: How often should she check her BP?
[17-03-2025 12:11] PPM 1: Only on Sundays 10 times
[17-03-2025 12.15] PA: There is pain continuously when she opens the eyes and having slight pain in
the forehead too. She feels better when she closes her eyes. Intolerant to light also.
[17-03-2025 19:14] PA: She completed her dinner at 7pm
[17-03-2025 19:18] PPM 1: Is it a ragi floured roti? What curry is that?
[17-03-2025 20:08] PA: Yes, ragi roti, steamed gourd leaf paste (made in airfyr), peas and potato curry.
PPM 1 - 👏
[18-03-2025 07:48] PA: Morning Tea with roasted chola
[18-03-2025 08:36] PPM 1: 👍
[18-03-2025 09:57] PA: Patient completed her lunch with this plate at.9.30
[18-03-2025 20:25] PPM 1: Ragi?
[18-03-2025 20:25] PA: Yes
[18-03-2025 20:26] PPM 1: Ragi and?
[18-03-2025 20:28] PA: Ragi, jawar ,isobgul and whole wheat flour
[19-03-2025 06:56] PA: In the morning at takes black tea with chola
[19-03-2025 10:23] PA: She takes boiled chana in her breakfast
[19-03-2025 11:40] PPM 1: Has she reached Disha?
[19-03-2025 11:43] PA: Yes
[19-03-2025 11:43] PA: At 9.25 am
[19-03-2025 20:04] PPM 1: Inputs from her local Ophthalmologist in Kolkata today:
She is a diagnosed case of Meesmann's epithelial dystrophy.
She has undergone left eye Photo Therapeutic Keratectomy in 2018 at LVPEI.
She has severe dry eyes. The left eye has some opacity and irregular ocular surface. Otherwise, she's
doing well. Her best-corrected visual acuity is 6/6N6 in both eyes.
No diabetic retinopathy or any peripheral lesion in either eye.
She was complaining of a Left sided field loss, but her field testing didn't reveal any significant
abnormalities.
For the case report @CR
[19-03-2025 20:06] PPM 1: @PA can you deidentify the patient's printed prescription provided today
and share here so that it can also be archived in the case report?
[19-03-2025 20:22] PA: Ok. She will try as early as possible.
[20-03-2025 08.20] PPM 1: Conversations with her local ophthalmology (to be added to her case report @CR)
[19/03, 21:08] cm : How did they diagnose this dystrophy? Was it on corneal biopsy histopathology
after keratectomy?
[19/03, 21:22] Ophthalmology: No. It was diagnosed at this local centre long back.
The diagnosis is entirely clinical.
[19/03, 21:28] Ophthalmology: On retroillumination, epithelial microcysts appear as transparent dew
drops.
I've tried to take a retro illumination picture today.
[21-03-2025 11.40] PPM 1: Red arrow curvilinear ptk scar
Yellow arrow opacity. In this one, the PTk scar is visible. And lateral to that, close to the edge is the
opacity.
Green dots photographic artefacts
Right eye
Left eye
[21-03-2025 21.17] PPM 1: 👍
[21-03-2025 21.48] PA: BP is 113/57, PR 90
[22-03-2025 16:22] PPM 1: 👍
[22-03-2025 17:08] PA: Evening tea
[23-03-2025 06:54] PA: Fasting blood sugar level is 94mg/dl
[23-03-2025 07:03] PA: At 7am BP is 122/82. From last 6 days patient has not
taken BP medicine.
[23-03-2025 12:45] PA: Patient completed her lunch at 10.30.
[23-03-2025 12:49] PA: Before lunch she takes Glimiperide 1mg in 1/2Tab and after that takes
metformin 500 in 1/2 tab
[23-03-2025 12:50] PA: After 2 hours of lunch sugar level is 129
[23-03-2025 17:49] PPM 1: 👍
[23-03-2025 22:05] PA: After dinner patient takes metformin 500 in 1/2tab ..and after 2 hours sugar
level is 96
[23-03-2025 22:26] PPM 1: 👍
[24-03-2025 08:38] PA: Cake made of Ragi flour nuts,flexed seeds, season seeds, oats and dates.
[24-03-2025 08:47] PPM 1: 👏 Season or Sesame seeds?
[24-03-2025 08:47] PA: Sesame seeds.
[24-03-2025 12.51] PA: Lunch vegetable rice and aloo curry.
[24-03-2025 13:00] PPM 1: In train?
[24-03-2025 13:41] PA: Yes
[24-03-2025 17:52] PA: Evening snacks, puffed rice and black tea.
[24-03-2025 19:15] PPM 1: 👍@~PPM3 this patient is reaching tomorrow. Will be good if you can
also meet them in the super speciality ward where we shall admit them
[24-03-2025 21:57] PPM 3: yes sir I will come tomorrow and meet them.
[25-03-2025 08:24] PA: Patient will reach within short time then what will be the next step?can u help?
[25-03-2025 08:28] PPM 1: Wait in the OPD and I shall come and admit.
If you find any doctor there in OPD tell them that
[25-03-2025 08:29] PA: Ok
[25-03-2025 12.52] PPM 1: Reviewed in OPD by @~PPM4 and @PPM5
BP: 90/60
On abdominal examination:
Divarication of recti along with a suspected small parietal hernia at the right hypochondrium
Planned ultrasound
Also evening visit by Dr @~PPM3 along with Dr @~PPM4 to review her BP instrument and
glucometer and compare it with the results from the ward devices
Conversations with an Ophthalmologist around her corneal dystrophy:
[25/03, 10:20] S: Looks absolutely normal.
Corneal dystrophy is not very significant. Retina also normal. Field test normal...
.
Nothing to worry. Just a routine follow up is enough.
[25/03, 12:46] S: Severe dry eye requires using the necessary drops. ..
[25/03, 12:54] CM: Is it possible that it wasn't significant corneal dystrophy when they did the photo
therapeutic keratectomy?
Wouldn't it be routinely confirmed in a biopsy specimen from the keratectomy?
[25/03, 12:56] S: Biopsy can't be done. It will scar the cornea. PTK is restricted to severe cases when the
opacities are superficial.
Only when the opacities are deep and corneal grafting is required, then biopsy can be done.
Most can be diagnosed clinically using slit lamp.
[25/03, 12:57] S: PTK just ablates the tissue. No specimen .... laser ablation
[25/03, 13:14] CM: So we need corneal slit lamp images before her PTK to ascertain how bad it was
before they decided to do her PTK
[25/03, 13:18] S: Yes.... Or the visual acuity data
@PPM 3 please collect the data around her visual acquity before the PTK surgery if possible.
[25-03-2025 15.10] PA:
[25-03-2025 18.53] PA: BP is 103/62, PR 89.
[25-03-2025 19:24] PPM 3: Sir, with the ward BP instrument it's coming as 150/90 mmHg.
[25-03-2025 19:31] PPM 1: At the same time!
[25-03-2025 19:31] PPM 1: Let's try another electronic BP instrument from the ICU
[25-03-2025 19:33] PPM 3: yes sir.
[25-03-2025 19:33] PPM 3: okay sir.
[25-03-2025 19:46] PPM 1: Also for the other 18F patient admitted today would you like to prepare a
PaJR and share her detailed deidentified history from fetal life there? Please do also collect her signed
informed consent and you can find some forms in Bengali or English in the ICU
[25-03-2025 19:49] PPM 3: Yes, sure sir
[25-03-2025 20.07] PA: Dinner, 2 Idlies, chutney sambar and noodles.
[26-03-2025 08:34] PA: Patient feels very weak with darkness of eyes, slight pain in shoulder and
arms. If possible can check with another machine? patient think that this BP machine is not working
[26-03-2025 09:22] PPM 1: @~PPM4 @~PPM3 can you please check her BP from multiple electronic
machines in the AMC at the same time and share here?
[26-03-2025 09:49] PA: In the morning the patient takes some roasted makhana.
[26-03-2025 10:33] PPM 1: Breakfast needs to be more substantial though with all the same elements of the ideal food plate as reiterated here 👇
[26-03-2025 13:29] PA: In lunch
[26-03-2025 13:33] PA: Half dosa and little curd rice.
[26-03-2025 14:49] PA: At 2.45pm. BP is 110/70
[26-03-2025 19:07] PA: At 7 p.m checked BP. 130/70 by ward machine. Parallelly checked by own
machine the BP is 118/67. at the same time same place. She is totally confused.
[26-03-2025 19:23] PPM 1: There would be a few minutes gap between switching different machines so
it can't be at the same time although can be with the same arm.
We need to check at least 10 such comparative readings
[26-03-2025 21.09] PA: Dinner with dosa and noodles.
[27-03-2025 08:05] PA: Morning Tea with nuts
[27-03-2025 08.47] PA: BP 92/64, PR 67
[27-03-2025 08:56] PPM 1: Now we can add +10 or + 20 to the above readings going by our recent
limited discoveries that can be further validated by more meticulous recordings on a number of
different devices as @PPM2 is currently doing in his UK patient
[27-03-2025 09:03] PPM 4: Sir can we get the PajR link to this patient? I want the BP recordings
[27-03-2025 10:06] PPM 1: All PaJR case report links are in the case report link in every
PaJR group's description box.
There are many other PaJRs with BP readings that @CR can share with you in the collective group
if you are interested
[27-03-2025 10:26] PA: At breakfast Idly with chutney and sambar.
[27-03-2025 19:49] PA: At 7.45 pm BP checked by ward machine that is 140/70 and checked by own
machine it is 112/69.
[27-03-2025 22.00] PPM 1: After how many minutes of checking with the previous ward instrument?
[27-03-2025 22:04] PA: Just 1-2mints gap
[28-03-2025 07:58] PA: In ward machine 110/80, with own machine 103/64.
[28-03-2025 08:00] PA: Fasting sugar is 122 by ward glucometer but 145 by patient's own glucometer
[28-03-2025 08:00] PPM 1: Great 👏👏
So now the BP readings are matching!
[28-03-2025 08:01] PPM 1: And now the glucometer values are not matching!
[28-03-2025 09:07] PA: Morning Tea with roasted nuts and makhana
[28-03-2025 15:37] PA: Patient completed her lunch with this plate
[28-03-2025 16:24] PA: BP checked by ward machine 110/70. And own machine 110/69
[28-03-2025 16:25] PPM 1: 👍
[28-03-2025 16:30] PA: Post lunch Sugar level is 172mg/dl in own monitor and 152mg/dl with ward
monitor.
[28-03-2025 16:40] PA: Blood taken at same time?
[28-03-2025 16:54] PA: Yes. mostly 1 min gap
[28-03-2025 16:56] PA: She takes methi and mouri water
[28-03-2025 23:45] PA: Sugar level is increasing .2 hours after dinner sugar level is 194
[29-03-2025 10:01] PPM 1: Nothing to worry.
[29-03-2025 13.40] PA: Lunch with noodles and curry.
[29-03-2025 14:40] PPM 1: The last noodles plate of our city.
[29-03-2025 17:28] PA: Yes..
[29-03-2025 17:29] PA: Enjoying evening tea with boiled nuts.
[30-03-2025 07:57] PPM 1: The vada pao of Mumbai means the patient has reached there
[30-03-2025 08:01] PA: No, now the train is at Pune station
[30-03-2025 09:07] PPM 1: Yes Vada pao is entire Maharashtra I guess
[30-03-2025 09:17] PA: I think. This is 1st time for Mumbai.. Entire railway track
sorrounded by hill area. It looks amazing. Enjoying very much ..
[30-03-2025 09:18] PPM 4: Yes, it is indeed very green, silent and nice but for the Industry😌
[30-03-2025 09:19] PPM 4: I remember a board by name "Dr. Vadapav" in Surat😄
[30-03-2025 09:37] PPM 1: Share images
[30-03-2025 09.40] PA:
https://youtu.be/D9Qd7aItjKg?si=bD9TKzk5bVvaInCY
[30-03-2025 09:43] Rakesh Biswas Sir: 👏👏
[30-03-2025 10:10] PA: Don't know is it related this group or not, but the nature definitely frees us
from lots of monotony ...This hill area is in the" Sajhyadri "range and separate the Deccan platue to
Konkan coast.
[30-03-2025 21:48] PA: At dinner plate paneer fried rice.
[30-03-2025 23:14] PA: Can anyone create a group for a person who has continuously humming sound
in his left ear after severe accident.
[31-03-2025 06:31] PPM 3: Needs an Audiologist
[31-03-2025 07:45] PPM 1: Please add to that group if you know anyone who would be willing
[31-03-2025 07:45] PPM 1: I'll create it.
Please share age, gender and complaints duration.
[31-03-2025 07:48] PPM 3: Depends on local language..
.
[31-03-2025 08:02] PPM 1: Can English be a common ground and also Google translate may help?
[08-04-2025 06.36] PA: BP 135/84, PR 97. BP 123/81, PR 91.
[08-04-2025 06:42] PA: 1st time. 135
[08-04-2025 06:43] PA: After 3mints standing BP is 123/81
[08-04-2025 06:48] PA: From last 20 days she stopped her BP medicine as per dr.'s advice.
[08-04-2025 07:08] PPM 1: 👍
[08-04-2025 14:55] PA: Fever has come along with body ache and headache. can she take paracetamol 650?
[08-04-2025 15:14] PA: Sooji upma
[08-04-2025 15:50] PA: She has high fever history in past
[08-04-2025 16:19] PPM 1: Can
Please monitor it 4 hourly
[08-04-2025 16:21] PPM 1: Now?
[08-04-2025 16:23] PPM 1: Yes'' gradually increasing
[08-04-2025 16:23] PA: Now she takes paracetamol 650
[08-04-2025 18:20] PA: Even after 2 hours taking paracetamol fever has not gone down. Severe body and headache.
[09-04-2025 00:00] PA: At 11.56 pm temparature is 100.2F.she doesn't take any others paracetamol after taking one tab she feels abdomen pain looks like previous.so she stops paracetamol
[09-04-2025 10:27] PPM 1: How's the fever today?
[09-04-2025 10:40] PA: Now fever is 100F.At night It was over 102f., with severe pain. Feeling very weak.
[09-04-2025 10:46] PPM 1: 👆As long as she's able to eat these she should be fine.
Please collect her temperature readings 4 hourly and share here
[09-04-2025 10:54] PA: 4a.m. 102F
[09-04-2025 10:54] PA: 8Am 101.4F.
[09-04-2025 11:16] PPM 1: 👍
[09-04-2025 11:21] PPM 1: Check out this PaJR case report of a PaJR patient with viral fever recognised through the illness journey course reflected in the fever chart prepared by @CR 👇
@PPM 2 just to put it in your mind for your presentation today regarding graphical representation of PaJR journeys in the Ux
[09-04-2025 12:58] PPM 2: Link not loading?
[09-04-2025 13:08] PPM 1: This one could take time.
@~PA please confirm if the above link is also not opening from your end
[09-04-2025 13:20] PA: The link is opening
[09-04-2025 14:21] PA: Nuts, raw mango, mint, black pepper juice
[09-04-2025 14:34] PA: 101fever 12.30
[09-04-2025 14:34] PA: She is not able to take solid food and feels very weak.
[09-04-2025 20:05] PPM 1: Any more temperature recordings?
[09-04-2025 23:14] PA: 4.30pm 100.4F. 9pm 100F
[09-04-2025 23:21] PA: Increasing severe muscle cramp then the patient takes methi mouri water, normal water and raw mango sherbat. after that she feels better.
[10-04-2025 06:53] PA: Now she has no fever. Feeling better
[10-04-2025 07:02] PA: 1st she realises without paracetamol she is feeling better and fever has gone down. There is still some discomfort, but she believes it will be fine soon. Feeling very happy
[11-04-2025 07:06] PA: Morning Tea with roasted chola
[11-04-2025 07:09] PA: Again fever has come along with headache, nose burning sensation and body ache
[11-04-2025 07:10] PA: Now temparature is 100F
[11-04-2025 07:56] PPM 1: How many paracetamols did your patient take yesterday?
[11-04-2025 07:58] PA: No paracetamol sir
[11-04-2025 07:58] PPM 1: No paracetamol yesterday and no recorded fever yesterday right?
[11-04-2025 07:58] PA: It is too much phobia
[11-04-2025 07:59] PA: No fever that's why she didn't take any record
[11-04-2025 08:02] PA: Suddenly here weather was totally changed after evening. Heavy rainfall, lightning and too much windy I think that's the reason for fever and cold
[11-04-2025 08:02] PPM 1: So subjectively she didn't have fever yesterday but it's difficult to now say if she may have objectively had fever on measuring
[11-04-2025 08:03] PPM 1: Hope you read the poetic way it was described by another 63M PaJR patient in his group
[11-04-2025 08:03] PA: Acha
[11-04-2025 19.34] PA: Ragi roti and Jackfruit curry
[11-04-2025 20:41] PPM 1: Jackfruit 👏
[11-04-2025 22:15] PA: Yes.
[11-04-2025 22:24] PA: Today the patient has no fever but her throat is completely choked and discomfort for swallowing.
[12-04-2025 07:20] PPM 1: Paracetamol will work here too
[12-04-2025 08:21] PA: After taking paracetamol abdomen pain starts. Then what should she do?
[12-04-2025 08:24] PA: Paracetamol doesn't suits her, so she takes hot water, and drinks hot black tea with ginger, boiled daal juice etc.
[12-04-2025 08:27] PPM 1: Alright can avoid medication. That's the best way forward
[12-04-2025 08:31] PA: Also do gargle with hot water and have black tea
PPM 1 - 👍
[12-04-2025 19:07] PA: Can't swallow, severe pain in throat,
[12-04-2025 19:21] PA: Patient takes paracetamol in afternoon
[12-04-2025 20:40] PPM 2: Can try betadine gargles
[12-04-2025 20:46] PA: she feels constant irritation, watering in right eye. Same symptoms of conjunctivitis.
[12-04-2025 21:04] PPM 1: Check for the drops last prescribed by her Ophthal in her case report
[13-04-2025 06.40] PA: BP 126/81, Fasting Sugar level 144mg/dl
[13-04-2025 07:41] PA: On the higher side. Is she taking glimiperide 0.5 mg in the morning? Did she miss her dose yesterday?
[13-04-2025 08:07] PA: No sir , yesterday she took glimiperide.5 before breakfast.
[13-04-2025 08:10] PA: In her past history she noticed that her throat pain nd high Sugar level is related.
[13-04-2025 08:11] PA: Several times she noticed that.
[13-04-2025 08:14] PA: Gargle with Betadine, hot water drinking is not working.It was very painful for her, can't swallowing.
[13-04-2025 08:16] PA: Now she has 100F
[13-04-2025 08:23] PPM 1: And when is she taking today's breakfast with the same tablet?
[13-04-2025 08:24] PPM 1: Good observation. Yes it's possibly related. Internal medical inflammations are known to exacerbate hyperglycemia @Meta AI ? Please substantiate with valid references
[13-04-2025 08:24] Meta AI: Internal medical inflammations can indeed exacerbate hyperglycemia. Here's how it works:
The Inflammation-Hyperglycemia Connection
- Chronic low-grade inflammation promotes insulin resistance and hyperglycemia, contributing to the development of chronic complications in diabetes.
- Inflammatory cytokines can stimulate stronger immune and inflammatory responses, leading to cytokine release and hyperglycemic surges.
- Hyperglycemia, in turn, upregulates inflammatory and oxidative stress markers, creating a vicious cycle.
Evidence from COVID-19 Studies
A study published in the International Study of Inflammation in COVID-19 (ISIC) found that:
- Patients with diabetes mellitus (DM) had higher levels of inflammatory biomarkers, such as soluble urokinase plasminogen activator receptor (suPAR), C-reactive protein (CRP), and procalcitonin, compared to those without DM.
- The association between DM and adverse outcomes in COVID-19 was largely mediated by hyperinflammation, as assessed by suPAR levels.
- Hyperglycemia and higher insulin doses were independent predictors of adverse outcomes, with effect sizes unaffected by adjusting for suPAR levels.¹
Key Takeaway
The interplay between inflammatory cytokines and hyperglycemia can worsen outcomes in patients with internal medical inflammations, such as those with diabetes. Managing inflammation and hyperglycemia is crucial in these cases.
[13-04-2025 08:24] Meta AI: https://diabetesjournals.org/care/article/45/3/692/140930/Inflammation-Hyperglycemia-and-Adverse-Outcomes-in
[13-04-2025 08:39] PA: Today, now she is not taking breakfast
[13-04-2025 09:14] PPM 1: Why?
[13-04-2025 09:17] PA: Regularly she takes breakfast at 10.30am In the meantime she takes nuts nd black Tea
[13-04-2025 09.20] PPM1: So she'll take her 0.5 mg glimiperide at the usual time that is 10:30AM today 👍
[13-04-2025 10.29] PA: 130/84 PR 123
[13-04-2025 10:29] PPM 1: Thanks for sharing these clinical images which definitely provides better information on the current status of this patient's illness.
[13-04-2025 12.17] PA: Sugar level 204mg/dl.
[13-04-2025 13:32] PA: Definitely there is serious infection. There was severe throat pain since last night, burning sensation in ears, eyes red and painful and whole face is swollen. Blood pressure and sugar level are increasing Is there anything that can give relief? Paracetamol is not helping at all.
[13-04-2025 13:43] PA: For last 2 years, same problem was happening whenever there is frequent long train journey .2years ago after her daughter 's Madhyamik exam she went to Haridwar, Rishikesh, Teheri and Gangotri. After returning home from Haridwar same infection happened.
[13-04-2025 13:45] PA: It might be due to the long journey and heat wave.
[13-04-2025 13:48] PA: In the past, Clavam 625 helped.
[13-04-2025 13:50] PA: Please advise the patient with medication to get relief. BP 140/65.
[13-04-2025 14:24] PPM 1: After how many days?
[13-04-2025 14:25] PPM 1: Has she taken paracetamol 650 six hourly four times a day or taken it sos?
[13-04-2025 14:26] PPM 1: Can we search her case report for a similar episode that was logged here where she recovered with Paracetamol alone @CR?
[13-04-2025 14:27] PPM 1: 204mg/dl. Two hours after her breakfast and she took 0.5 mg glimiperide before breakfast? Also she's taking Tablet Metformin after every meal?
[13-04-2025 14:33] PA: Daal sidho with vegetables
[13-04-2025 14:41] PA: Yes
[13-04-2025 14:44] PA: Taken paracetamol once after breakfast around 10.30am
[13-04-2025 15:04] CR: There are many episodes of fever and eye redness and sore throat. The PA can go through the case report.
[13-04-2025 15:10] PA: From her memory she noticed that in the year 2015, 2018, 2021, 2023, 2024 and 25 also she travelled long journey in the month of March, May and faced this type of situatio, she had to take Clavam 625 as per Doctor's advice except 2025
[13-04-2025 15:14] PA: Yes, mam and high fever
[13-04-2025 15:58] PPM 1: Lets hope she doesn't have to break her 2025 record
[13-04-2025 15:59] PA: Yes sir.
[13-04-2025 16:54] PA: After lunch she takes metformin 500 in 1/2 tab, 2 hours after lunch sugar level is 103mg/dl.
[13-04-2025 16:55] PA: Today she doesn't take rice.
[13-04-2025 20:56] PPM 1: 👍
[13-04-2025 20:57] PPM 1: Four hourly temperature recording?
[13-04-2025 21:01] PA: Temparature nei tai r pathaini. sokalei 100F chilo belay aste aste golar pain o komche
[13-04-2025 21:08] PPM 1: Aebar o clavum khawa holo na!
[13-04-2025 21:41] PPM 1: Two hours post dinner?
[13-04-2025 22:10] PA: Yes sir, after dinner she took metformin 5oo in half tab, and 2hours after dinner sugar level is 148mg/dl and BP 124/83
[13-04-2025 22:14] PA: Apnader treatment e jotota co-operate kora jay chesta korchi. onkber nischoy help hobe asha kori .satty chaina r antibiotic khete,sarir e r kichu nei,ektutei kmn kahil hoye porche patient.
[13-04-2025 22:16] PA: Apni guide korle asha kori khub taratari sustho hoye uthbe.
[14-04-2025 07:22] PA: Morning Tea
[14-04-2025 18:45] PPM 1: 👍
[14-04-2025 18:48] PPM 1: @~PA @CR is this patient's recent Ophthal evaluation done in Mumbai shared here?
[14-04-2025 18:51] CR: No
[15-04-2025 00:42] PA: No sir, will try but can't deidentify
[15-04-2025 07:17] CR: Send to my number, I will deidentify
[15-04-2025 07:26] PA: Thanks.
[15-04-2025 16.45] PPM 1: 👍
[15-04-2025 16:59] PA: Feeling more better..
[15-04-2025 17:14] PA: I have no taste in mouth, everything feels bitter and sweating a lot. Yesterday due to some work pressure she had to force herself to work. feeling very weak but improving gradually
[15-04-2025 19:24] PA: At dinner Jeera rice with potato curry
[16-04-2025 07:15] PA:: Morning Tea
[17-04-2025 21:54] PA: At dinner rice with dal
[18-04-2025 09:10] PA: At breakfast ragi roti and curry
[18-04-2025 12:09] PA: Patient completed her lunch with rice and drumstick and veg curry
[19-04-2025 20:44] PA: At lunch time rice with curries
[19-04-2025 20:46] PA: Tiffin time soaked nuts and chola
[19-04-2025 20:47] PA: At night
[19-04-2025 20:49] PA: Homemade Jeera rice and grated paneer, nuts n carrot potato stuff curry.
[20-04-2025 05:03] PA: Fasting blood sugar is 112
[20-04-2025 06:01] PPM 1: 👍
[20-04-2025 07:11] PA: Tea without sugar
[20-04-2025 09.05] PA: 156mg/dl
[20-04-2025 18:12] PPM 1: 👍
[20-04-2025 18:18] PA: 2 hours after lunch sugar level is 185
[22-04-2025 01:26] PA: After Breakfast she travelled for zuluk.on the way she took veg momo nd cofee
[22-04-2025 09:55] PPM 1: Dzuluk was once a transit point to the trade route between Kalimpong and Tibet. The route was in use even a few decades ago until the 1959 Chinese crackdown in Tibet. It was commonly used by traders traveling to Tibet through Jelep La ("La" stands for mountain pass) as an overnight base.
[22-04-2025 09:56] PPM 4: 🤲
[22-04-2025 11:59] PA: Yes,sir.
[22-04-2025 11:59] PA: Now Visiting Nathula Pass going to Changu lake .
[22-04-2025 11:59] PA: In the morning from the Thambi view point Kanchanjangha view was excellent .Nathula Pass was really amazing nd feeling proud as an Indian..
[22-04-2025 16:59] PPM 1: Our experiences of the same places from 1993:
[22-04-2025 20:05] PA: Dinner plate rice dal and sabji
[23-04-2025 08:35] PA: Now at breakfast puri and sabji
[24-04-2025 07:40] PA: Morning Tea
[24-04-2025 08:24] PPM 1: 👍
[24-04-2025 14:37] PA: Lunch menu rice dal and sabji
[25-04-2025 22.54] PA: Rubodex Hair Oil, Rubodex Herbal Shampoo, Rubodex Forte Tablet daily. Can the patient use this product for stopping hair fall?
[26-04-2025 06:56] PPM 1: Its herbal so none of us here can answer this. We can only review products that may have undergone some scientific trials
[26-04-2025 06:57] PA: Ok
[26-04-2025 07:08] PA: From last September patient and her daughter have been experiencing a lot of hair fall. Almost 1/3 is gone So they wanted to know whether any product can be used in this case?
[26-04-2025 07:11] PPM 1: We don't know about this product.
The scientific way to find the efficacy of any product is to put the search engine query as:
Name of the "drug" and efficacy and then check out the results.
In the above case of rubodex we shall first need to check which drug is present in it
[27-04-2025 06:52] PA: Fasting blood sugar level is 111
[27-04-2025 09:52] 33F PA: From other people's experience:
1. Have the patient and her daughter had their Vitamin D level checked? If not, they can add that while having other regular blood tests prescribed by doctors.
2. Have they changed their water they shower with since September?
[27-04-2025 10:12] PA: No sir, recently they haven't checked Vit.D level and haven't changed the bath water from September.
[27-04-2025 10:31] PA: After lunch the patient took metformin 5oo in half tab nd 2 hours after sugar level is 159
[27-04-2025 10:39] PA: BP 113/77 After 3min standing 117/76
[27-04-2025 12:09] PA: At lunch Rice, Dal, bitter gourd pakoda, sabji
[27-04-2025 12:44] PPM 1: Vitamin D in India could be part of an ongoing pandemic of unintentional over-testing and overtreatment.
It's rare to see Indians with normal vitamin D levels!
"Indian population is diverse and unfortunately Indian data published have largely overlooked the issue of defining reference range as per Indian population. The application of reference range for Vitamin D levels derived from western population might not be suitable to Indian population because of the latitudinal geographic location, abundant sunshine and dietary eating habits. It is recommended that assessment of Vitamin D should be performed by Tandem Mass Spectrometry (TMS) but most of the testing facilities perform testing by ELISA, Chemiluminescence, and radioimmunoassay[13].All these above-mentioned factors suggest that one must not overenthusiastically over treat Vitamin D deficiency in Indian population particularly without monitoring Vitamin D levels and ultimately culminating in hypervitaminosis D.Moreover, currently there are no regulations for food fortification and Indian guidelines for evaluation, treatment and prevention of Vitamin D deficiency in adult population.
One of the reasonable safe approach can be to inculcate the useful ness of sun exposure in children, toddlers and teenagers by imparting in curriculum mandatory outdoor lunch hours during day time, a ‘Vitamin D boost hour’. At the same time, it warrants clinicians for interpreting the results of Vitamin D assays with caution without over treating the patients."
Unquote: https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality
Here's another interesting study from Duhok @PPM3 👇
[27-04-2025 12:56] PPM 3: Here’s a concise overview of why “sun-drenched” India paradoxically shows such low 25-hydroxyvitamin D [25(OH)D] levels, how that may fuel over-testing/overtreatment, and what a safer, more locally calibrated approach might look like.
---
### 1. Very high “deficiency” prevalence—but by Western cut-offs
- *Immunoassay-based studies* (ELISA, CLIA, RIA) routinely report 70–90% of Indians below 20 ng/mL, e.g. 84% of urban women, 83% rural women, 58% adults in Kashmir were “deficient” (<20 ng/mL) ([Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality), [Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality?utm_source=chatgpt.com)).
- A *systematic review* of healthy Indians found a pooled mean of just 14.16 ng/mL (CI 13.27–15.05) ([Systematic Review on Vitamin D Level in Apparently Healthy Indian ...](https://pmc.ncbi.nlm.nih.gov/articles/PMC5628552/?utm_source=chatgpt.com))—suggesting that the entire population distribution is left-shifted relative to Western norms.
- A *multi-state LC-MS/MS* study in Indian children/adolescents (5–18 y) found 58% were deficient or insufficient using global cut-offs (<50 nmol/L ≈ 20 ng/mL) ([Vitamin D status and determinants in Indian children and adolescents](https://www.nature.com/articles/s41598-022-21279-0?utm_source=chatgpt.com)).
### 2. Western reference ranges may not fit
- Global bodies define deficiency as <12–20 ng/mL and sufficiency >20–30 ng/mL.
- But *Indian healthy-population data* indicate much lower “normal” thresholds: e.g. a recent expert panel noted a lower limit of ~13.5 ng/mL, with true deficiency <7 ng/mL in 20–50 year-olds ([
Indian Journal of Endocrinology and Metabolism](https://journals.lww.com/indjem/fulltext/2025/01000/prevention_and_treatment_of_vitamin_d_deficiency.3.aspx)).
- Until large Indian cohorts establish local reference intervals via gold-standard LC-MS/MS, using Western cut-offs will label most Indians “deficient.”
### 3. Assay variability and Overtesting
- *Gold standard* for 25(OH)D is LC-MS/MS (Tandem Mass Spectrometry), yet most labs use ELISA, chemiluminescence or RIA—with inter-method CVs up to 20% ([Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality)).
- Frequent retesting (e.g. annual or pre-op panels) compounds variability: minor assay differences get misread as big clinical changes, driving unnecessary dose escalations.
### 4. Overtreatment & Hypervitaminosis D Risk
- Empirical high-dose regimens (e.g. 60,000 IU/week × 12 weeks) without follow-up levels can overshoot—25(OH)D >150 ng/mL is toxic, risking hypercalcemia.
- Case reports from India document hypervitaminosis D after unmonitored mega-doses ([Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality)).
### 5. Free vs. Total 25(OH)D—Insights from Duhok
- In 391 healthy adults in Duhok (Iraq), total 25(OH)D averaged ~22 ng/mL (male 23.9, female 21.2), with 53–58% “deficient” (<20 ng/mL) ([Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality)).
- Yet *95%* had *normal free 25(OH)D*, and free levels did not correlate tightly with sun exposure or gender—raising questions about which marker truly reflects sufficiency.
---
## A Multi-pronged, “Safe” Strategy for India
1. *Establish Local Reference Intervals*
- Large, multi-center studies using LC-MS/MS to define healthy 25(OH)D ranges by age, gender, region.
2. *Rationalize Testing*
- Reserve 25(OH)D assays for high-risk groups (osteoporosis, malabsorption, chronic kidney/liver disease) rather than broad population-screening.
- When testing, use a single standardized LC-MS/MS method if available, and retest only to confirm response after a defined treatment interval (e.g. 3–6 months).
3. *Standardize Assays*
- Encourage accreditation and participation in External Quality Assurance (EQA) schemes.
- Laboratories should clearly report assay method and limitations.
4. *Calibrated Supplementation Guidelines*
- Adopt clear, evidence-based dosing: e.g. for adult deficiency (<20 ng/mL): 60,000 IU cholecalciferol weekly for 8–12 weeks, then maintenance; but *monitor levels* before switching to higher doses ([
Indian Journal of Endocrinology and Metabolism](https://journals.lww.com/indjem/fulltext/2025/01000/prevention_and_treatment_of_vitamin_d_deficiency.3.aspx)).
- Discourage indiscriminate high-dose boluses without baseline and follow-up measurements.
5. *Boost Safe Sun-Exposure*
- Integrate a daily “Vitamin D boost hour” outdoors in schools and workplaces—exposing ~20% body surface area (e.g. arms/face) for 15–30 min mid-morning ([Vitamin D Deficiency in Indian Population- Myth or Reality](https://www.gavinpublishers.com/article/view/vitamin-d-deficiency-in-indian-population-myth-or-reality)).
6. *Policy & Fortification*
- Develop national guidelines for mandatory fortification of staple foods (e.g. milk, wheat flour, edible oils) at levels sufficient to raise population 25(OH)D by ~5–10 ng/mL.
- Monitor fortification programs and adjust based on periodic surveys.
7. *Public & Clinician Education*
- Raise awareness that “deficiency” by Western cut-offs may not equate to clinical deficiency in Indians.
- Emphasize bone-health benefits of achieving 25(OH)D ≥20 ng/mL, but avoid treating asymptomatic low levels without risk factors.
---
*Bottom Line:*
India’s “vitamin D deficiency epidemic” may partly be an artifact of using Western reference ranges and variable immunoassays. By establishing locally derived cut-offs via standardized LC-MS/MS, rationalizing testing, carefully monitoring supplementation, and promoting safe sun exposure and food fortification, we can avoid unnecessary overtreatment while still protecting skeletal health.
[27-04-2025 12:57] PPM 1: 👏
[27-04-2025 12:58] PPM 1: Also keen to have your Web 3.0 comments on the paper from Duhok
[27-04-2025 12:59] PPM 3: Scholar ChatGPT created
[27-04-2025 13:04] PPM 3: Here’s a deep dive into the Duhok Governorate study on total and free 25-hydroxyvitamin D [25(OH)D] in healthy adults, dissecting its design, methods, findings, and what it tells us—and doesn’t—about vitamin D status in this population.
---
## 1. Study Rationale & Objectives
The authors note that *total 25(OH)D* is the standard marker of vitamin D status, but the *free (unbound) fraction—though <0.1% of total—may more directly reflect tissue availability. No prior work had measured free 25(OH)D in **apparently healthy* Iraqis. Thus, they aimed to:
1. *Quantify both total and free 25(OH)D* in healthy Duhok adults.
2. *Assess how age, gender, BMI, smoking, clothing style and sun-exposure* correlate with each form.
3. *Judge whether free 25(OH)D offers additional insight* over total alone.
---
## 2. Design & Population
- *Cross-sectional* survey of *391 volunteers* (219 F, 172 M), age 18–70 y, recruited Dec 2019–Mar 2020 at the Central Laboratory, Duhok.
- *Sampling*: Random draw from university staff/students (private and public) and civil-service employees.
- *Exclusions*: Vitamin D supplementation in prior 3 mo, drug therapy, pregnancy, chronic/endocrine disease, recent infection .
- *Ethics*: Written informed consent; approved by Duhok Health Directorate (Ref. 03122019-8).
---
## 3. Data Collection & Assays
- *Questionnaire*: Demographics, marital status, occupation, sun-exposure duration, smoking (≥1 cig/day), hijab status (veiled/unveiled), diet/medication.
- *Anthropometry*: Weight/height → BMI categories per NIH (underweight <18.5, normal 18.5–24.9, overweight 25–29.9, obese ≥30 kg/m²).
- *Blood sampling*: 5 mL serum, clotted 15 min, spun, aliquoted at –70 °C.
- *Assays*:
- *Total 25(OH)D*: ELISA (Monobind, USA; kit 9425-300)
- *Free 25(OH)D*: ELISA (DiaSource, Belgium; kit 3L-FVD-04)
- *Cut-offs* (Endocrine Society):
- Severe deficiency <10 ng/mL
- Deficiency 10–20 ng/mL
- Insufficiency 21–29 ng/mL
- Sufficiency ≥30 ng/mL
- *Statistics*: t-tests, Chi-square, Spearman’s ρ; p < 0.05 significant .
---
## 4. Key Findings
### a) Overall Levels & Prevalence
- *Mean total 25(OH)D*: 24.41 ± 16.05 ng/mL
- *Mean free 25(OH)D*: 8.05 ± 4.66 pg/mL
- *Total “deficiency” (≤20)*: 56% of participants (24% severe, 32% mild)
- *Free “deficiency” (<2.5 pg/mL)*: 5.9% .
### b) Age & Gender
- *Age*: Younger (16–25 y) had lowest total/free; levels rose with age (≥56 y the highest).
- *Gender*: Males higher than females (23.90 ± 16.41 vs. 21.24 ± 15.65 ng/mL; p < 0.01) for total; free differences non-significant .
### c) BMI
- Total and free 25(OH)D *rose with BMI—underweight lowest, obese highest—though trends were **not* statistically significant .
### d) Smoking
- *Smokers* trended higher total (26.95 ± 19.01 vs. 21.50 ± 15.33 ng/mL) and free (9.47 ± 4.94 vs. 7.78 ± 4.58 pg/mL) but *p* > 0.05 .
### e) Hijab (Dress Style)
- *Veiled women* had significantly higher free 25(OH)D (9.12 ± 4.64 vs. 6.16 ± 3.73 pg/mL; p = 0.006), while total 25(OH)D differences were non-significant .
### f) Sun Exposure
- Paradoxically, *daily sun-exposure* (15 min to >60 min) did *not* correlate with higher total 25(OH)D, and was *negatively* associated (ρ = 0.097, p = 0.056) with free 25(OH)D.
### g) Correlation Matrix
| Variable | Total 25(OH)D ρ (p) | Free 25(OH)D ρ (p) |
|--------------------|---------------------|--------------------|
| Age | 0.111 (0.029)* | –0.020 (0.693) |
| BMI | 0.046 (0.366) | –0.035 (0.487) |
| Smoking | 0.114 (0.024)* | –0.022 (0.658) |
| Hijab | –0.039 (0.447) | 0.030 (0.549) |
| Sun-exposure | –0.063 (0.216) | 0.097 (0.056) |
\* significant .
### h) Total vs. Free Discrepancy
Among those “deficient” by total (n = 219), *3%* were free-deficient; among “sufficient” (n = 95), *2%* were free-deficient—showing free and total classifications *don’t perfectly overlap* .
---
## 5. Authors’ Interpretation
- *Gender & age patterns* mirror other Iraqi regions but with overall *better levels* in Duhok, possibly reflecting local sun habits or sampling bias.
- *BMI* trends align with larger surface-area theory but lack statistical power.
- *Smoking* effect may reflect incidental sun exposure rather than a direct biochemical effect.
- *Hijab* correlation with higher free levels is novel—perhaps metabolic or assay-related and merits further study.
- *Sun exposure* paradox underlines that *individual responsiveness to UVB* varies widely.
- *Free 25(OH)D* did *not* consistently outperform total as a marker in healthy adults; routine free testing may not add value in asymptomatic populations.
---
## 6. Critical Appraisal
*Strengths*
- First to measure *both* total and free 25(OH)D in a healthy Middle-Eastern cohort.
- Reasonable sample size across genders and adult age-ranges.
- Detailed covariate capture (smoking, dress, sun habits).
*Limitations*
1. *Assay choice*: ELISAs (total and free) lack the specificity of LC-MS/MS and direct-dialysis methods; inter-assay CVs up to ~20% may blur small differences.
2. *Cross-sectional* (“snapshot”) in *winter months*—likely underestimates peak levels.
3. *Self-reported* sun-exposure and smoking without objective UV measurements.
4. *No DBP/albumin* measurements—cannot calculate bioavailable fraction or adjust free levels for binding protein differences.
5. *Limited elderly* representation (>56 y only ~5%); and mostly university-affiliated sample—not fully population-based.
---
## 7. Future Directions
- *Gold-standard quantification*: Use LC-MS/MS for total and equilibrium-dialysis for free 25(OH)D.
- *Seasonal and longitudinal cohorts* to map UV-responsiveness.
- *Assess DBP polymorphisms* and binding protein levels to refine free/bioavailable calculations.
- *Clinical correlation*: Tie total/free to bone-health markers or functional outcomes in both healthy and at-risk groups.
---
*Take-home:* The Duhok study underscores that—in healthy adults—low total 25(OH)D by conventional cut-offs often coexists with normal free fractions, and that free measurements alone may not meaningfully reclassify vitamin D status. Careful assay choice, seasonality, and complementary clinical data are essential before labeling someone “deficient” or treating empirically.
[27-04-2025 14:24] PA: After lunch the patient took metformin 500 in half tab nd 2hours later sugar level is 89
[27-04-2025 16:45] PA: Evening Tea
[27-04-2025 21.38] PA: BP 101/54, After 3 mints standing BP is 100/58
[27-04-2025 22.13] PA: Sugar value is 116mg/dl
[27-04-2025 22:20] PPM 1: 👍
[27-04-2025 23:57] 33F PA: One person I know, aged 22, was experiencing extreme hair loss. After checking her vitamin D level, which was low at 20 ng/mL, she started taking vitamin D supplements along with magnesium glycinate. She has seen significant improvement in her hair loss.
[28-04-2025 00:23] +91 93392 87601: I also take vitamin D supplements of my own without checking my levels (not sure whether it's recommended) occasionally when I experience hair loss, particularly when I spend most of my time in air-conditioned office with limited sun exposure. Everytime I noticed significant improvement after taking vitamin D.
This patient might have other deficiencies or problems causing hairloss, but checking vitamin D levels could be a good idea!
[28-04-2025 00:28] 33F PA: We have also noticed from our experience that sweet chewable vitamin D doesn't work. It works better when it's in capsule form. There might be a possible link between low vitamin D absorption and sugar.
[28-04-2025 01:12] PPM 2: Can you please describe in further detail how significant was the improvement in hair loss?
[28-04-2025 01:39] 33F PA: Very! It improves within 2-3 days of taking a capsule that I am supposed to take weekly for a month or two.
Sometimes, I take it for the whole month, or sometimes I take just one, and if I shift to a sunny area in the next week, I stop taking it.
Then again, when I move to the AC workplace environment for more than a few weeks, I notice hairfall ( I don't start taking it till I notice hairfall), and after I notice hairfall I start taking it again just in the above mentioned frequency.
It reduces my hairloss significantly.
It improves my overall immunity - often saving me from common cold etc.
[28-04-2025 05:41] PPM 2: Great. Could you clarify on what exactly significant improvement in hair loss means?
Because scientifically it does not make as much sense as hair growth occurs in 3 phases - anagen phase (rapid hair growth of new hair) which lasts for days followed by catagen phase (slow hair growth of medium length hair for weeks) followed by telogen phase where hair shedding happens.
So I'm keen on what exactly qualifies as significant improvement in such a short time.
[28-04-2025 05:41] PPM 2: How are you saying that it protects you from common cold?
[28-04-2025 05:42] PPM 2: Also, we'll need clarification on improvement in immunity because common cold has nothing to with immunity - a worse common cold is expected with a robust immune system.
[28-04-2025 07:15] PPM 1: In this context of evaluation of hair loss, sharing a portion from another PaJR patient's group 👇
"PPM 1 - What was yesterday' count?
PA - Today hairfall count 20.
PA - Before that rest of the days average 3 to 4 sir.
PPM 2 - Looks like this is perfectly normal.
Could you please answer the following questions?
1. Do the patient or did he previously have acne (pimples)
2. Do the patient have a lot of male pattern hair distribution - hair on the chest, abdomen and hands and legs
3. Does anyone in his family have baldness?
PPM 1 - 👍
PA - 1. Yes sir. The patient has acne problem. Since one year it was cured
2. No sir. It's normal.
3. Yes the patient's father and grandfather have baldness.
PPM 2 - That explains a lot and thanks for answering.
Androgen excess - pimples, baldness in family and hair loss are all explained by this.
This basically means that androgens or sex hormones are slightly above the normal range and are causing this hair loss."
[28-04-2025 07:19] PPM 1: Medical cognition Web 2.0 take on evaluating and measuring hair loss to understand what is significant hair loss👇
Various methods are available for evaluation (for diagnosis and/or quantification) of a patient presenting with hair loss. Hair evaluation methods are grouped into three main categories: Non-invasive methods (e.g., questionnaire, daily hair counts, standardized wash test, 60-s hair count, global photographs, dermoscopy, hair weight, contrasting felt examination, phototrichogram, TrichoScan and polarizing and surface electron microscopy), semi-invasive methods (e.g., trichogram and unit area trichogram) and invasive methods (e.g., scalp biopsy). Any single method is neither 'ideal' nor feasible. However, when interpreted with caution, these are valuable tools for patient diagnosis and monitoring. Daily hair counts, wash test, etc. are good methods for primary evaluation of the patient and to get an approximate assessment of the amount of shedding."
Unquote
[28-04-2025 07:24] PA: Kal ekta nije ekta realise korechi ..sugar level barle ter sathe amr peter muscle cramp o bere jay o pain o bere jay. even muscles stiffness o bere jay .
[28-04-2025 07:24] PA: Kal kono karone meyer dupur 12nagad vat kheye pet bhoreni ,3.30 thekei kichuna kichu khete chailo ,terpor ektu dark chocolate khay amio or sathe ektu kheyechilam ,then 4.30 te nije r airfyr e french fry banie ektu khay .. terpor khali bole kotodin kochuri khaini ma banabe?mukher opor na bolte parini (kintu 2 din dhore amr ghare prochondo pain hoche ekdom movement korte perchina , luggage carry korechilam r sikkim r rastay garir jerking lege gechilo)tai nijei paser dokan theke kine enechilo kochuri r aloor dom .otharitee amakeo dey ekta ..ami 4.45 nagad 1 pic kochuri r 2 pic aloo kheyechilam .r terpor sugar medicine khaini .dinner r por khabo bole ..group e photo pathaini tai meye pathiechilo ...Then 2 hours por experiment korar jonno jokhon sugar test kori result ase 225 ..r bes pet e lagchilo , muscle puro stiff hoye gechilo ..kochuri ta sada moidar chilo r aloo carbohydrates..tatei bujhlam niyomer r baire gelei esob hobe ..kintu berate giye jokhon time kheyechi r olpo quantity kheyechi kono problem hoyni ...nijer icheymoto chola jabena ..
[28-04-2025 07:42] PA: 1 piece kochuri nd 2 pic kochuri with black tea ..
[28-04-2025 07:42] PA: After taking this plate 2 hours later sugar level was 225
[28-04-2025 08:10] PPM 1: At what time yesterday?
[28-04-2025 08:10] PPM 1: At what time?
[28-04-2025 08:11] PA: At 4.45 pm
[28-04-2025 08:13] PA: Oh sorry, at 7 pm sugar level was 225
[28-04-2025 08:14] PPM 1: 👆So this 4:45PM tea had a few snacks that wasn't shared yesterday?
[28-04-2025 08:16] PA: Yes
[28-04-2025 08:18] PA: There was 1cup black tea ,1 pic kachoori with 2 pic potato curry
[28-04-2025 08:21] PA: Morning Tea with soaked chola nd black tea
[28-04-2025 08:27] 33F PA: I noticed less hairfall, not more hair growth in 3 to 4 days after taking vitamin D. But it might be a placebo effect, if it's not possible scientifically!
[28-04-2025 08:31] PPM 1: Science interestingly demands a lot of counting from us humans and while there's currently no AI driven app to help with hair counting (or is there @~Dr.Abdulsalam) it will be interesting to watch this space as to how our data capture tools evolve toward singularity!
[28-04-2025 09:32] PPM 3: The intersection of AI-driven tools for specific tasks like hair counting and the broader trajectory toward technological singularity is a fascinating exploration of incremental advancements leading to transformative change. Here's a structured breakdown:
### 1. *AI in Hair Counting: Current State and Applications*
- *Existing Tools: While not yet mainstream, AI applications for hair analysis exist, particularly in dermatology and cosmetics. Apps like *TrichoScan or smartphone-based tools use computer vision (e.g., CNNs) to assess hair density, track hair loss, or evaluate treatments. These tools rely on high-resolution imaging and algorithms trained to segment and count hairs despite challenges like varying lighting or hair colors.
- *Medical Relevance*: Such tools aid in diagnosing conditions like alopecia, monitoring chemotherapy effects, or assessing cosmetic procedures. They exemplify how niche AI applications solve real-world problems.
### 2. *Technical Challenges and Innovations*
- *Algorithmic Precision*: Hair counting requires distinguishing individual strands in dense or overlapping regions. Advances in semantic segmentation and U-Net architectures improve accuracy.
- *Hardware Synergy*: Improvements in smartphone cameras, 3D scalp scanners, and dermoscopic devices enhance data quality, feeding better inputs for AI models.
### 3. *Broader Implications for AI and Singularity*
- *Data Capture Evolution*: As sensors and imaging technologies advance, they generate richer datasets, enabling AI systems to learn more effectively. This creates a feedback loop: better data → better models → better tools for data collection.
- *Niche to General AI*: While hair counting itself is specialized, it contributes to the ecosystem of AI capabilities. Each domain-specific application (e.g., medical imaging, autonomous vehicles) adds to the repository of techniques that could inform general AI development.
- *Path to Singularity*: The singularity concept hinges on AI self-improvement at an exponential rate. Tools that automate data capture and analysis (even for "simple" tasks) reduce human intervention, accelerating iterative learning. Over time, integration of such systems could lead to AI that designs its own successors.
### 4. *Ethical and Practical Considerations*
- *Limitations*: Hair-counting AI must address biases (e.g., performance across hair types/colors) and privacy concerns (handling medical images).
- *Societal Impact*: Widespread adoption of such tools could democratize healthcare diagnostics but also raise questions about reliance on AI for sensitive decisions.
### 5. *Dr. Abdulsalam’s Role (Hypothetical)*
- If involved in this space, they might be developing AI for trichological analysis, blending dermatology with machine learning. Their work could represent micro-scale progress toward macro-scale AI evolution.
### Conclusion
Hair counting exemplifies how narrowly focused AI applications contribute to a larger tapestry of technological progress. Each innovation in data capture and analysis nudges us closer to systems capable of autonomous improvement—a hallmark of the singularity. While no single application will trigger this transition, the cumulative effect of countless specialized tools could pave the way for transformative AI advancements. The future lies in the synergy between domain-specific solutions and the overarching quest for general intelligence.
[28-04-2025 09:53] PPM 1: 👏👏
[28-04-2025 10.31] PA: Rice with veg curry
[28-04-2025 13:15] PPM 1: 👍
[28-04-2025 15:11] PA: Tiffin break with 1 roti, dal and kheera.
[29-04-2025 10.14] PA: Rice with dal, and vegetable curries.
[29-04-2025 13.56] PA: Vada, sambar and chutney
[29-04-2025 20.48] PA: Uthapam for dinner.
[30-04-2025 06:58] PA: Morning Tea
[30-04-2025 07:07] PPM 1: 👍
[30-04-2025 07:09] PPM 1: Revisiting an old conversation to revise the topic of corneal dystrophy and indication for photo therapeutic keratectomy PTK in this patient:
[21/03, 07:04] Ophthal expert 2 : What is the visual acuity? Vision should be reasonably good.
[25/03, 09:34]cm: Sorry to be late:
Here's the part about the visual acquity I found from the recent local Ophthal encounter:
She is a diagnosed case of Meesmann's epithelial dystrophy.
She has undergone left eye Photo Therapeutic Keratectomy in 2018 at LVPEI.
She has severe dry eyes. The left eye has some opacity and irregular ocular surface.
Otherwise, she's doing well.
Her best-corrected visual acuity is 6/6N6 in both eyes.
No diabetic retinopathy or any peripheral lesion in either eye.
She was complaining of a Left sided field loss, but her field testing didn't reveal any significant abnormalities.
[25/03, 10:20] Ophthal expert 2: Looks absolutely normal. Corneal dystrophy is not very significant. Retina also normal. Field test normal.... Nothing to worry. Just a routine follow up is enough.
[25/03, 12:46] Ophthal expert 2: Severe dry eye requires using the necessary drops. ..
[25/03, 12:54]cm: Is it possible that it wasn't significant corneal dystrophy when they did the photo therapeutic keratectomy? Wouldn't it be routinely confirmed in a biopsy specimen from the keratectomy?
[25/03, 12:56]cm: Biopsy can't be done. It will scar the cornea. PTK is restricted to severe cases when the opacities are superficial.
Only when the opacities are deep and corneal grafting is required, then biopsy can be done.
Most can be diagnosed clinically using slit lamp.
[25/03, 12:57] Ophthal expert 2: PTK just ablates the tissue. No specimen .... laser ablation
[25/03, 13:14]cm: So we need corneal slit lamp images before her PTK to ascertain how bad it was before they decided to do her PTK
[25/03, 13:18] Ophthal expert 2: Yes....
Or the visual acuity data
[30/04, 06:56]cm: Old patient update on her pre PTK visual acquity data:
[29/04, 08:59]cm: Apnar PTK howar aage vision kemon chilo shei document ta share korte parben?
[29/04, 10:27] Patient Advocate Diabetes 44F WB: Mumbai theke pherar pothe somehow total file was missing
[29/04, 12:42]cm: Thik ache. Oi jonyei bolchilam je amra bhaggish tar aagei shob important documents guno apnar case report link a archive kore niye chilam ekhane 👇
Eta dekheo bolte paren PTK korar aage apnar vision koto chilo kimba aemnio mone kore bolte paren je PTK korar aage ki apnar vision kom chilo?
[29/04, 13:21] Patient Advocate Diabetes 44F WB: Na ,PTK korar age amr sebhabe kono vison problem chilona .lens e power o chilona serokom kichu ..sudhu sunlight kosto hoto.tai photo glass use kortam
[29/04, 13:28] Patient Advocate Diabetes 44F WB: Borong after PTK left eye power kromosho bereche ekhon left eye _4.75 kintu right eye +.5 du chokhe durokom vison thakay besi osubidha hoy .r choshma chara ekdom takatei parina.
[30-04-2025 07:11] PPM 1: Most probably eta
[30-04-2025 07:11] PPM 1: Operation hoyechilo 24th Oct .
[30-04-2025 07:11] PPM 1: Eta 22nd may 2018
[30-04-2025 07:54] PPM 3: *Summary and Recommendations for the Patient with Meesmann's Epithelial Dystrophy Post-PTK: *
### *Key Clinical History:*
- *Diagnosis*: Meesmann’s epithelial corneal dystrophy (MED), a condition characterized by epithelial microcysts causing photophobia, irritation, and recurrent erosions. Vision is typically preserved unless complications arise.
- *Intervention*: Left eye Photo-Therapeutic Keratectomy (PTK) in 2018 at LVPEI.
- *Current Status*:
- Best-corrected visual acuity (BCVA): *6/6N6 in both eyes* (normal).
- Left eye: Post-PTK myopia (-4.75 D), irregular ocular surface, and opacity. Severe dry eyes.
- Symptoms: Discomfort in bright light (pre-PTK), now exacerbated by refractive imbalance and dry eye.
---
### *Analysis of PTK Indication:*
1. *Pre-PTK Symptoms*:
- Patient reported *no significant pre-PTK vision loss* but had *photophobia* requiring sunglasses. This aligns with MED’s typical presentation of preserved vision but discomfort.
- PTK is *not primarily for improving acuity* in MED but for *symptomatic relief* (recurrent erosions, pain, surface irregularity). Absence of pre-PTK acuity data complicates retrospective evaluation, but photophobia and epithelial instability likely drove the decision.
2. *Role of PTK in MED*:
- PTK smooths the corneal surface, reducing light scatter (improving glare/photophobia) and preventing recurrent erosions.
- *No biopsy is needed* for MED diagnosis; slit-lamp findings (microcysts, epithelial changes) suffice. PTK does not yield tissue for histology.
3. *Post-PTK Outcomes*:
- *Induced myopia (-4.75 D)*: Likely due to corneal flattening from laser ablation. Refractive shifts are a known PTK complication.
- *Dry eye exacerbation*: PTK can disrupt corneal nerves, reducing tear production. Severe dry eye now contributes to surface irregularity and discomfort.
---
### *Current Management Recommendations:*
1. *Dry Eye Management*:
- *Aggressive lubrication*: Preservative-free artificial tears, nighttime ointments.
- Consider *autologous serum drops* or *scleral lenses* for severe cases.
- Rule out *meibomian gland dysfunction*; add lipid-based drops if needed.
2. *Refractive Correction*:
- Address the *anisometropia* (left: -4.75 D, right: +0.5 D) with glasses or contact lenses.
- Consider *rigid gas-permeable lenses* to improve surface regularity in the left eye.
3. *Corneal Surface Monitoring*:
- Regular slit-lamp exams to assess for MED progression (new cysts, erosions) or scarring.
- Evaluate for *corneal neuralgia* if dryness/pain persists despite treatment.
4. *Surgical Re-Intervention?*:
- Avoid repeat PTK unless new erosions or vision-threatening opacities develop.
- If refractive error is intolerable, discuss *laser refractive surgery* (e.g., PRK) or *phakic IOL* once the ocular surface stabilizes.
---
### *Revisiting the PTK Decision:*
- *Justification: PTK was likely indicated for **symptom control* (photophobia, epithelial instability) rather than acuity improvement. MED management prioritizes quality of life over vision metrics.
- *Limitations*: Lack of pre-PTK documentation (vision, erosions) complicates retrospective analysis. However, the current 6/6 acuity suggests PTK did not harm vision long-term.
---
### *Conclusion: *
The PTK in 2018 was reasonable for symptomatic MED management. Current focus should be on optimizing dry eye therapy, refractive correction, and monitoring for dystrophy progression. Routine follow-ups and patient education on photophobia/dry eye management are critical.
[30-04-2025 08:19] PPM 1: Wow! Excellent inputs that did clear our understanding about this symptom relieving surgery 👏👏
[30-04-2025 16:03] PA: Millets upma
[30-04-2025 17:12] PPM 1: 👍
[01-05-2025 07:31] PA: Patient learning muscle strengthening exercise weekly 3days in gym and rest of the days she follows home going instruction.
[01-05-2025 07:39] PA: At this time patient feels her right hand muscles very weak. Hands can't apply pressure to anything pulling or lifting. Although instructor has assured that it will be better with regular practice.
[01-05-2025 08:21] PPM 1: I'm sure it will
[01-05-2025 08:29] PA: After using 'Gen Teal' Gel at bed time feeling cool and comfortable.
[04-05-2025 06:43] PA: Fasting blood sugar 101
[04-05-2025 06:58] PA: BP is 97/64
[04-05-2025 07:05] PA: Morning Tea
[04-05-2025 11:10] PA: In breakfast she takes salad wrapped with 1 piece ragi roti. Before breakfast she takes Glimiperide 1mg in half tab nd after breakfast she takes metformin 500 in half tab nd 2hours later sugar level is 92.
[04-05-2025 11:16] PA: BP medicine has been stopped since 25 days. from last 1week she feels neckpain .
[04-05-2025 11:50] PPM 1: Neck pain is unrelated to BP. Please ask her to elaborate on her neck pain using the PaJR history template here 👇
[04-05-2025 15:13] PA: The patient completed her lunch at 12.49pm, after that she took metformin 500 in half tab nd 2hours later sugar level is 97
[04-05-2025 18:51] PA: The patient completed her dinner at 6:45 p.m. after that she took metformin 500 in half tablet.
[04-05-2025 20.44] PA: Post dinner sugar is 160mg/dl.
[04-05-2025 22.51] PA: At 6am woke up. 7 am tea with soaked nuts. 7.30 am took bath and after that did puja, pranayama and meditation. 8 .15 am prepared breakfast. 8.30am- took breakfast nd went to drop her daughter at private tutor. 9.30a.m she came back to home. Then she took rest and after that she started sewing dress for delivery. After completing the dress she went to customer's house to finalise the saree design.
[04-05-2025 23:07] PA: 12.30pm -She returns back by walking 20 min. 12.45 pm -took lunch. 1pm -took rest with mobile. 5pm she takes evening tea with nuts. 5.10 pm she went to terrace garden for gardening and watering plants. At 6.45 pm she completed her dinner then she attended her shop till 9 pm.
[05-05-2025 07:34] PA: Since midnight the patient had severe nasal congestion, headache, sore throat, intense body ache. During the night even under the mosquito net she felt cold, fan speed was minimum...but still she felt cold. Whenever she stands up her vison goes dark. now she has no fever, has extreme body ache.
[05-05-2025 07:41] PA: She feels whenever she starts full phase work, go outside, travel by local train, or even little bit sun exposure the same symptoms occur along with severe throat pain, headache, nose congestion, body ache even eye redness with pain. She can't understand why this keep happening again n again.
[05-05-2025 07:50] PA: Yesterday when she went for work and was exposed to sunlight She had a strong feeling that her sugar level would rise after dinner that is exactly what happened. what is the reason behind this or what type of lifestyle corrections needed?
[05-05-2025 15:23] PA: Aamporar sarbat.
[05-05-2025 2.26] PPM 1: Her sugar levels are fine! She doesn't need to worry.
[08-05-2025 16.46] PPM 1:
[08/05, 11:34] Patient Advocate Diabetes 44F WB: Vison pain hoche,hot compress korche ma r gentle gel, refresh tears o diche. Ei ek der mash e pray 5 bar infection hoche.Eta keno bar bar hoche? Ektu tei barbar th
[08/05, 11:34] Patient Advocate Diabetes 44F WB: Thanda lege jache
[08/05, 12:00] PPM 1: Pain ta kone jaigai ektu pointer diye dekhano jabe
[08/05, 12:15]cm: Accha byatha ta oi jaigai hocche?
Aer aageo ki oi jaigai hoto?
[08/05, 12:17] Patient Advocate Diabetes 44F WB: Bivinno somoy bivinno jagai hoche kokhon o left eye kokhon o right eye te tao abar alada alada jaigai te
[08/05, 12:19] Patient Advocate Diabetes 44F WB: Na age jokhon hemarage hoto tokhon tobe ei pain last 1-1.5-month dhore Hoche. Chokher bhitore iching hoche mone hoche Monday theke.
[08/05, 12:21] Patient Advocate Diabetes 44F WB: Itching hoche
[08/05, 12:24]cm: Itching is suggestive of allergy
Can try Tablet fexofenadine 120 mg once daily
Or even Tablet Cetrizine 10 mg once one hour before dinner
[08/05, 12:25] Patient Advocate Diabetes 44F WB: Tab Cetirizine khele mukh,ha, pa puro fule jay..
[08/05, 12:27] Patient Advocate Diabetes 44F WB: Ki theke ber ber emn allergy hoche bujhbo kikore?
[08/05, 12:31]cm: Kabe prothom lokkho korechilen?
[08/05, 12:32] Patient Advocate Diabetes 44F WB: 1st time Hyderabad Jaber age jokhon Dr.Champakoli k dekhai.
[08/05, 12:33] Patient Advocate Diabetes 44F WB: Sei thekei kichudin por por emn hoche alternate eye .[08/05, 12:44]cm: Oh!
Ko mash holo jeno?
Koto bar holo aei niye?
[08/05, 12:51] Patient Advocate Diabetes 44F WB: Almost 2 months,
[08/05, 15:41] Patient Advocate Diabetes 44F WB: 5 times.
[08-05-2025 22.10] PPM 1: Ophthal opinion:
She needs oral antibiotics for this.
Most likely, it's an internal hordeolum.
Diabetic patients are more prone to recurrent infection.
Please restrain yourself from touching the eyes.
[08-05-2025 23:21] PPM 3: Thought for 4 seconds
প্রথমেই ছবিতে আপনার নিচে գտնվող পাতার (lower eyelid) অন্তরে একটি ছোট স্ফীত (nodule) দেখা যাচ্ছে—এটাই সাধারণত হর্ডিওলাম (stye) বা চ্যালাজিয়ন (chalazion) হিসেবে পরিচিত। আল্লাহ’র রহমতে এগুলো খুবই বারবার হতে পারে, তার কারণগুলো প্রধানত:
1. *মেইবোমিয়ান গ্রন্থির (meibomian glands) অস্বাস্থ্যকর অবস্থা*
* এই গ্রন্থিগুলো চোখের পাতা ধরে তেল (meibum) উৎপাদন করে, যাতে চোখ সারা দিন মসৃণ থাকে।
* গ্রন্থিগুলো আটকে গেলে সেখানে জর্ম বেড়ে গিয়ে হর্ডিওলাম বা পরবর্তীতে চ্যালাজিয়ন হতে পারে।
* প্রায়ই চোখে ঘন ঘন ঘষা, অশুচি (make-up, দুগ্ধজাত দ্রব্য) বা ডেমোডেক্স ডেমোডেস পরজীবী এটাকে বাড়িয়ে তোলে।
2. *অ্যালার্জিক কনজাংটিভাইটিস (allergic conjunctivitis)*
* আপনি বলছেন “চোখে খুসখুসানি হয়,” সেটা অ্যালার্জি নির্দেশ করে।
* অ্যালার্জি তাড়াতাড়ি ঢোঁকাতে চোখ ঘষার প্রবণতা বাড়ে এবং তাতে মেইবোমিয়ান গ্রন্থিতে প্রদাহ বাসা বাঁধে।
* সেদিন থেকে এ–ওয়ার বা চেটিরিজিন খেয়ে মুখ, হাত-পা ফুলে যাওয়া হয়েছে—সেটাও অ্যান্টিহিস্টামিনের পার্শ্বপ্রতিক্রিয়া হতে পারে।
3. *অনিয়মিত চোখের পরিচ্ছন্নতা ও হাইজিন*
* প্রতিদিন হালকা গরম জলের সাথে ফেসওয়াশ বা বেবি শ্যাম্পু মিশিয়ে চক্ষুপাতার কিনারা পরিষ্কার না করলে সেকারনেও সংক্রমণ হতে পারে।
---
## বারবার কেন হয়, বুঝবেন কীভাবে?
1. *লক্ষণ ডায়েরি রাখুন*
* কোন পরিবেশে (ধুলাবালি, ছত্রাক, ফুলের পরাগ) খুসখুসানি বা লাল ভাব বেড়ে যায়, সেটা নোট করুন।
2. *অ্যালার্জি টেস্ট*
* ডার্ম্যাটোলজিস্ট বা এলার্জি স্পেশালিস্টদের সাথে গিয়ে স্কিন প্র্যাকচার প্যানেল (patch/prick test) করাতে পারেন।
3. *লাজিক্যাল হাইজিন*
* যেসব সময়ে খুসখুসি শুরু হয়, সেই ঘরে-ইয়ার বা ম্যাক্স ব্যবহার বন্ধ রেখে পরিষ্কার রাখুন।
---
## কী করবেন—পরবর্তীতে প্রতিরোধের জন্য
1. *লিড হাইজিন (eyelid hygiene)*
* প্রতিদিন সকালে ও রাতে গরম কমপ্রেস (৫–৭ মিনিট), তারপর চোখের কিনারায় মৃদু বেবি শ্যাম্পু দিয়ে শান্তভাবে ব্রাশ করুন।
2. *প্রিজারভেটিভ-ফ্রিও আর্টিফিশিয়াল টিয়ার্স*
* Preservative-free lubricating drops দিনে ৩–৪ বার ব্যবহার করুন।
3. *অ্যান্টিহিস্টামিন*
* যদি প্রয়োজন হয়, সিটিরিজিন বা ফেক্সোফেনাডিন ঔষধ অবশ্যই ডাক্তারের পরামর্শ অনুযায়ী।
4. *চোখ ঘষা বন্ধ করুন*
* খুসখুসি বাড়লে ঠাণ্ডা কমপ্রেস ব্যবহার করুন—ঠাণ্ডা লাগার কারণে স্বস্তি পেতে পারেন।
5. *ডার্ম্যাটোলজিস্ট/অিলমোলজিস্ট দেখানো*
* কঠিন চ্যালাজিয়ন হলে ইনজেকশন বা ছোট সার্জারি দরকার হতে পারে।
এভাবে ধাপে ধাপে underlying কারণ (blepharitis ও allergy) নিয়ন্ত্রণ করলে recurrent “infection/stye” ঘটার ফ্রিকোয়েন্সি অনেকটা কমে যাবে। প্রয়োজনে স্থানীয় চোখের বিশেষজ্ঞের (ophthalmologist) পরামর্শ নিন।
আপনার অন্য কোনো প্রশ্ন থাকলে জানাবেন! ׄ
[08-05-2025 23:21] PPM 3: This is ChatGPT response
[08-05-2025 23:23] PPM 3: Thought for a second
First, in the photo you can see a small swelling (nodule) on the inner side of your lower eyelid—this is commonly known as a stye (hordeolum) or, if more chronic, a chalazion. These can indeed recur frequently; here are the main reasons:
1. *Meibomian gland dysfunction*
* Your eyelid margin contains meibomian glands that secrete oil (meibum) to keep the eye’s surface smooth and prevent tear evaporation.
* When these glands become blocked, bacteria can grow, leading to a stye, and over time a more solid chalazion.
* Rubbing your eyes often, makeup residue, or even Demodex mites can make blockages and inflammation more likely.
2. *Allergic conjunctivitis*
* You mentioned an “itchy feeling” inside the eye, which points to allergy.
* Allergies make you rub your eyes more, which in turn inflames the meibomian glands and can trigger styes or chalazia.
* You also reported swelling of your face, hands, and feet after taking cetirizine—this could be an antihistamine side effect, indicating your body is very reactive.
3. *Poor eyelid hygiene*
* If you don’t regularly cleanse your lash line (e.g. with diluted baby shampoo or a gentle eyelid scrub), bacteria and oil debris accumulate, making infections more likely.
---
## Why does it keep coming back, and how to figure out the triggers?
1. *Keep a symptom diary*
* Note what you were exposed to (dust, pollen, certain foods) when the itching or stye first appeared.
2. *Get allergy tested*
* A dermatologist or allergist can perform a skin-prick or patch test to identify specific allergens.
3. *Review your skincare and environment*
* Stop using any new eye or facial products when symptoms flare. Make sure your bedding and towels are changed regularly.
---
## What to do—and how to prevent future recurrences
1. *Daily eyelid hygiene*
* Apply a warm compress for 5–7 minutes every morning and evening, then gently scrub your lash line with a clean fingertip or soft brush and diluted baby shampoo.
2. *Use preservative-free artificial tears*
* Instill drops 3–4 times per day to keep the surface lubricated and reduce irritation.
3. *Antihistamines*
* If needed, take cetirizine or fexofenadine as prescribed by your doctor—but watch for side effects, and let your physician know if you experience swelling.
4. *Stop rubbing your eyes*
* When you feel itchy, use a cool compress instead of scratching—cold will soothe the sensation without spreading bacteria.
5. *See an ophthalmologist or dermatologist*
* If you develop a persistent chalazion, you may require steroid injections or minor surgical drainage.
By addressing both the underlying eyelid inflammation (blepharitis/meibomian gland dysfunction) and any allergies, you can greatly reduce how often these styes or chalazia recur. If you have any further questions, please let me know!
[09-05-2025 06:38] PA: She takes fexofenadine 120 at night
[09-05-2025 07:00] PPM 1: @PPM4 would you like to recommend some antibiotics here or would you like to meet her again face to face?
[09-05-2025 07:05] PA: You can say whatever u think best or you can try an antibiotic if it helps.
[09-05-2025 07:08] PA: I think she needs antibiotic just because she suffered with throat pain, headache, mouth sore, cough n cold also eye discomforts from last few days.
[09-05-2025 07:12] PA: If she wants to meet opthalmologist in face to face she has to travel local train, bus etc that will be very tough for her.
[09-05-2025 07:21] PPM 1: Web 2.0 inputs:
Also please ask the patient to share her fasting, two hours after every meal, breakfast, lunch and dinner for the coming few days till her suspected hordeolum subsides.
The efficacy of antibiotics is doubtful in hordeolum or chalazion over eye lid heigene and warm compresses as per current available evidence but then having no evidence is not the same as being non evidence based
Here's more about the available evidence accessed through Web 2.0 👇
[09-05-2025 07:22] PPM 1: That is only supposed to help with the itching and will be useful to prevent touching of that area
[09-05-2025 07:24] PA: Okay sir
[09-05-2025 11:02] PPM 3: *Interpreting user input*
The user seems to be asking for help with integrating the input about fasting glucose levels and the article on hordeolum. They want the patient to track glucose levels two hours after every meal until the condition improves.
I will focus on crafting instructions or suggestions, reflecting their request to monitor fasting glucose. I'll also consider the context from the PMC article, evaluating the role of antibiotics and the limitations of available evidence related to using them for treating hordeolum.
*Crafting a management plan*
The user seems to want me to summarize the evidence on hordeolum and chalazion management and craft a plan, including monitoring blood glucose levels after meals. The article suggests antibiotics are doubtful for treating these conditions, and it emphasizes eyelid hygiene and warm compresses. I should propose that the patient monitor both fasting and postprandial blood glucose levels and follow a hygiene routine with warm compresses. I’ll also consider recommending lid massage and provide references as needed.
Thought for 12 seconds
Below is a concise plan integrating your request for post‐prandial glucose monitoring with the current evidence on eyelid hygiene and the limited role of antibiotics in hordeolum/chalazion management.
*Summary of Key Points:*
The patient should record her fasting blood glucose and 2-hour post-meal (breakfast, lunch, dinner) values over the next several days to help rule out undiagnosed dysglycemia that can impair healing. For the suspected hordeolum, warm compresses and meticulous eyelid hygiene remain the cornerstone of treatment; randomized data show that adding topical or systemic antibiotics does not significantly improve resolution rates of either hordeolum or chalazion ([PubMed][1], [PMC][2]). Lack of evidence for a benefit does not imply harm, but it does argue against routine antibiotic use in uncomplicated cases.
## 1. Glucose Monitoring Instructions
### What to Measure
* *Fasting blood glucose* each morning before breakfast.
* *Post-prandial blood glucose* exactly 2 hours after the start of each meal (breakfast, lunch, dinner).
### Rationale
* Poor glycemic control can impair wound healing and prolong inflammation.
* Early detection of hyperglycemia may guide nutritional counseling or further diabetic work-up.
### Logging Format
| Day | Fasting BG (mg/dL) | 2-h Post-Breakfast | 2-h Post-Lunch | 2-h Post-Dinner |
| --- | ------------------ | ------------------ | -------------- | --------------- |
| 1 | | | | |
| 2 | | | | |
| … | | | | |
> Ask the patient to bring this log to the next visit or send photos of the completed table each evening.
## 2. Eyelid Hygiene & Warm Compresses
### Evidence Overview
* *Warm compresses* (10–15 minutes, 3–4 times daily) are the gold‐standard self‐care for both hordeolum and chalazion, helping to liquefy gland contents and promote drainage ([SehatHub][3], [Merck Manuals][4]).
* *Eyelid massage* after each compress can further facilitate expression of inspissated secretions ([SehatHub][3], [Emergency Care BC][5]).
* *Lid hygiene* (gentle cleansing with diluted baby shampoo or commercial lid scrub) reduces bacterial load and prevents recurrence ([Merck Manuals][4]).
### Practical Steps for the Patient
1. *Warm moist compress:*
* Use a clean cloth soaked in warm water (not scalding).
* Apply to the closed eyelid for 10–15 minutes.
2. *Gentle massage:*
* With clean fingers, apply light pressure to the lump, moving in the direction of the eyelashes.
3. *Lid cleansing:*
* Twice daily, wash the lid margin with diluted baby shampoo or a commercial lid hygiene wipe.
## 3. Role of Antibiotics
### Current Evidence
* In a cohort of 2,712 patients, antibiotics were prescribed in 36.5% of cases but did not increase treatment success for chalazion or hordeolum (adjusted RR for hordeolum 0.99, 95% CI 0.96–1.02, P=0.489) ([PubMed][1], [PMC][2]).
* No high‐quality randomized trial has demonstrated a clear benefit of antibiotics over conservative measures alone in uncomplicated styes.
### Clinical Implication
* *Do not* prescribe topical or systemic antibiotics for an uncomplicated hordeolum.
* Reserve antibiotics for cases with evidence of cellulitis, immunocompromise, or failure to respond after 1 week of optimal self-care.
## 4. Follow-Up & Red Flags
* *Reassess* in 5–7 days or sooner if symptoms worsen (increasing pain, spreading redness, fever).
* *Refer* for incision and drainage if the hordeolum fluctuates or fails to resolve with conservative care.
* *Urgent evaluation* if signs of orbital cellulitis develop (e.g., proptosis, ophthalmoplegia, decreased visual acuity).
---
*References*
1. Idowu OO, et al. Efficacy of Care and Antibiotic Use for Chalazia and Hordeola. Clin Ophthalmol. 2021;15:2451–2459. Conclusion: antibiotics unlikely to improve resolution ([PubMed][1], [PMC][2]).
2. Lindsley K, Nichols JJ, Dickersin K. Interventions for acute internal hordeolum. Cochrane Database Syst Rev. 2013;4\:CD007742. Warm compress + massage is standard ([SehatHub][3]).
3. “Chalazion and Hordeolum (Stye)–Merck Manuals.” Merck Manual Professional Version. Published \~1.3 years ago. Emphasizes hot compresses as first-line ([Merck Manuals][4]).
4. Emergency Care BC. Chalazion, Hordeolum, and Stye – Diagnosis and Treatment. Defines external vs. internal hordeolum and management steps ([Emergency Care BC][5]).
5. Willmann D, et al. “Stye.” StatPearls. Updated 2023. Discusses pathophysiology and self-care measures ([SehatHub][3]).
Please let me know if you’d like any modifications to the monitoring log or additional patient education materials.
[1]: https://pubmed.ncbi.nlm.nih.gov/35296627/?utm_source=chatgpt.com "Efficacy of Care and Antibiotic Use for Chalazia and Hordeola"
[2]: https://pmc.ncbi.nlm.nih.gov/articles/PMC8931268/?utm_source=chatgpt.com "Efficacy of Care and Antibiotic Use for Chalazia and Hordeola - PMC"
[3]: https://sehathub.com/hordeolum-stye-an-easy-guide-to-eye-infection?utm_source=chatgpt.com "Hordeolum (Stye): An Easy Guide to Eye Infection - SehatHub"
[4]: https://www.merckmanuals.com/professional/eye-disorders/eyelid-and-lacrimal-disorders/chalazion-and-hordeolum-stye?utm_source=chatgpt.com "Chalazion and Hordeolum (Stye) - Eye Disorders - Merck Manuals"
[5]: https://emergencycarebc.ca/clinical_resource/clinical-summary/chalazion-hordeolum-and-stye-diagnosis-and-treatment/?utm_source=chatgpt.com "Chalazion, Hordeolum, and Stye – Diagnosis and Treatment"
Scholar GPT👆
[09-05-2025 11:09] PPM 1: Nice! Now translate this to Bengali
[09-05-2025 11:18] PPM 3: Thought for 4 seconds
## মূল সংক্ষেপণ
পরবর্তী কয়েক দিনের জন্য প্রতিদিনের সকালের উপবাসকালীন ও প্রতিটি মূল আহারের (নাশতা, দুপুরের খাবার, রাতের খাবার) দুই ঘণ্টা পরের রক্তে গ্লুকোজ পরিমাপ করে নিন। সন্দেহভাজন হোর্ডিওলামে অ্যান্টিবায়োটিকের কার্যকারিতা অনিশ্চিত; তাই স্ব-পরিচ্ছন্নতা (আইলিড হাইজিন) ও উষ্ণ কমপ্রেসই প্রধান চিকিৎসা পদ্ধতি। রুটিন ক্ষেত্রে অ্যান্টিবায়োটিক প্রয়োজন নেই, তবে অন্য জটিলতা দেখা দিলে বিবেচনা করতে হবে।
---
## ১. গ্লুকোজ পর্যবেক্ষণের নির্দেশনা
### পরিমাপের ধরণ
* *উপবাসকালীন রক্তে গ্লুকোজ (Fasting BG):* প্রতিদিন সকালে, নাশতা করার পূর্বে।
* *দুপুর-পরবর্তী রক্তে গ্লুকোজ (2-ঘণ্টা পর):* প্রতিটি প্রধান আহারের (নাশতা, দুপুর, রাতের খাবার) শুরু হওয়ার দুই ঘণ্টা পরে।
### কারণ
* গ্লুকোজ নিয়ন্ত্রণ না থাকলে ক্ষতসংশ্লেষণ প্রভাবিত হয় ও প্রদাহ দেরিতে কমে।
* আগাম হাইপারগ্লাইসেমিয়া শনাক্ত করে ডায়াবেটিস বা পুষ্টি-পরামর্শের পথনির্দেশনা করা যায়।
### লজিং ফর্ম্যাট
| দিন | উপবাসকালীন BG (mg/dL) | ২-ঘণ্টা পর নাশতা | ২-ঘণ্টা পর দুপুরের খাবার | ২-ঘণ্টা পর রাতের খাবার |
| --- | --------------------- | ---------------- | ------------------------ | ---------------------- |
| ১ | | | | |
| ২ | | | | |
| … | | | | |
> রোগীকে প্রতিদিন সন্ধ্যায় ছবি তুলে পাঠাতে বা পরবর্তী ভিজিটে এই লজ আনতে বলুন।
---
## ২. চোখের ঝিল্লি পরিচ্ছন্নতা ও উষ্ণ কমপ্রেস
### প্রমাণভিত্তিক সারসংক্ষেপ
* *উষ্ণ কমপ্রেস:* প্রতিদিন ৩–৪বার, প্রতিবার ১০–১৫ মিনিট করে অতিরিক্ত ঘনত্বযুক্ত সেক্রেশন তরলীকরণ করে নির্গমনে সহায়তা করে।
* *ঝিল্লি ম্যাসাজ:* প্রতিটি কমপ্রেসের পর হালকা চাপে তেলীয় পদার্থ বের করে দিতে সাহায্য করে।
* *আইলিড হাইজিন:* নবজাতক শিশুর শ্যাম্পু বা বাণিজ্যিক লিড স্ক্রাব দিয়ে মার্জিতভাবে পরিচ্ছন্ন রাখা পুনরুৎপত্তি বন্ধে কার্যকর।
### রোগীর জন্য নির্দেশনা
1. *উষ্ণ আর্দ্র কমপ্রেস:*
* গরম (তাপমাত্রা স্বাচ্ছন্দ্যময়) পানিতে কাপড় ভিজিয়ে চোখের উপর বসিয়ে দিন ১০–১৫ মিনিট।
2. *হালকা ম্যাসাজ:*
* পরিষ্কার আঙুল ব্যবহার করে চোখের পাতা মসৃণ ভাবে লালিকার দিকে হালকা চাপ দিন।
3. *লিড ক্লিনসিং:*
* দিনে দুইবার, শিশুশ্যাম্পু বা লিড ওয়াইপ দিয়ে পাতা ধুয়ে ফেলুন।
---
## ৩. অ্যান্টিবায়োটিকের ভূমিকা
### বর্তমান অবস্থা
*অ্যান্টিবায়োটিক একত্রে ব্যবহারে সুস্পষ্ট সুবিধা পাওয়া যায় না; অনির্দিষ্ট ক্ষেত্রে অপ্রয়োজনীয়।
* শুধুমাত্র সেলুলাইটিস, ইমিউনোকমপ্রোমাইজড রোগী, বা ১ সপ্তাহের স্ব-সেবায় সমস্যা না কমলে বিবেচনা।
### ক্লিনিকাল প্রয়োগ
* *সাধারণ হোর্ডিওলায়* রুটিনভাবে অ্যান্টিবায়োটিক দেবেন না।
* পড়নে বিপজ্জনক উপসর্গ (বেশি ব্যথা, বিস্তারকারী লালচে ভাব, জ্বর) হলে এবং সেলুলাইটিসের সন্দেহ হলে ব্যবস্থা নিন।
---
## ৪. ফলো-আপ ও সতর্ক সংকেত
* *পুনর্মূল্যায়ন:* ৫–৭ দিনের মধ্যে, বা উপসর্গ বাড়লে শীঘ্রই।
* *ইনসিশন ও ড্রেনেজ:* ফ্লাকচুয়েশন দেখা দিলে বা নিজ সেবায় সমাধান না হলে।
* *জরুরি মূল্যায়ন:* যদি অরবিটাল সেলুলাইটিসের লক্ষণ (প্রোটোরপসিস, চোখ ঘোরানো কঠিন, দৃষ্টিশক্তি কমে) দেখা দেয়।
---
> *উল্লেখ:* আপনি লজিং টেবিল বা রোগী শিক্ষা উপকরণে কোনো পরিবর্তন বা অতিরিক্ত তথ্য চান কিনা জানান।
[09-05-2025 11:18] PPM 3: Is it 👍?
[09-05-2025 11:25] PPM 1: Yes 👍
A very few small understable errors such as logging mentioned as lodging etc
[09-05-2025 11:42] PA: Today should she check her blood sugar level after breakfast?
[09-05-2025 12:00] PA: She completed her breakfast at 10 am, then she takes metformin 500 in half tab .and 2 hours later sugar level is 179 mg/dl.
[09-05-2025 16.10] PA: After lunch she takes metformin 500 in half tab nd 2hours later sugar level is 92
[09-05-2025 16:28] PPM 1: Did she take any medicine before breakfast?
[09-05-2025 16:30] PA: Yes, she takes Glimiperide 1mg in half tab before breakfast.
[09-05-2025 16:48] PPM 4: Can you please send a close-up photo? Only left lower lid.
[09-05-2025 16:55] PPM 4: Is the initial swelling resolved already?
[09-05-2025 17:02] PA: This is right eye
[09-05-2025 17:03] PA: Affected eye
[09-05-2025 17:06] PA: Still, pain is there
[09-05-2025 17:12] PPM 4: Stye is external hordeolum. And, Chalazion is not a chronic stye.
Chalazion is chronic painless swelling, develops when the meibomian gland opening is blocked, and secretion gets accumulated inside.
Stye usually involves the sebaceous gland of zeis or Moll, acute staphylococcal infection.
Internal hordeolum is an acute infection of the meibomian gland.
For stye and chalazion, we don't need oral antibiotics. Only topical medications are sufficient.
But for internal hordeolum, as the infection is deep inside, we need oral antibiotics.
[09-05-2025 17:14] PPM 4: Sorry. I thought it's left.
[09-05-2025 17:14] PPM 4: Can you please evert the lid and take a photo?
[09-05-2025 17:15] PA: How can she get relief?
[09-05-2025 17:16] PPM 3: *Differentiating Stye (Hordeolum), Chalazion, and Internal Hordeolum*
1. *Stye (External Hordeolum)*
- *Cause: Acute bacterial infection (typically *Staphylococcus) of the *sebaceous glands of Zeis or Moll* (associated with eyelash follicles).
- *Symptoms*: Painful, red, tender bump near the eyelid margin. May present with pus.
- *Treatment: **Topical antibiotics* (e.g., erythromycin ointment) and warm compresses. Oral antibiotics are unnecessary due to superficial infection.
2. *Chalazion*
- *Cause: **Chronic, non-infectious obstruction* of the *meibomian gland*, leading to granulomatous inflammation and painless swelling.
- *Symptoms*: Firm, painless nodule in the eyelid, often chronic. No active infection.
- *Treatment: **Warm compresses*, lid hygiene, and possibly intralesional steroids. Antibiotics are not indicated.
3. *Internal Hordeolum*
- *Cause: Acute bacterial infection of the **meibomian gland* (deeper within the eyelid).
- *Symptoms*: Painful swelling deeper in the eyelid, often with localized redness.
- *Treatment: **Oral antibiotics* (e.g., doxycycline or amoxicillin-clavulanate) are required due to the depth of infection; topical agents may not suffice.
*Key Differences*:
- *Infection vs. Obstruction*: Styes and internal hordeolums are infections (acute), while chalazia are obstructive (chronic).
- *Location*:
- Stye: Superficial (Zeis/Moll glands).
- Internal Hordeolum: Deep (meibomian gland).
- Chalazion: Obstructed meibomian gland without infection.
- *Pain*: Styes and internal hordeolums are painful; chalazia are painless.
- *Antibiotics: Oral antibiotics are **only* needed for internal hordeolum.
*Clinical Takeaway*: Proper diagnosis guides treatment—avoid oral antibiotics for styes/chalazia and reserve them for deep infections (internal hordeolum).(DeepSeeK Response)
[09-05-2025 17:17] PPM 4: It definitely is not a stye or chalazion. It's internal hordeolum.
How long is the swelling there?
[09-05-2025 17:18] PA: 3days
[09-05-2025 17:18] PPM 4: Painful from the beginning?
[09-05-2025 17:19] PA: Yes, mam
[09-05-2025 17:20] PA: If she takes warm compress gets relief
[09-05-2025 17:22] PPM 4: *Warm moist fomentation onto closed eyelids
*Zaha eye ointment (azithromtcin1%) twice daily at the lid margin
*T. Clavam 625 mg twice daily for 5 days.
Along with her usual antacid.
[09-05-2025 17:24] PA: Gentle gel?
[09-05-2025 17:24] PA: Sustane ultra, nd refresh tears?
[09-05-2025 17:25] PPM 4: Please continue them.
[09-05-2025 17:25] PA: Ok
[09-05-2025 17:29] PPM 4: Yes. For chalazion and internal hordeolum, the predisposing condition is the meibomian gland dysfunction. It's very common in chronic diabetic patients.
[09-05-2025 17:33] PPM 4: Warm moist মানে তুলো আর জল একসঙ্গে ফুটিয়ে উষ্ণ থাকতে থাকতে চোখ বন্ধ করে চোখের পাতাতে সেঁক দেওয়া।
বারবার হচ্ছে মানে meibomian gland dysfunction আছে। সারাবছর ধরেই সেঁক দিন। এতে dry eyes ও ভালো থাকে।
[09-05-2025 18:12] PA: Acha
[09-05-2025 21.41] PA: After dinner she took metformin 500 in half tab nd 2hours later sugar level is 186mg/dl
[09-05-2025 21.42] PPM 1: 👍
[09-05-2025 21:49] PA: What is the reason for the difference between sugar level of after meal and dinner?
[09-05-2025 21:49] PA: Is it normal?
[09-05-2025 21:52] +91 91638 78286: After dinner she took fexofenadine 120.then 2 hours later she checked sugar level
[09-05-2025 21:55] PPM 2: What do you think?
[09-05-2025 23:08] PA: Eagerly waiting for your reply
[10-05-2025 06:49] PA: Fasting blood sugar levels is111
[10-05-2025 08:25] PPM 1: After lunch was 92 which was also because of the effect of glimiperide 0.5 mg in the morning that she's taking and after dinner the effect of glimiperide became less (wore off in literal terms) and the sugar control fell although one can confidently say it's still under fair control with no cause for worry as far as current blood sugar control is concerned
[10-05-2025 09:42] PA: Ok
[10-05-2025 10:27] PA: At present the patient takes all these medicines for eye.
[10-05-2025 16:44] PA: Tiffin break with watermelon, sweet
[10-05-2025 22:33] PA: The Patient needs to meet Dr. face to face.
[10-05-2025 22:34] PA: It is very painful to open the eyes.
[11-05-2025 19.54] PPM 1: Hope the patient was able to meet the local ophthalmologist face to face?
[12-05-2025 15:59] PA: How many calories does she consume in these 2 plates?
[12-05-2025 15:59] PA: Fruits nd sooji upma
[12-05-2025 16:05] PPM 1: Share the plates with August AI in WhatsApp
[12-05-2025 16:05] PA: Ok
[12-05-2025 16:06] PPM 1: Activate August AI: Type the number (+91 8738030604) on the screen into WhatsApp, send a “hi,” and voila! August AI is ready to assist.
[12-05-2025 16:08] PPM 1: 📸In this image, there is an Indian meal consisting of:
- Rice 🍚 1.0 cup - approx 205 kcal
- Dal (Lentil Soup) 🥣 1.0 cup - approx 180 kcal
- Mashed Potato 🥔 0.5 cup - approx 100 kcal
- Bitter Gourd 🥒 1.0 piece - approx 15 kcal
- Total Calories: 🔥 500 kcal
- Proteins: 🥩 19g
- Carbs: 🍞 88g
- Sugars: 🍬 4g
- Fat: 🥑 10g
[12-05-2025 16:09] PPM 1: 📸In this image, there is a bowl consisting of:
- Granular mixture (likely grain/nut based) 🥣 1.5 cup - approx 300 kcal
- Peanuts 🥜 0.25 cup - approx 180 kcal
- Meat/Protein pieces 🥩 3.0 oz - approx 70 kcal
- Total Calories: 🔥 550 kcal
- Proteins: 🥩 30g
- Carbs: 🍞 51g
- Sugars: 🍬 6g
- Fat: 🥑 35g
[12-05-2025 16:10] PPM 1: 📸In this image, there is a plate consisting of:
- Mango 🥭 1.0 medium - approx 201 kcal
- Lime 🍋 3.0 wedges - approx 1 kcal
- Total Calories: 🔥 202 kcal
- Proteins: 🥩 2g
- Carbs: 🍞 52g
- Sugars: 🍬 46g
- Fat: 🥑 1g
[12-05-2025 16:10] +91 91638 78286: In this plate is it right intake of calories?
[12-05-2025 16:11] PPM 1: Which plate?
[12-05-2025 16:11] PA: Meal plate with rice dal and potato.
[12-05-2025 16:11] PPM 1: 👆this one?
[12-05-2025 16:11] PA: Yes
[12-05-2025 16:14] PA: Too much carbs. what should she have to correct then?
[12-05-2025 16.17] PA: Should have checked the two hour post meal sugars.
[15-05-2025 09:45] PA: Now the patient's eye condition.There is no pain but swelling is there. After doing hot compress it was very painful so she didn't take it.
[15-05-2025 17:56] PA: Evening Tea with muri nd nuts
[15-05-2025 18:22] PPM 1: 👍
[17-05-2025 08:45] PA: Pain is there. Antibiotic course completed 3days before. Discomfort is there, if she closes her eye feels good.
[17-05-2025 08:45] PA: Any advice?
[17-05-2025 10:33] PPM 3: The role of surgery in managing a resistant stye (hordeolum) is considered when conservative treatments (e.g., warm compresses, eyelid hygiene, antibiotics) fail, typically after 4–6 weeks, or if the lesion causes significant symptoms (e.g., pain, visual impairment). Here's a structured overview:
### Indications for Surgery:
1. *Failure of Conservative Treatment*: Persistent infection or inflammation unresponsive to antibiotics and warm compresses.
2. *Chronic Evolution*: If the acute hordeolum progresses to a chronic chalazion (granulomatous inflammation).
3. *Symptomatic Relief*: For large, painful, or vision-obstructing lesions.
### Surgical Options:
1. *Incision and Curettage (I&C)*:
- *Procedure*: Performed under local anesthesia. A small incision is made (typically on the inner conjunctival surface to minimize scarring) to drain pus and remove necrotic material.
- *Outcome*: Rapid symptom relief and reduced recurrence risk.
2. *Steroid Injection*:
- *Consideration*: Intralesional steroids (e.g., triamcinolone) may be used for inflammation-dominant lesions, but avoided if active infection is suspected.
### Key Considerations:
- *Diagnostic Accuracy*: Confirm the lesion is a stye/chalazion and rule out other pathologies (e.g., tumors, cysts) via biopsy if uncertain.
- *Timing*: Surgery is delayed until acute infection subsides to reduce complications.
- *Risks*: Scarring, infection, or eyelid deformity (rare with proper technique).
### Postoperative Care:
- *Antibiotics*: Topical or oral agents to prevent secondary infection.
- *Warm Compresses*: Continued to promote healing.
- *Follow-up*: Monitor for recurrence or complications.
### Conclusion:
Surgery is a safe, effective option for resistant styes, providing definitive management when conservative measures fail. The choice between I&C and steroids depends on clinical presentation and infection status.
[17-05-2025 10:40] PPM 1: Thanks. Can you also comment on the image and tell us if this is an external or internal hordeolum or an internal hordeolum manifesting externally? If it's an internal hordeolum manifesting externally what really happens to the difference in management strategies of both these entities that we discussed here earlier?
[17-05-2025 10:49] +964 750 136 1306: Thank you for sharing the image. Based on visual assessment (not a substitute for clinical diagnosis), the swelling appears to be:
* *Located at the lower eyelid margin, close to the **lash line*, and
* Associated with a *localized red, tender nodule*.
---
### 🧿 *Preliminary Interpretation*
This presentation is *highly suggestive of an internal hordeolum (meibomian gland origin) that is manifesting externally*. Here's why:
| Feature | External Hordeolum | Internal Hordeolum (External Manifestation) |
| ---------- | ---------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------- |
| Origin | Gland of Zeis or Moll | Meibomian gland (deep, tarsal plate) |
| Location | Lid margin near lash follicle | Often *central or posterior lid*, can push outward as abscess grows |
| Appearance | More superficial | Often *deeper, more diffuse swelling that **may point outward* |
| This Case | Appears tender, red nodule *below* the lash line but with *deep tarsal swelling* → consistent with an *internal hordeolum erupting externally* | |
---
### 🧪 *Key Clinical Insight*
An *internal hordeolum manifesting externally* behaves *similarly to an abscess* that tracks outward through softer tissue as it evolves. This can *mimic or look like* an external hordeolum but often:
* Feels more indurated,
* May be more painful, and
* Can leave *residual nodules* (which may later require I\&D or steroid drops if they evolve into a chalazion).
---
### 🔄 *Management Implications: Internal vs External Hordeolum*
| Treatment Aspect | External Hordeolum | Internal Hordeolum (esp. externally manifesting) |
| ------------------------------- | ------------------------------------- | ------------------------------------------------------------------------------------------------------- |
| *Warm Compresses* | ✅ 4–6 times daily | ✅ More critical for deeper gland drainage |
| *Topical Antibiotic Ointment* | Often sufficient (e.g., erythromycin) | Used adjunctively but may *not penetrate tarsal gland* well |
| *Oral Antibiotics* | Rarely needed | 🔺 Consider *oral dicloxacillin or amoxicillin-clavulanate* if cellulitis or deep infection suspected |
| *Incision & Drainage (I\&D)* | If large or persistent after 2–3 days | May require *deeper incision through conjunctival side* if pointing inward |
| *Follow-Up* | Often resolves rapidly | May evolve into *chalazion*, requiring delayed management |
---
### 🚨 When to Refer
If the swelling:
* Persists beyond 5–7 days despite warm compresses,
* Becomes larger, indurated, or fluctuant,
* Is associated with fever, preseptal cellulitis signs, or visual disturbance → *ophthalmology referral is warranted.*
---
## ✅ Suggested Action Now
* Begin warm compresses immediately (5–6 times/day).
* Use topical *antibiotic ointment* (e.g., erythromycin ophthalmic) 2–3 times/day.
* Watch for signs of fluctuation (may indicate abscess).
* Consider oral antibiotics if worsening, especially if spreading redness, tenderness, or systemic signs develop.
Let me know if you’d like a *visual schematic* of how internal hordeola can present externally or a *flowchart* of the treatment strategy.
> *Disclaimer*: This evaluation is educational and not a substitute for a licensed ophthalmologist’s assessment. Please consult a healthcare provider for a definitive diagnosis.
[17-05-2025 16:55] PPM 1: Deep seek?
[17-05-2025 20.52] PPM 3: Scholar
[18-05-2025 06.55] PA: Fasting sugar 102mg/dl
[18-05-2025 07:09] PPM 1: 👍
[18-05-2025 11:15] PA: After breakfast she takes metformin 500 in half tab nd 2hours later sugar level is 58
[18-05-2025 11:16] PA: Before breakfast she also took Glimiperide 1mg in half tab.
[18-05-2025 11:22] PPM 1: Oh! Better switch back to 0.5 mg glimiperide!
[18-05-2025 11:23] PPM 1: Oh okay that means your patient took 0.5 mg!
Perhaps then we need to be careful and stop taking glimiperide for a few days
[18-05-2025 13.32] PA: 132mg/dl
[18-05-2025 13:45] PA: Does she has to stop Glimiperide from tomorrow and for how many days?
[18-05-2025 13:49] PA: How muc gap should there be between medicines nd food?
[18-05-2025 13:55] PPM 1: Whenever a change is made to medicines the patient has to monitor if the body is responding well or will need to revert back to the previous doses.
She can continue metformin immediately after all the three meals she has been taking after stopping glimiperide from tomorrow
[18-05-2025 13:59] PA: Ok sir
[18-05-2025 15.19] PA: Patient had mango and kheera.
PPM 1: 👍
[18-05-2025 17.26] PA: The patient had fruits at 3pm, after that she took metformin 500 in half tab nd 2hours later sugar level is 130.
[18-05-2025 23:36] PA: After dinner she took metformin 5oo in half tab nd 2hours later sugar level is 76
[19-05-2025 06:57] PA: Morning tea with soaked nuts and chola
[19-05-2025 09:22] PA: Yesterday after dinner the sugar level was 76. From today metformin will continue just as it is?
[19-05-2025 09:24] PA: Should the patient stop glimiperide? And continue metformin after meals?
[19-05-2025 09:25] PPM 1: Yes and after checking today's we can perhaps if necessary restart 0.5 mg
[19-05-2025 09:27] PA: Ok sir.
[19-05-2025 09:32] PA: Does she need to do a sugar level check today? It has never been low before. Is it possible that sugar check monitor is malfunctioning?
[19-05-2025 09:36] PPM 1: Alright she can then stop today's glimiperide and not check for today
[19-05-2025 09:38] PA: Ok.
[20-05-2025 06:04] PA: Blister has burst
[20-05-2025 06:08] PA: A lot of pus and blood have come out and applied Azithromycin ointment.
[20-05-2025 16:49] PPM 1: 👍
[21-05-2025 07.34] PA:
[21-05-2025 08.15] PPM 1: 👍
[25-05-2025 05.49] PA: Fasting blood sugar level is 105
[25-05-2025 05:55] PA: BP 114/72
[25-05-2025 07:02] PA: For the last 7 days Glimiperide has been stopped .
[25-05-2025 07:43] PPM 1: 👍 Potential food allergy update from this patient:
[25/05, 07:13] Patient Advocate Diabetes 44F WB: Sir, last 3 din age sandhey bela dinner(1pic ragi roti nd oler torkari) complete korar kichukhon por mango slice 2pic kheyechilam . Terpor nijer kajer jonno beroi ,hothath vison gola ,kaan jala korte thake ..bujhte perchilamna ki korbo ..rastay chilam .khub kosto hochilo mone holo khub thanda lege geche . metformin kinte medicine shop kai then osubidha r kotha boli,ora kan check kore bole ekdom clean .mone hoy allergy theke hoche ..
[25/05, 07:15] Patient Advocate Diabetes 44F WB: Joto somoy jache sarir vison kharap hote start kore,mone hochilo kmn hapie jachi ,matha kmn korche r kromosho gota sarir jolte sure kore even chokh porjonto ...kono rokom e barie fire amr ma k boli abr kan r gola dekhe dite .ma o bolen kichu nei ..
[25/05, 07:22] Patient Advocate Diabetes 44F WB: Hathath i meye bole ekhon i allergy r medicine khao tmr allergic attack hoche .. oler torkari kheyecho ..allready mukh fulte suru kore puro right side pet obdhi burning sensation chilo .Rat hoye jaoyay r apnake birokto korini gorom jol kheye r chokh senk diye r Fexofenadine 120 kheye suye pori .
[25/05, 07:23] Patient Advocate Diabetes 44F WB: Porer din kono jala chilona but pet, chest kmn uneasiness chilo ..pore r kono osubidha chilona .
[25/05, 07:33]cm: Chintar kono karon nei
[25/05, 07:36] Patient Advocate Diabetes 44F WB: Abr kal dupure oi mango slice freeze rakha chilo ta mixi machine e blend kori homemade aam doi r ice cream banabo bole (without sugar ).ter theke 1_2spoon hobe hate jetuku chilo ,ta khai . kichukhon por theke abr 2 din ageker moto same gola kaan jala suru hoy ..r kmn sarir ta jhimie jachilo ..kichukhon ghumie gechilam mone hoy ..mone nei .. terpor tok ma r kotha sune pati lebu khai ..hathath erokom hole ki korbo?mone hoche aam thekei allergy hoche .amr peka peyara,black grapes,kochu,sapla type danta.vendi,mach ,dhoop ba perfume allergy ache..pagolermoto sarir jalte thake ..
[25/05, 07:38] Patient Advocate Diabetes 44F WB: R ekhon kdin aam khabona .khub ekta khai na ..er thekeo ki hote pare allergy?
[25/05, 07:39]cm: @Meta AI what are the various foods scientifically reported to be associated with food allergy?
[25/05, 07:39] Meta AI: Foods associated with allergies can be categorized into common and less common allergens. Here's a breakdown:
Common Food Allergens:
- Dairy: Cow's milk is a common allergen in children, often causing symptoms like skin rashes, stomach cramps, and diarrhea. Lactose intolerance is different from a milk allergy.
- Peanuts: A severe and often lifelong allergy that can cause anaphylaxis, with symptoms like runny nose, skin reactions, and digestive problems.
- Eggs: More common in children, egg allergies can cause skin reactions, stomach aches, and respiratory issues like wheezing.
- Fish and Shellfish: Both can cause severe reactions, including anaphylaxis, with symptoms like skin irritation, swelling, and breathing difficulties.
- Tree Nuts: Similar to peanuts, tree nut allergies can be severe and cause symptoms like itchy mouth, throat swelling, and abdominal pain.
- Soybeans: A common childhood allergy that can cause symptoms like skin rashes, diarrhea, and stomach cramps.
- Wheat: Often confused with celiac disease, wheat allergy symptoms include watery diarrhea, bloating, and stomach aches.
- Sesame: Sesame seeds and oil can cause severe reactions, including anaphylaxis, with symptoms like skin irritation, abdominal pain, and breathing difficulties.
Less Common Food Allergens:
- Fruits and Vegetables: Some people are allergic to specific fruits and vegetables, often experiencing mild symptoms like itchy mouth or throat.
- Spices: Certain spices like mustard, coriander, and paprika can cause allergic reactions, including stomach problems and anaphylaxis.
- Corn: Corn allergy symptoms include hives, nausea, stomach cramps, and respiratory issues.
It's worth noting that over 160 food materials have been identified as allergenic, and more than 170 foods have been reported to cause allergic reactions in the US. However, the top 8-12 food allergens account for over 90% of all food allergic reactions.¹ ²
[25/05, 07:39] Patient Advocate Diabetes 44F WB: Eto kichu likhlam apner bujhte subidha hobe bole ..
[25/05, 07:39] Meta AI: https://scind.org/Health/article/Food-Allergy-Top-12-Food-Allergens-In-India
[25/05, 07:40]cm: Aeguno case report aeo archive korar jonye group a share korchi
[25/05, 07:41] Patient Advocate Diabetes 44F WB: Tahole peanut khaoa thik hobena bolun?
[25/05, 07:41] Patient Advocate Diabetes 44F WB: Acha
[25-05-2025 10:33] PA: Patient completed her breakfast at 8.30 am with 1 pic roti ,chana nd small amount of pickle.
[25-05-2025 10:34] PA: Forgot to send the photo of breakfast.
[25-05-2025 10:36] PA: After breakfast she takes metformin 5oo in half tab nd 2hours later sugar level is 149.
[26-05-2025 13:19] PA: After breakfast she takes metformin 500 nd 2hours later sugar level is 105
[26-05-2025 16:37] PA: After lunch she takes metformin 500 in half tab nd 2hours later sugar level is 101.
[26-05-2025 16:40] PA: Today the patient doesn't take rice. She takes sabudana khichdi with vegetables and a little bit of chatni nd payes.(As prasad)
[26-05-2025 16:45] PPM 1: 👍
[26-05-2025 22:14] PA: She completed her dinner at 8pm . after that she took metformin 500 in half tab nd 2hours later sugar level is 148
[27-05-2025 07:13] PPM 1: 👍
[28-05-2025 07:12] PA: Morning Tea
[28-05-2025 09:34] PPM 1: Participatory medical cognition Web 2.0-3.0:
In the context of this patient's current therapeutic uncertainty surrounding her hordeolum (assuming we have conclusively resolved the initial diagnostic uncertainty around it's being internal or external) here's a Web 3.0 chat with perplexity on this issue that highlights the fall back options from supposed higher hierarchies of evidence (phase 3 trials) to guideline driven evidence based on phase 1 trial driven pathophysiologic rationale @PPM5 particularly important in carrying forward the insights from our recent build up to newer designs
Conversational AI Transcripts:
[28/05, 09:01]cm: What is the evidence of efficacy for oral doxycycline to prevent internal hordeolum?
[28/05, 09:01] Perplexity: There’s actually no solid evidence that oral doxycycline helps prevent or treat internal hordeolum (stye). Large studies show that adding oral or topical antibiotics (including doxycycline) to conservative treatments like warm compresses doesn’t improve outcomes for hordeolum compared to conservative care alone.
Doxycycline is sometimes used for chronic eyelid inflammation or in special cases (like rosacea-related issues), but for routine hordeolum, it’s not proven to help. Have you or someone you know been prescribed doxycycline for a stye? 👀
[28/05, 09:19]cm: Can you share any link to a randomised controlled trial between any antibiotic and placebo in internal hordeolum (are they same as external hordeolums) to show that antibiotics are no better than placebo or hot compress in internal hordeolum?
[28/05, 09:19] Perplexity: There are no randomized controlled trials comparing antibiotics (oral or topical) with placebo or hot compresses for internal hordeolum—so there’s no high-quality evidence that antibiotics work better than conservative treatment. Most guidelines recommend warm compresses as first-line, and antibiotics are only considered for severe or non-resolving cases.
Also, internal hordeolum (infection of the Meibomian glands) is not the same as external hordeolum (stye), which affects glands near the eyelashes.
Would you like more info on how to manage a stubborn hordeolum? 😊
[28/05, 09:21]cm: So antibiotics are considered then in stubborn internal or external hordeolums? What's the difference in the management between these two?
[28/05, 09:21] Perplexity: Yes, antibiotics—usually oral—are considered in stubborn or severe cases of both internal and external hordeolums, especially if there’s spreading infection or preseptal cellulitis. For most cases, though, warm compresses are the main treatment, and antibiotics are only used if the hordeolum doesn’t resolve or gets worse.
Management differences:
1. Internal hordeolum (deeper, Meibomian gland): More likely to need oral antibiotics and sometimes incision and drainage if not improving.
2. External hordeolum (superficial, Zeis gland): Usually resolves with compresses; topical antibiotics may be used if draining or recurrent, but oral antibiotics are rarely needed unless severe.
So, the main difference is internal hordeolums are deeper and more likely to need oral antibiotics if stubborn, while externals are usually milder and treated conservatively. Want tips on the best way to do warm compresses? 😊
[28/05, 09:23]cm: Which oral antibiotics would be better for internal hordeolum? Are their any studies that you can share to provide insights on which oral antibiotics would be better?
[28/05, 09:23] Perplexity: For stubborn internal hordeolum, oral antibiotics like cephalexin, amoxicillin (with or without clavulanic acid), doxycycline, erythromycin, and Bactrim DS are commonly used, mainly because they cover staph bacteria—the usual culprits. Cephalexin and amoxicillin/clavulanic acid are often first-line, especially for soft tissue infections, while doxycycline is sometimes chosen for its anti-inflammatory properties, particularly if there's underlying chronic eyelid inflammation.
However, there are no high-quality randomized controlled trials directly comparing oral antibiotics for internal hordeolum or showing superiority of one over another—most recommendations are based on general soft tissue infection management and clinical experience, not head-to-head studies. So, choice of antibiotic usually depends on patient allergies, local resistance patterns, and severity.
Want to know about typical dosing or how long to take these antibiotics? 😊
[28/05, 09:24]cm: Please share the URLs to the studies that recommended the antibiotics you mentioned above
[28/05, 09:24] Perplexity: Here are some sources that discuss oral antibiotics used for internal hordeolum, though none are randomized controlled trials directly comparing different antibiotics or showing one is better than another:
1. Cephalexin (Keflex) and azithromycin are recommended for larger or more painful internal hordeola, especially if warm compresses alone don’t help. This article suggests cephalexin 500mg twice daily, and alternatives like azithromycin or levofloxacin for those with allergies.
2. Doxycycline is also used, especially for chronic or inflammatory lid disease—usually 50-100mg twice daily for 2-3 weeks.
3. Erythromycin and Bactrim DS are sometimes considered, but again, this is based on general practice for skin and soft tissue infections, not specific head-to-head trials for hordeolum.
You can read more in these articles:
- [Review of Optometry: How and Why to Use Oral Meds]
- [Review of Optometry: When A Drop Isn’t Enough]
- [SDEyes: Simplifying Systemic Antibiotics (PDF)]
- [Medscape: Hordeolum Medication]
Let me know if you want a summary of what these sources say about dosing or duration! 👀
[28-05-2025 09:38] PPM 5: Very interesting. Looks like we need to have different levels of acceptance of what constitutes evidence. And web 3.0 makes this possible.
[28-05-2025 09:39] PPM 3: *Comprehensive Analysis of Therapeutic Options for Internal Hordeolum*
### *1. Evidence for Oral Doxycycline in Hordeolum*
- *Lack of High-Quality Evidence*: No randomized controlled trials (RCTs) support the efficacy of oral doxycycline (or other antibiotics) for treating or preventing internal hordeola. Studies show antibiotics do not outperform conservative measures like warm compresses (source: Perplexity transcript, Medscape guidelines).
- *Off-Label Use Rationale*: Doxycycline is occasionally used in chronic cases due to its anti-inflammatory properties, particularly in patients with concurrent conditions like rosacea or meibomian gland dysfunction. This is based on mechanistic reasoning (phase 1/2 trial logic) rather than phase 3 trial data.
---
### *2. Guideline-Driven Management*
- *First-Line Therapy*:
- *Warm Compresses*: 10–15 minutes, 3–4 times daily. Mechanistically improves blood flow and promotes drainage.
- *Eyelid Hygiene*: Gentle scrubs with diluted baby shampoo or commercial lid wipes.
- *Antibiotics in Stubborn Cases*:
- *Indications*: Lack of improvement after 48–72 hours, signs of spreading infection (e.g., preseptal cellulitis), or recurrent hordeola.
- *Empirical Choices*:
- *First-Line: Cephalexin (500mg BID) or amoxicillin/clavulanate (875/125mg BID) for broad-spectrum coverage against *Staphylococcus spp.
- *Alternatives*: Doxycycline (50–100mg BID) for anti-inflammatory benefits, azithromycin (if compliance is an issue), or Bactrim DS (for MRSA coverage in high-risk regions).
- *Duration*: Typically 7–10 days, extended to 2–3 weeks for chronic inflammation.
---
### *3. Internal vs. External Hordeola: Key Differences*
| *Feature* | *Internal Hordeolum* | *External Hordeolum* |
|----------------------------|-------------------------------------------------|--------------------------------------------|
| *Anatomy* | Meibomian gland (deeper) | Zeis/gland of Moll (superficial) |
| *Severity* | More likely to require oral antibiotics | Often resolves with compresses alone |
| *Complications* | Higher risk of cellulitis or abscess | Rarely progresses |
| *Procedural Needs* | May require incision & drainage if persistent | Rarely needed |
---
### *4. Hierarchy of Evidence in Clinical Decision-Making*
- *Phase 3 Trials*: Absent for hordeolum management. Current guidelines rely on:
- *Lower-Level Evidence*: Retrospective studies, case series (e.g., Medscape, Review of Optometry articles).
- *Pathophysiologic Rationale: Antibiotics target *Staphylococcus spp. (common pathogens), while doxycycline’s MMP inhibition may reduce glandular blockage.
- *Fallback Strategy*: When RCTs are unavailable, guidelines prioritize safety, mechanistic plausibility, and expert consensus (Web 3.0 "participatory cognition" principle).
---
### *5. Practical Recommendations*
- *Stepwise Approach*:
1. Conservative measures first (warm compresses + hygiene).
2. Oral antibiotics if no improvement or systemic signs (e.g., fever, erythema).
3. Incision & drainage for fluctuant, non-resolving lesions.
- *Patient Counseling*: Emphasize adherence to compresses; avoid squeezing the lesion.
---
### *6. Research Gaps & Future Directions*
- *Unmet Needs*: RCTs comparing antibiotics vs. placebo in internal hordeola.
- *Innovative Designs*: Adaptive trials or real-world evidence (RWE) platforms leveraging AI/Web 3.0 tools to aggregate global case data.
*Conclusion*: While oral doxycycline lacks robust evidence for hordeola, its use in refractory cases is guided by pathophysiologic rationale and clinical experience. Conservative management remains cornerstone therapy.
[01-06-2025 06:44] PA: Fasting sugar level is 110.
[01-06-2025 12:33] PA: Breakfast completed at 10.30 with smashed potatoes tawa roti..After that she took metformin 500 in half tab nd 2hours later sugar level is 129
[01-06-2025 12:36] PA: Forgot to send the photo of breakfast plate.
[01-05-2025 15.08] PA: Post lunch 123mg/dl
[01-06-2025 15:47] PPM 1: 👍
[01-06-2025 21.27] PA: 163mg/dl.
[04-06-2025 09:34] PA: At present condition of right eye
[04-06-2025 09:37] PA: Doing Hot compress but no pus.
[08-06-2025 06.15] PA: 121mg/dl
[08-06-2025 10.39] PA: After breakfast she takes metformin 500 in half tab nd 2hours later sugar level is 108mg/dl.
[08-06-2025 14:39] PA: After lunch the patient took metformin 500 half tab. Post meals sugar level is 119mg/dl
[08-06-2025 16:35] PA: Patient had her lunch at 12.20pm
[08-06-2025 21:46] PA: 191 sugar level
[08-06-2025 21:49] PA: After dinner she took metformin 5oo in half tab nd 2hours later sugar level 191
[08-06-2025 22:53] PA: Suddenly, last night while getting down from the upstairs, she felt the pain in her right knee. She couldn't straighten her leg and walk properly. Then she applied an ice pack but couldn't fold her leg. This morning the pain is gone but feels very weak. The same problem is being experienced in the right elbow since last few days.
[08-06-2025 23:15] PA: She is going to the gym again for the last 2 days. Maybe she got hurt unknowingly or maybe due to hard work or any other reason Sir?Are these the symptoms of osteoarthritis...?
[08-06-2025 23:23] PA: From this morning she feels abdominal pain, and in the evening she has vomited along with mild cramp.
[08-06-2025 23:26] PA: Why is this happening? Is it because of too much hard work? But she is not able to walk or work at the same speed as before..
[09-06-2025 07:22] PPM 1: @Meta AI @PPM3 @PPM6 would you like to share your Inputs on the patient's queries? Her full case report is linked in the description box
[08/06, 22:53] Patient Advocate Diabetes 44F WB: Suddenly, last night while getting down from the upstairs, she felt the pain in her right knee.she couldn't straighten her leg and walked properly. Then she applied an ice pack but couldn't fold her leg. This morning the pain is gone but feels very weak. The same problem has been happening in the right elbow for a few days.
[08/06, 23:15] Patient Advocate Diabetes 44F WB: He has started going to join the gym again for the last 2 days. Maybe she got hurt somehow at the gym without realising or recently she has started working too hard. Or any other reason .Sir ,is it the symptoms of osteoarthritis...?
[08/06, 23:23] Patient Advocate Diabetes 44F WB: From this morning she feels abdominal pain ,and in the evening she has vomited along with mild cramp.
[08/06, 23:26] Patient Advocate Diabetes 44F WB: Why is this happening? it because of too much hard work ?but she is not able to walk or work at the same speed as before..
[09-06-2025 07:22] Meta AI: Based on the symptoms described, it seems like this 44-year-old female patient is experiencing some unusual and concerning health issues. Let's break it down:
1. Sudden knee pain and weakness: The patient's sudden onset of knee pain, inability to straighten her leg, and subsequent weakness could be indicative of a few potential issues, including injury, overuse (especially given her recent gym activities), or possibly even an inflammatory condition.
2. Similar issues with the elbow: The fact that she's experiencing similar problems in her right elbow suggests it might not be purely related to injury or overuse specific to one joint. It could be worth exploring systemic causes or conditions that affect multiple joints.
3. Abdominal pain and vomiting: The addition of abdominal pain and vomiting adds another layer of complexity. These symptoms could be related to various factors, including gastrointestinal issues, medication side effects, or even a systemic reaction.
Given these symptoms, osteoarthritis might not be the sole explanation, especially considering the sudden onset and the combination of joint and abdominal symptoms. Other potential considerations could include:
- Autoimmune or inflammatory conditions: Conditions like rheumatoid arthritis or lupus could present with joint pain and systemic symptoms.
- Medication side effects: If the patient is on any medications for diabetes or other conditions, these could potentially cause or contribute to some symptoms.
- Overuse or strain: Given her recent increase in physical activity, strain or overuse injuries are definitely possible.
Given the complexity and combination of symptoms, it would be prudent for the patient to consult with her healthcare provider for a thorough evaluation. A healthcare professional could conduct a detailed history, physical examination, and potentially some diagnostic tests to determine the underlying cause of these symptoms.
In the meantime, it might be advisable for her to ease up on the gym activities and monitor her symptoms closely. If symptoms persist or worsen, medical attention would be necessary to rule out any serious conditions.
[09-06-2025 11:45] PPM 3: Based on the information provided, here's a breakdown of the patient's symptoms and potential considerations:
### *Musculoskeletal Symptoms (Knee & Elbow):*
1. *Sudden Right Knee Pain & Locking (Last Night):*
* *Possible Causes:* Meniscus tear, ligament sprain (ACL, MCL), patellar dislocation/subluxation, severe knee strain, loose body in the joint, flare-up of pre-existing arthritis.
* *"Couldn't straighten leg" (Extension Block):* Highly suggestive of a mechanical issue within the knee joint, like a *meniscus tear* (especially a "bucket handle" tear) or a loose body.
* *Improvement (Pain Gone, Weakness Remains):* While pain easing is positive, persistent weakness and the history of locking require evaluation. Inflammation or residual muscle inhibition after an acute injury can cause weakness.
2. *Right Elbow Pain (Past Few Days):*
* *Possible Causes:* Tendinitis (e.g., tennis/golfer's elbow), bursitis, ligament sprain, arthritis flare, referred pain.
* *Gym Connection:* Very plausible, especially if new or increased activities involve gripping, pushing, pulling, or lifting weights. Overuse injuries are common.
3. *Gym Activity:*
* *Significant Factor:* Restarting gym activities 2 days prior is highly relevant. Overexertion, improper form, or using too much weight too soon are common causes of acute joint/muscle injuries. Even minor trauma during exercise can be forgotten but cause injury.
4. *Osteoarthritis (OA) Question:*
* *Possible, but Sudden Locking is Less Typical:* While OA can cause pain and stiffness, the *sudden inability to straighten the knee* is more characteristic of an acute mechanical injury (like a meniscus tear) than typical OA. OA pain usually develops more gradually and worsens with use. However, pre-existing mild OA could be aggravated by the gym activity.
* *Age Consideration:* OA is less common at 44 but not impossible, especially with prior injury, obesity, or heavy physical work.
### *Abdominal Symptoms (Today):*
1. *Abdominal Pain & Vomiting with Mild Cramp:*
* *Possible Causes:* Gastroenteritis ("stomach bug"), food poisoning, stress/anxiety response to pain, medication side effect (if any new meds), dehydration (especially if reduced fluid intake due to pain), or unrelated GI issue (e.g., gastritis). Diabetic gastroparesis is possible but less likely to start suddenly with vomiting.
* *Connection to Joint Pain/Exercise?*
* *Direct Musculoskeletal Link?* Unlikely. Pain doesn't typically refer from knee/elbow to abdomen causing vomiting.
* *Indirect Links?* Possible. Significant pain can cause nausea/vomiting. Dehydration from exercise/inadequate intake could contribute to cramps and nausea. Intense stress/anxiety about the joint issues could trigger GI upset.
### *Overall Assessment & Key Questions:*
* *Two Likely Separate Issues:* The *knee/elbow problems* strongly point to *acute musculoskeletal injuries, highly likely **related to the recent gym activity. The **abdominal symptoms* are more suggestive of a *concurrent GI issue* (like a bug) or a secondary effect of pain/stress/dehydration.
* *The Knee Locking is a Red Flag:* This symptom specifically warrants prompt medical evaluation to diagnose the mechanical cause (like a meniscus tear).
* *Underlying Diabetes:* While not directly causing these specific acute symptoms, it's crucial background. Diabetes can slow healing and increase infection risk. Blood sugar control may also be disrupted by stress, pain, vomiting, and reduced activity.
### *Recommendations for the Patient:*
1. *Seek Medical Evaluation TODAY:*
* *Priority:* The knee (due to locking) and the new abdominal/vomiting symptoms need assessment.
* *Who to see:* Primary Care Physician (PCP) or Urgent Care. An Orthopedic evaluation for the knee may be needed soon after.
2. *Knee & Elbow Care:*
* *Rest:* Avoid activities aggravating knee/elbow (especially gym, stairs, kneeling, heavy lifting).
* *Ice:* Continue applying ice packs (15-20 mins every 2-3 hours).
* *Compression:* A light elastic bandage might help with swelling (knee), but don't wrap tightly.
* *Elevation:* Elevate the leg (knee) when resting.
* *Avoid Locking Mechanisms:* Be very careful not to force the knee into positions that caused locking.
3. *Abdominal Symptom Care:*
* *Hydration:* Sip clear fluids (water, broth, oral rehydration solutions) frequently in small amounts. Dehydration is a risk with vomiting.
* *Rest:* Allow the GI system to rest.
* *Bland Diet:* If vomiting stops and hunger returns, start with very bland foods (BRAT diet: Bananas, Rice, Applesauce, Toast).
4. *Diabetes Management:*
* *Monitor Blood Sugar:* Vomiting, illness, and stress can significantly impact blood glucose levels. Monitor more frequently.
* *Check for Ketones:* If blood sugar is consistently high (or if unable to keep fluids down), check urine for ketones (important for T1D, still relevant for T2D if very ill).
* *Medications:* Continue diabetes medications as prescribed unless advised otherwise by a doctor and able to eat/drink normally. Be cautious with certain meds (like SGLT2 inhibitors) if dehydrated/vomiting - consult doctor/pharmacist.
5. *Hold Gym Activities:* Absolutely stop gym activities until both the musculoskeletal injuries and GI symptoms are fully evaluated and resolved.
*Conclusion:* While overexertion at the gym is a very likely trigger for the joint injuries, the specific mechanism of the knee locking needs urgent diagnosis. The abdominal symptoms are likely a separate issue but also require assessment. OA is a less likely primary cause for the acute knee locking. *Prompt medical evaluation is essential to diagnose both the knee/elbow issues and the cause of vomiting, manage pain, prevent complications, and guide safe return to activity, especially considering the patient's diabetes.*
[09-06-2025 16:40] PPM 1: She has a long history of pain abdomen though and deepseek may not have seen the entire case report link?
[09-06-2025 16:52] PA: No sir ,there is no swelling or inflammation on right knee .now she feels no pain but slightly weakness.
Time line of her problems
[09-06-2025 17:07] PA: One more thing,she recalls that last year she fell down on the road and after that her right knee and elbow were seriously injured nd took almost 3-4months to recover from that condition but there used to be occasional pain in between.R there any connection between that pain and current knee nd elbow pain?
[09-06-2025 17:18] PPM 1: Possible
[12-06-2025 15.13] PA: Yesterday, the patient eye check up was done.Warm moist fomentation and Systane Ultra Eye drops 4 times a day have been advised
PPM 1: 👍
[15-06-2025 06:11] PA: Fasting blood sugar level is 119mg/dl
[15-06-2025 07:09] PPM 1: 👍
[15-06-2025 08:49]PA: At breakfast 1 roti, stir fried parwal and small piece of tomato after that she takes metformin 500 half tab at 8.45 am. Post breakfast sugar is 123mg/dl
[15-06-2025 14:44] PA: The patient had lunch by 12.30 pm with rice dal and cauliflower then she took metformin 500 half tab and 2hours later sugar level is 125mg/dl.
[15-06-2025 21:13] PA: Since morning feeling very uneasy, shortness of breath, sweating, throat pain dryness
[15-06-2025 21:13] PA: Very tired
[15-06-2025 21:20] PA: After dinner she took metformin 500 half tab nd 2hours later sugar level is 154
[15-06-2025 21:23] PPM 1: Continuously from morning till night or in any particular time?
[15-06-2025 21:29] PA: When it was 12.30 felt uneasy. Then 4pm.
[15-06-2025 21:32] PA: After dinner continuously feels dizziness, mild pressure in the middle of the chest with the above mentioned problem.
[15-06-2025 22:07] PPM 1: How long did it last during 12:30 and then 4 pm?
[15-06-2025 23:02] PA: Half an hour..
[16-06-2025 09:39] PPM 1: 👍
[17-06-2025 16:14] PA: The last pic of the right eye is absolutely ok there is no pus or discomfort .
[17-06-2025 16:16] PA: From this morning in her left eye she feels itching, redness and mild pain. She also continues systane ultra eye drop in 4 times nd warm moist fomentation.in both eyes
[17-06-2025 16:31] PPM 1: ### অনুবাদ (Translation in Bengali)
এই ছবিতে একটি প্লেটে ক্রিস্পি ফ্রাইড বেবি কর্ন দেখা যাচ্ছে, যা মশলাদার, চকচকে সসে টস করা হয়েছে এবং তার সাথে রয়েছে কাটা বেল পিপার ও উপরে ছড়ানো তিল। এটি একটি জনপ্রিয় ইন্দো-চাইনিজ ডিশ, সম্ভবত চিলি বেবি কর্ন বা হানি চিলি বেবি কর্ন হতে পারে[#].
আপনি কি এটি বাড়িতে তৈরি করেছেন, না কি রেস্টুরেন্ট থেকে অর্ডার করেছেন?[#]
আপনার বার্তাটি বাংলায় অনুবাদ করা হয়েছে। যদি আরও অনুবাদ বা সাহায্য প্রয়োজন হয়, জানাবেন।[#]
[17-06-2025 16:32] PPM 1: Let's hope this doesn't last long
[18-06-2025 13:16] PPM 4: It looks like episcleritis.
How is it today? Are you putting Lotepred?
[18-06-2025 14:19] PA: From last evening she started Lotepred.
[19-06-2025 09:08] PPM 1: @PPM3 @PPM7 @PPM5 there are a few points still necessitating analysis in this patient
1) the connection and overlap between her episcleritis and internal hordeoleum symptoms
2) The efficacy of Loteprednol etabonate ophthalmic suspension 0.5 % for Ophthal inflammations such as episcleritis
https://pmc.ncbi.nlm.nih.gov/articles/PMC3459083/
[19-06-2025 09:19] PPM 3: Based on your query and the provided research article, here's a concise analysis addressing your two points:
### 1. *Connection Between Episcleritis and Internal Hordeolum*
- *Episcleritis* involves inflammation of the superficial episcleral vessels, often idiopathic or linked to autoimmune conditions (e.g., rheumatoid arthritis).
- *Internal Hordeolum* is an acute infection/blockage of meibomian glands (staphylococcal origin).
- *Overlap*: While distinct entities, both may coexist if:
- There's an underlying *systemic inflammatory condition* (e.g., rosacea, autoimmune disorders).
- *Ocular surface dysregulation* (e.g., dry eye, blepharitis) predisposes to both infections and sterile inflammation.
- *Clinical Implication*: Screen for systemic associations (e.g., rheumatologic workup) and optimize ocular surface hygiene if blepharitis is a common denominator.
---
### 2. *Efficacy of Loteprednol Etabonate 0.5% for Episcleritis*
The article focuses on *postoperative inflammation*, but key insights support its use for episcleritis:
- *Mechanism*:
Loteprednol is a *retrometabolically designed corticosteroid* with high lipophilicity and glucocorticoid receptor affinity, enabling potent anti-inflammatory effects at the site of action.
- *Safety Profile*:
- Minimal IOP elevation: Only *0.5–1.7%* of patients had clinically significant IOP spikes (vs. 6.7% with prednisolone acetate).
- Rapid metabolic inactivation reduces systemic absorption and HPA-axis suppression.
- *Relevance to Episcleritis*:
- Episcleritis is typically *steroid-responsive* but requires agents with low IOP risk due to potential chronic/recurrent use.
- Loteprednol is FDA-approved for anterior segment inflammation (e.g., uveitis), and its efficacy in postoperative inflammation (55–64% resolution rates) supports off-label use for episcleritis.
- *Evidence Gap*:
The article does not explicitly study episcleritis, but its efficacy in vascular/periocular inflammation (e.g., conjunctival hyperemia, chemosis) suggests applicability.
---
### Key Recommendations
1. *For Episcleritis*:
- Loteprednol 0.5% (e.g., Lotemax®) is a *safe first-line steroid* (4× daily, tapered over 1–2 weeks).
- Monitor IOP if used >2 weeks or in known steroid responders.
2. *For Hordeolum*:
- *Acute phase*: Warm compresses + antibiotic ointment (e.g., erythromycin).
- If recurrent/chronic, evaluate for *blepharitis* or *demodex*, and add lid hygiene.
3. *Systemic Workup*:
- Rule out connective tissue disorders (ANA/RF) if episcleritis is recurrent or bilateral.
> 📌 *Summary*: Loteprednol’s targeted efficacy and safety make it suitable for episcleritis, while hordeolum requires infection control. Overlap suggests investigating shared triggers (e.g., rosacea, autoimmune dysregulation).
Would you like further details on steroid alternatives (e.g., NSAIDs for episcleritis) or management algorithms?
[19-06-2025 09:21] PPM 3: Based on the research article, here are the *absolute numbers* for Loteprednol etabonate 0.5% efficacy and safety in postoperative ocular inflammation:
---
### *1. Efficacy in Resolving Inflammation*
(Resolution = ≤5 anterior chamber cells + none-to-trace flare)
| *Study* | *Loteprednol Group* | *Vehicle/Placebo Group* | *Difference* |
|-------------------------------|------------------------|----------------------------|----------------|
| Stewart et al. (1998) [¹] | 64% (73/114 patients) | 29% (33/113 patients) | +35% (40 more patients resolved) |
| Loteprednol Study Group 2 [²] | 55% (56/102 patients) | 28% (28/101 patients) | +27% (28 more patients resolved) |
| *Pooled Data* | ~60% (129/216) | ~28.5% (61/214) | *+31.5% (68 more patients resolved)* |
---
### *2. Safety: Clinically Significant IOP Spikes (≥10 mmHg Increase)*
| *Study* | *Loteprednol Group* | *Control Group* |
|---------------------------------------------|------------------------------|----------------------------|
| Stewart et al. (1998) [¹] | 2.6% (3/114 patients) | 0% (0/113) |
| Loteprednol Study Group 2 [²] | 0% (0/102 patients) | 1% (1/101) |
| Novack et al. (Long-term safety review) [³] | 1.7% (28/1,648 patients) | 0.5% (vehicle), 6.7% (prednisolone) |
---
### *3. Comparison with Other Steroids*
- *vs. Prednisolone Acetate 1%* (Grigorian et al. study [⁴]):
- *IOP at final visit*:
- Loteprednol: 12 ± 3 mmHg (n=10 patients)
- Prednisolone: 16 ± 1 mmHg (n=10 patients).
- *Mean IOP difference*: +4 mmHg higher with prednisolone.
- *In Known Steroid Responders* (Bartlett et al. crossover [⁵]):
- *IOP increase over 42 days*:
- Loteprednol: +4.1 mmHg (n=19 patients).
- Prednisolone: +9.0 mmHg (n=19 patients).
---
### *4. Pain/Discomfort Resolution*
- Pooled data (Comstock & Usner [⁶]):
- *Pain resolution*: 84% (Loteprednol) vs. 56% (placebo).
- *Discomfort resolution*: 79% (Loteprednol) vs. 42% (placebo).
---
### *Key Takeaways*
1. *Efficacy: Loteprednol resolved inflammation in **~60% of patients* (vs. 29% with placebo).
2. *Safety: Only **0–2.6%* had significant IOP spikes (vs. 6.7% with prednisolone).
3. *Steroid Responders: Mean IOP increase was **4.1 mmHg* (vs. 9.0 mmHg for prednisolone).
> ⚠ *Note: These numbers are from **postoperative inflammation studies* (cataract surgery). While not directly studying episcleritis/hordeolum, Loteprednol's anti-inflammatory profile supports its use for similar anterior segment inflammations.
Would you like calculations for other comparisons (e.g., difluprednate)?
[19-06-2025 09:23] PPM 1: Thanks 👏
Very useful
