68M Of Acute Myocardial Infarction Telangana PaJR

 

29-01-2025

This is an online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

PPM 1 - From the ward now:

68M with giddiness and this ECG at 4:00PM yesterday. 👆

PPM 1 - This is at 5:00 PM just before starting thrombolysis. 👆

PPM 2 - How was his blood pressure at this time sir? Clearly the RCA is gone!

PPM 1 - 👍

This is his phenotype. He's a smoker.

BP was barely recordable at 70mm Hg.

PPM 2 - Can somehow feel the locomotor brachii across continents!!

PPM  1 - 👍

PPM 2 - Just to add what I learned here - apparently Ticagrelor 180 vastly (read as marginally) outperforms Clopidogrel in loading doses.

And apparently Atorvastatin is not really a part of the loading regimen. A beta blocker is if left sided MI

Let's hope those T wave inversions start appearing in the right sided leads.

PPM 1 - Sharing what happened next.

ECG just after thrombolysis. Note involvement of newer arterial segments. Will share the echo video also that particularly shows a dyskinetic segment at this LAD territory, perhaps an acute dyskinesia as there's no myocardial thinning noticed.

And these are today's ECG changes! The storm seems to have all but abated. The patient never had chest pain. His giddiness subsided after the thrombolysis either because of it or spontaneously with time!

PPM 2 - Finally TWI in inferior leads! The vessel wall has opened and possibly can be linked to subsiding giddiness?

PPM 1 - 👍

Here's the bedside clinical imageology for the patient 👇

https://youtube.com/shorts/Poex_pSfwj8?feature=shared

01-02-2025

 PaJR discussion update on 1/2/25

PPM 1 - Update Myocardial infarction Day 4, K2:

PPM 2 - Junctional rhythm with frequent sinus capture?

PPM 1 - Or the opposite with sinus arrest and junctional escapes?

Interesting changes in ECG since yesterday!

Can help with interpretation @PPM2 @PPM3 @PPM4.

The two ECGs above and below are a minute apart.

PPM 1 - Today's ECG: @PPM3 @PPM4

Today is Day 5, K2.

PPM 1 - His chest X-ray today.

His phenotype today.

👆The radiology suggests he could be in K3

Especially comparing with this chest X-ray during admission as attached here, where the cardiomegaly suggests a chronic CVD too.

PPM 3 - 👍

PPM 2 - Yes. How can we differentiate between the two?

01-02-2025

Feedback received from another group 

RB - Will be grateful for your comments on the day 4 and 5 (today's) ECG of this patient of inferior wall myocardial infarction which are accessible here 👇.

https://pajrcasereporter.blogspot.com/2025/01/68m-of-acute-myocardial-infarction.html?m=1

ECG CME India - Thanks with regards 🙏🙏 for these series of ECGs

Ist ECG on the screen:

🔽 Junctional rhythm with Bradycardia ( please see the inferior leads with inverted p in these leads)

,associated Low voltage

🔽 evidence of Acute MI in inferior leads :ST elevation  with tendency to have Q genesis

Plus

Anterior MI -as evident by mild ST elevation with the virtual loss of R > only visible as tiny r  in most of Anterior leads

Comments

Acute MI with inferior as well, site of lesion most possibly proximal LAD, prior to its Diagonal branch.

I request you Sir to further rearrange the subsequent ECGs directly on the screen,so as to be visualised with more clarity.

My PRANAM SIR

🙏🙏

DR.K, ECG CME India: Proximal LAD with wrap art involvement

BKS CME India:  Bradycardia HR approximate 48

Recent IWMI,  ectopic atrial rhythm 

Possible old AWMI

Possible hypokalemia

Possible SA node infarction or stunning leading to origin of ectopic atrial rhythm 

 Possible Site of origin of ectopic p wave superior to TA annulus

Site of occlusion prox RCA.

RB - Thanks sir.

RB - Thanks sir.

RB - Sir if you click on the ECGs their resolution improves and one can zoom in easily.

BKS CME India: Dr RB, there are many ECG on link you posted. I answered first ECG. It is very unfair to audience that they are reading our post without seeing ECG. Please take screenshot of all  ECG and post it with chronological order with foot note of comments like day, point of pre/post thrombolysis etc. Me and Dr.K.  sir will repost. Will be meaningful to our group members.  Thanks.

DR.K. ECG CME India - Thanks Dr RB Sir and Dr S. sir.

My regards to both of you 🙏🙏

I would like to revise My opinion after seeing the entire series of ECGs, which I could not see earlier.

🔽 On the first ECG there is evidence of Acute inferior MI with more ST elevation in lead 111and simultaneous mild ST elevation in V1 as well, which should not be ignored and Rt sided chest leads would have been explored to assess it's true nature - 

Now it is more suggestive of the involvement of RCA-Proximal, please see the presence of  rhythm with P inversion in inferior leads with bradycardia - possible involvement due to the SA node leading to bradycardia and inverted p due to low ectopic p.

Initially by seeing the precordial leads this gave me the impression of the simultaneous involvement of anterior MI.

Since on last ECG the precordial leads comes to normalcy through gradual steps this confirms.

✅ there is mainly involvement of Proximal RCA with involvement of SA node with resultant Bradycardia and inverted p in inferior leads might be due to low ectopic p

This is known fact that with RCA involvement the changes are transient. may last for a few days only. ✅ There was transient anterior myocardial ischemia as well over anterior leads, possibly due to shunting of blood therein.

Thanks with Regards 🙏🙏

NB: This would be my request that all the ECGs must have been posted directly serial wise on the front to have direct visualisation by All and then this would be meaningful and appreciable to All the elite members of this group.. And interpretation would also be easier.

With Regards 

🙏🙏

 RB - Thanks Sir for the valuable inputs along with Dr @⁨BKS CME India⁩ 

We try to record most of our cases as whole case reports that contain clinical, radiological and electrophysiology of the patients and this case report keeps getting updated in real time as a life time health record with all clinical images, radiology and electrophysiology available in a serial manner as per patient's timeline. There are over 5000 such cases available through our dashboard and it keeps growing everyday. Our idea behind this is to create a case based reasoning engine toward supplementing what is currently labeled deep phenotypic data in age old precision medicine: https://pmc.ncbi.nlm.nih.gov/articles/PMC6163835/ 

Modern day AI driven LLMs make it easier for us to thematically analyse these case reports toward newer individual patient centred insights.

I can understand that it would be important to segregate just the serial ECGs for the audience here from the over-all patient data and I shall try to do this ASAP and share here again just that portion. 🙂🙏.

03-02-2025

PPM 1 - 

Yesterday's ECG update: The nodal dysfunction pattern appears to have vanished and the old inferior wall pattern as well as a fresh LBBB appears to have gotten consolidated. The patient appears to have been shifted out of the ward yesterday.

Dr.BKS - Nice out come well treated, 👌🏻👍

Dr K: Every step as per evolution on ECG has been well followed Sir till the patient appears well suitable ro be shifted out of the ward .

Thanks with Regards🙏🙏

Dr K: to be shifted.

 Today's ECG update:

The patient had been shifted out from the critical ward to a step down ward and we located his ECG done today (attached) and here it again seems to have changed in terms of yesterday's LBBB! The patient is asymptomatic since two days.

Dr.K: Thanks Sir

The patient is asymptomatic and most possibly vitals being normal.No crepitations over the chest and the patient I think is otherwise positive signs free except this   LBBB on ECG with minor change over lead 6 

Again my speculation remains the same. We have to keep close observation over the further ECG changes. Better to have cardiac Echo as well to review the functional integrity.

Do not hesitate to have the second local opinion if needed.🙏🙏

RB: Thanks Sir

His cardiac echo on day 1 is available here 👇

https://youtube.com/shorts/Poex_pSfwj8?feature=shared

It shows anteroseptal and infero septal dyskinesia.

 Dr K: The recent most? Do you feel any need. for revascularization procedure?

RB:  Not as per what current evidence would deem necessary. He missed the window for primary ptca and its currently not symptomatic enough for a rescue ptca.

PPM 1 - 

Today's ECG update:

The patient had been shifted out from the critical ward to a step down ward and we located his ECG done today (attached) and here it again seems to have changed in terms of yesterday's LBBB! The patient is asymptomatic since two days.

03-02-2025

Dr. K: EF?

RB: Given the dyskinetic segment, with albeit good lvpw contractility the overall visual EF in the above video appears to be 30%

Dr.K:  I think we should consider to know the vascular patency with viability of the remaining myocardium .

Plus advise the patient to remain within his physical limitation.

BKS: Good enough,,  MR, AR Normal MV, AV, ,SO, Ischemic insult of RCA,. It should resolve  gradually, LBBB should also resolve in couple of days.

 LBBB has dual blood supply RCA &LAD. SO, here it should resolve.

Dr.K: Yes. There might be the impact of post ischemic stunning- this should get resolved within a few days.

Dr.BKS: Lvef is visible on scree of ECHO clip.

It is 43%

RB: Thanks Sir.

It's been our practice and we also teach that to our students, to rely more on the visual estimation of EF than go by the quantitative estimate of m mode which measures just an ice pick cross section using the uni-dimensional cursor, while our vision can work across the entire volume of the heart by eye balling and it's also supported by evidence 👇

https://pubmed.ncbi.nlm.nih.gov/34654586/

BKS: 👌👍True

RB: Thanks Sir what appears intriguing though is the change from day before yesterday's ECG where the LBBB pattern is also visible in V6 while in yesterday's it has disappeared from V6!

Dr.K: Thanks Sir.

I have also marked this at v6 position and mentioned on my posting last day.Most likely this sort of clockwise rotation might be due to somewhat more wrong placing of the exploring electrode at V6.

[06-06-2025 12.33] PPM 1: Reviewing him now again in the OPD.

Now that his cardiac problems have settled with minor residual NYHA II intermittently, he is more concerned about his fluorotic enthesitis/fibrosis symptoms of spondyloarthropathy and knee OA!

19F Urinary Bladder Exstrophy Ascites Telangana PaJR

 24-01-2025

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent form. 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.

OPD right now:

19F with urinary bladder extrophy since birth. She was operated and her bladder open abdomen was closed with a small opening preserved through which she became accustomed to draining her own urine using a small infant feeding tube after washing the tube in water and washing her hands. Recently she has had some stones coming out through that orifice which made the urologists perform another procedure following which she developed mild ascites which they tapped for tests and then sent to us.

She's already given her inter in science and we are looking for medical students @PPM3 who can help her to get into MBBS. Her father died when she was 1 year old and her mother has managed to bring up her and her elder sister against all odds working as a farm laborer. Recently her elder sister died in a car accident although her sister's daughters are also studying inter and nearly her age!

While all medical students read about this disease in anatomy, I was struck by the actual  rarity of her disease.

To quote:

"Extreme rarity of the disease limits the surgical opportunities to practice the complex closure required in these patients. For this reason, patients have the best outcomes when the bladder closures are performed at high volume centers where surgical and nursing teams have extensive experience in caring for the disease.[6] The highest volume center in the United States, and the world, is the Johns Hopkins Hospital in Baltimore, Maryland; they have seen over 1300 exstrophy patients in the past 50 years"!

https://en.m.wikipedia.org/wiki/Bladder_exstrophy 

@PPM4 if you saw the Wiki image above and could read the article then you may by now have realised why they were instructed that she would never become pregnant. Ambiguous genitalia is a frequent clinical problem also dealt with by endocrinologists like @PPM2 where their focus could be on ruling out CAH while we would unfocus in trying to answer her multi modal requirements @PPM5

@PPM3 has done a fabulous job since yesterday, in looking after her career path toward becoming a doctor and @PPM7 you may remember him as that first year MBBS UG who presented a case in the CME you chaired in 2023!

@PPM6 hope we shall be able to get a pelvic ultrasound today along with an OBG consult for her fertility issues and get a radiology USG guided ascitic tap. I tried to tap the fluid yesterday and couldn't get it and wish I could blame the diameter of the iv needle we were provided.

PPM 7 - Yes, I do remember. 

Very heartening to see this breed of doctors. 

Where is he working now?

PPM 1 - Telangana.

PPM 1 - Reviewed her again today in the OPD with @PPM8 and @PPM6 

Whatever ambiguity we may have been knowledge biased to have harbored around a possibility of ambiguous genitalia was removed by the subsequent MRI that was again done by our hardworking intern who managed to convince the MS why she needs an academic free MRI 👏👏

Uterus and ovaries are clearly seen and her bladder that is also seen is partly fashioned from her ileum

PPM 1 - Left ovary 👆

PPM 1 - Right ovary and adnexal mass. 👆

PPM 1 - Current problems to be further explored are:

1) Ascites

2) Bladder outflow

3) potential fertility issues as told to her earlier need to be clarified from OBG

4) Her career pathway toward becoming a doctor starting from cracking NEET under the PWD quota @PPM3.

PPM 3 - 👍

PPM 1 - @PA please share your patient's documents showing the details of her surgery done here as well as previously.

Please be careful to remove the patient's name or any other identifiers from those documents.

PPM 3 - Please feel free to share your patient's thoughts about becoming doctor and giving NEET. 

Is she planning to give exam this year?

PA - Yes. She wants to write the NEET exam.

PPM 3 - 👍

That's great. How is the preparation going on. Is she giving any practice exams for NEET?

PA - Not yet.

PPM 3 - Neet will probably be conducted in May 2025.

we have 4 more months to prepare for the exam.

PA - Now what can the patient do?

PPM 3 - Try to write 1 grand test of full syllabus.

The patient will get to know her weak chapters, try to make a schedule to read those chapters in first 2 months. 

Then revise remaining chapters in next 1 month. I would recommend to write atleast 1 grand test each week in last month (April).

PPM 1 - 👍

PPM 3 - https://drive.google.com/drive/folders/1DKB7O8yytBSCTvQ1468gRMzajoUEGuY6

These are some pdf I have related to neet.

Can you tell us what resources the patient use to study.

like books or pdfs, youtube classes etc.

PA - Books only.

PPM 1 - Where can she appear for that test? Here in this PaJR group?

PPM 3 - There are some apps like Physics Wallah sir. She can attempt a test for free.

If she is preparing at home, I would recommend to take only test series subscription online and give test every week.

PPM 1 - 👍

PPM 3 - Is she preparing at home?

PA - Yes.

PPM 3 - Okay.

When can she write a mock exam. Decide according to her convenience. Take time if she want to prepare. But tell us the date so we can follow up.

PPM 1 - 👍

PPM 3 - Will the patient take the test on Monday 27th January?

PA - She should go to the urologist on Monday.

PPM 1 - 👍

Let's hope next Monday.

PPM 3 - 3rd February?

PA - Okay sir.

PPM 3 - Does the patient have a computer at home?

PA - No sir.

PPM 3 - Online tests can be difficult on phone. But she can do it.

PA - Thanks for your support sir.

PPM 3 - Let the patient take this exam, prepare well. Update us with marks.

I recommend physics wallah.

Download this app, and take mock test under dropper batch section.

PPM 3 - 👍

PA - Okay.

PPM 3 - This one.. first test is free. so, no need to pay for anything.

PA - Okay sir.

But small problem sir. The patient is telugu medium.

PPM 3 - Okay. Don't use app.

Will share a pdf. This is NEET question paper. Set time for 3 hrs and attempt this paper. I will send answer key later. She can download these pdfs online.

27-01-2025

PPM 3 - @PA how is the preparation going? If any doubts share in the group. We will help you.

PPM 1 - @PA please update.

We got the MRI done on Saturday which is showing a good report

Did the patient meet the urology team today?

Can meet me in the ICU today afternoon at 2:30PM to finalize.

@PPM9 added here to witness how @PPM3 and team will be able to help her crack the NEET and become a doctor.

PPM 9 - 🙏

PA - Report has not come yet.

PPM 1 - No problem

We'll get that by afternoon today hopefully

Are you all in the hospital now?

PA - Yes.

PPM 1 - Was an ultrasound guided ascitic tap done today for her @PPM8?

PPM 8 - Not yet sir, they said that they’ll do it after 2pm.

PPM 1 - 👍

Well @PPM3  we would need hopefully this week before she can actually start working on her preparation as by this week we hope to resolve the diagnostic and therapeutic uncertainty surrounding her ascites.

@PPM8 any idea why the urologists replaced her tube insertion and urine collection (intermittent self urinary catheterization through the permanent suprapubic cystostomy) routine of 18 years with an indwelling foleys catheter since last few weeks? Can you talk to the urologists and find out?

PPM 3 - 👍

PPM 8 - Okay sir i’ll talk to them.

28-01-2025

PPM 1 - Was the ascitic tap done yesterday @PPM8?

PPM 8 - Sir, yesterday they have tried but it failed.

They asked the patient to come again today.

PPM 1 - Oh!

PPM 8 - @PPM1 Sir should we send ascitic fluid for any cultures?

PPM 1 - Alright that too and more importantly: 

Ascitic fluid for SAAG with serum albumin

Ascitic fluid for TLC DLC

Ascitic fluid for CBNAAT done free of cost here from our rntep center near pulmonology OPD.

Was it sent today at @PPM8?

PPM 8 - Yes sir sent

PPM 1 - I guess the reports would be ready by now?

PPM 8 - 

CBNAAT report will be given after 3 days sir.

PPM 1 - Oh low SAAG

Now more important report is the ascitic fluid TLC DLC which should have been available even before the biochemistry as the cells can get degenerated if not seen ASAP.

PPM 8 - Yes sir, the report has been given, will collect it from lab and share it asap.

PPM 1 - 👍

PPM 8 - Sir, the printed report will be given tomorrow morning.

PPM 1 - Thanks.

30-01-2025

PPM 1 - 

In view of the ascitic fluid reports that are suggesting inflammatory peritoneum, we may need to explore the peritoneal cavity laparoscopically and yesterday I talked to Professor regarding further plan and we agreed that it could be done in the same setting under one time anesthesia where the urosurgeons could go through her umbilical tube (fashioned through the mitrafan off procedure) to take out her stones from the urinary bladder while the general surgeons led by Professsor could do a laparoscopic exploration with peritoneal biopsy.

@PPM8 would you like to discuss this with the professor today and if necessary you can call me and I can talk to him to add more clarification if necessary at the same time?

@PPM8 can you share the CT and MRI abdomen images of her urinary bladder?

PPM 9 - @PPM3 did you talk to the 19f or her family?

PPM 3 - Not yet... will do next week, as she is still undergoing treatment.

PPM 8 - Sir, I have spoken to Dr. Urologist sir regarding this, he seemed to be agreeing to do the procedure and he shall speak to you about it.

PPM 1 - Thanks. He'll need to coordinate with the urosurgeons too.

31-01-2025

PPM 10 - 

PPM 1 - Thanks @PPM10 both Prof Gen Surgery and Prof Urology have agreed to do both procedures (stone removal and laparoscopic peritoneal exploration biopsy) at a single OT sitting.

PPM 10 - Ok sir 

They will come on Monday itseems sir.

PPM 1 - Ask the PGs of Urology and Prof,  General Surgery as to when would they plan to admit her for the OT.

PPM 10 - Ok sir.

PPM 3 - @PA regarding your PwD certificate

please apply for fresh certificate again. the percentage should be between 40 to 80% to qualify for NEET.

You have to go to nearest government hospital to get the certificate.  

ask them to mention: you have no mental illnesses in the certificate.

try to get the certificate before NEET counselling.

I speak telugu. if you have any doubts, you can call me. I will clarify.

PPM 1 - 👍

05-02-2025

PPM 3 - @PA any update on preparation?

PPM 1 - They did not come this Monday or today?

I guess she may have to hold that till her OT is decided

PPM 3 - Okay sir.

10-02-2025

PPM 1 - @PPM10 is she still in urology ward? When was her OT for stone removal exactly?

PPM 8 - Sir her surgery for stone removal was done on 5th.

PPM 1 - Can you check her in the ward and share how she's now and also share the OT and post operative recovered as well as daily notes since then?

PPM 8 - The patient is doing fine sir, she lost her mobile phone recently hence is not able to stay in contact with us.

PPM 8 - Surgery was done on 07-02-2025

PPM 1 - Thanks @PPM8

[11-03-2025 16:10] PPM 1: Urology Prof Murthy said she was discharged long back. Any update on the

 patient @PA?

[11-03-2025 16:15] PA: Hii sir

[11-03-2025 16:25] PPM 1: Hello! How is your patient?

[11-03-2025 16:26] PA: She is fine sir

[11-03-2025 16:27] PPM 1: Preparing for neet?

[11-03-2025 16:27] PPM 1: Have all your patient's stones been removed?

[11-03-2025 16:28] PA: Haa

[11-03-2025 16:29] PA: Only bladder stones are removed.

[11-03-2025 16:33] PPM 1: Kidney has stone's

[26-03-2025 14:17] PPM 3: @~PA@PPM1 Is the treatment regimen done? shall we discuss about

 NEET prep?

[26-03-2025 14:25] PPM 1: Yes. Her bladder stones were removed. No OT dates given yet for the renal stones

[26-03-2025 14:36] PPM 3: This year NEET UG is scheduled on 4th May (only a month till exam date)

key changes in exam patter this year

- previously the paper had 2 parts "A and B". Part B had 5 extra questions as choice for each subject.

 from this year they are removing these extra questions from exam.

- Previously exam time was 3 hours 20 minutes. now its only 3 hours. (as exam will have 20 less

 questions)

So, the probability of scoring high marks is less this year.. and some are predicting cutoff will also be

 less this year.

[26-03-2025 14:37] PPM 3: @~PA

please give an update regarding your preparation. 

if you have any doubts you can call after 6 pm

[26-03-2025 15.14] PPM 9: She can get it..

Once followup her PwD status certificate.

And just speak to their parents and guide her for 1 que paper each of last 10years per each day..

Dont stress her about exams.

Not at all necessary.

She has already demonstrated amazing nursing and doctoral skills in her family as its evident above in

 the blogspot.

@PPM 1 sir.

[02-04-2025 08:40] PA: Sir patient wants to start her neet preparation can you please help her?

[02-04-2025 09:33] PPM 1: 👆@~PPM3

[02-04-2025 09.40] PPM 3: 👍

[02-04-2025 18:00] PPM 3: @PPM1 @~PPM9, unfortunately this year NEET Registration last date was 7th March. As our @~PA was busy with the procedures and to-and-fro trips to the hospital she missed the registration for this year NEET UG. She decided to take a drop year and prepare well for next year's NEET. Current plan is to secure a PwD Certificate from nearby government hospital and join in a long term NEET course nearby her hometown

[02-04-2025 18:01] PPM 3: I request everyone to share inputs for a better plan of action ✨

[02-04-2025 18:29] PPM 9: Its on your shoulders.

Show us what you can best do, while @PPM1, me or any will be supportive and mentors.

[02-04-2025 18:53] PPM 1: Agree with your current plan. Meanwhile as @~PPM11 suggested earlier should we reapply for her PwD certificate through the web link he had shared? Also @PPM11 perhaps this patient will be the best flag bearer for introducing PMR to MBBS?

[02-04-2025 18:54] PPM 1: Also @~PPM11 you can interact with our MBBS students here @~PPM3 from KMC @~PPM12 from Indore and @~PPM13 @~PPM14 for more ideas on introducing PMR in MBBS

[02-04-2025 18:55] PPM 12: Sir PMR??

[02-04-2025 18:55] PPM 11: Physical Medicine and Rehabilitation

[02-04-2025 18:55] PPM 11: iapmr.in

[02-04-2025 18:55] PPM 12: Oh okay sir 👍

[02-04-2025 18:55] PPM 12: Got it

[07-04-2025 12.36] PPM 1: Reviewed her in OPD.

[07-04-2025 14:02] PPM 1: Prof @~PPM11 had shared this for disability certificate registration earlier 👇

https://swavlambancard.gov.in/Applyforudid

Also let's begin the neet preparation here or open a separate group with her and her friends where she will be a student rather than a patient @~PPM3

[07-04-2025 16:17] PPM 1: @~PPM3 also add us to that group. @~PPM11 I'm sure can add some good pointers for neet UG there and we need to sensitize UGs to PMR even before they get into MBBS

[07-04-2025 16:23] PPM 1: @~PA please check how the other patient student got his certificate done online👇

[17/03, 12:44] PPM 11: For all in this group. It is easy to get certified. Fill details and approach the hospital👇🏻

[17/03, 12:45] PPM 11: https://swavlambancard.gov.in/Applyforudid

[17/03, 12:49] pm: 👆@⁨Patient Advocate 52M Hypertension WB⁩ please check this

[07/04, 13:59] cm: @⁨Patient Advocate 52M Hypertension WB⁩ was this checked and done?

[07/04, 15:04] Patient Advocate 52M Hypertension WB: Yes Sir

[07/04, 16:13]cm: Oh that's very good news. Did they provide a certificate?

[07/04, 16:14] Patient Advocate 52M Hypertension WB: Yes sir one certificate provided by them

[07/04, 16:15]pm: Online?

[07/04, 16:19] Patient Advocate 52M Hypertension WB: Yes Sir online certificate along with ID card

[07-04-2025 17:52] PPM 3: @~PPM11 please help with the category for pwd to be selected for this patient. there is no clear suitable category in the options given on website.

[07-04-2025 17:56] PPM 11: Locomotor Disability

[07-04-2025 17:59] PPM 11: Career shall be directed by passion and passion only. Don't blindly follow NEET. That is my advice

[07-04-2025 18:59] PPM 3: true

[07-04-2025 20:00] PPM 1: She doesn't have any problem in locomotion though. Her disability is due to her congenital bladder exstrophy that needs her to have been doing intermittent self-catheterization through the artificial umbilical orifice connected to her surgically reconstructed urinary bladder ever since she was a child to be able to remove her urine everyday.

@~PPM 3 what are the available choices of disability?

[07-04-2025 20:06] PPM 11: Take the Domicile or Voter ID to Certifying Authority

[07-04-2025 20:06] PPM 1: Here it's mentioned as a "psychological, social, and professional disability."

https://www.sciencedirect.com/science/article/pii/S2214442022000134#:~:text=1.,genital%20organs%2C%20and%20the%20perineum.&text=While%20efforts%20are%20focused%20on,%2C%20social%2C%20and%20professional%20disability.&text=There%20are%20also%20surgical%20challenges,preserving%20the%20upper%20urinary%20tract.

[07-04-2025 20:08] PPM 11: I recollect comparative talk given by me in Bhopal regarding Indian and American Acts😌

[07-04-2025 20:08] PPM 11: We have to follow Indian Act for now

[07-04-2025 22:22] PPM 3: They do have a section for congenital disabilities but exstrophy was not mentioned. I think she should visit a nearby government hospital to get her certificate offline sir

[08-04-2025 03:13] PPM 11: Congenital limb deficiency and deafness don't fot. No offline allowed now

[08-04-2025 06:40] PPM 1: She doesn't have deafness. I feel we could try congenital disability. What are the specific congenital disabilities mentioned there @~PPM 3?

[08-04-2025 07:37] PPM 11: No

[08-04-2025 07:37] PPM 11: Only this

[08-04-2025 08:17] PPM 1: Okay I just saw this 👇

https://www.swavlambancard.gov.in/about-persons-with-disability

There appears to be only two categories:

1) Physical disability. —

2) Locomotor disability (a person's inability to execute distinctive activities associated with movement of self and objects resulting from affliction of musculoskeletal or nervous system or both), including—

It includes everything! I wonder what does physical disability include? It appears that the numbering is confusing the subsets and locomotor disability should be a subset of physical disability under which every disability is included so we need to look at which subset of locomotor disability fits her?

That would be the last category number 6 here:

6) Any other category as may be notified by the Central Government

[08-04-2025 08:20] PPM 11: But extrophy is not "notified" in 6 yet.

67M With Severe Cor Pulmonale Due to Chronic Bronchitis Telangana PaJR

23-01-2025

This is an Online E Log Book to discuss our patient's de-identified health data shared after taking his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Sharing an outlier to our often made diagnosis of a metabolic syn diabetic phenotype here as a valuable challenge to the ease of diagnosing through phenotype hypothesis.

This man doesn't have diabetes or hypertension after regular monitoring since last few days here in ICU.

67M with severe cor pulmonale due to chronic bronchitis

He said was smoking since 3 years of age after his mother died when he was 2 and his father made him work in his tobacco firm rolling tobacco leaves, which his 3 year old self loved consuming! He gave up smoking since last 5 years and was admitted with anasarca and shortness of breath.

EMR SUMMARY

Age/Gender : 67 Years/Male

Address :

Discharge Type: Relieved

Admission Date: 17/01/2025 07:20 PM

Name of Treating Faculty

@PPM3, @PPM4 and @PPM5

Diagnosis

RIGHT HEART FAILURE(COR-PULMONALE) OBSTRUCTIVE SLEEP APNEA

RELATIVE POLYCYTEMIA(HCT-50) PRE RENAL AZOTEMIA CELLULITIS OF LEFT LOWER LIMB

RIGHT SIDED CHRONIC HYDROCELE

Case History and Clinical Findings

Chief COMPLAINTS-ABDOMINAL DISTENSION SINCE 2 MONTHS SOB SINCE 20 DAYS

HOPI-

PATIENT WAS APPARANTLY ASYMPTOMATIC 2 MONTHS AGO AND THEN Developed Abdominal DISTENSION SINCE 2 MONTHS, ASSOCIATED WITH SHORTNESS OF BREATH SINCE 20DAYS GRADE III-IV MMRS, INSIDIOUS ONSET AND GRADUALLY PROGRESSIVE ,PND -, ORTHOPNOEA +

H/O YELLOWISH DISCOLORATION OF EYES SINCE 2 MONTHS

H/O PEDAL EDEMA SINCE 2 MONTHS, MODERATE,PITTING TYPE, EXTENDING UPTO KNEE NO H/O FEVER, SOLD SOUGH, ALLERGIES, CHEST APIN, PALPITATIONS, SWEATING, ABDOMINAL PAIN,

NOH/O NAUSEA, VOMITINGS, LOOSE STOOLS, BURING MICTURITION, DECREASE IN URINE OUTPUT

 

PAST HISTORY-

N/K/C/O DM, HTN, TB, EPILEPSY, ASTHMA, CVA,CAD

PERSONAL HISTORY DIET-MIXED

SLEEP-ADEQUATE APPETITE- LOST

BOWEL MOVEMENTS-- CONSTIPATION MICTURITION- NORMAL

ADDICTIONS-ALCOHOL SINCE 50 YEARS OCCASSIONALLY 90ML LAST INTAKE WAS 10 DAYS BACK

1CHUTTA PACK / 3DAY AND STOPPED 5 YEARS BACK

GENERAL EXAMINATION PT IS C/C/C TEMP.AFEBRILE

PR 116 BPM BP 90/70MMHG RR 23/MIN

SPO2 92% ON 4 L O2

GRBS 109 MG/DL

SYSTEMIC EXAMINATION:

CVS: S1 S2 HEARD , NO MURMURS RS: BAE +, NVBS

P/A: SOFT, NT, NO ORAGANOMEGALY CNS-NFND

REFERED TO GENERAL SURGERY I/V/O ULCER OVER LEFT LOWER LIMB RX1.CONTINUE TREATMENT ADVICED AS PER PHYSICIAN 2.TAB.CHYMEROL FORTE PO/TID

3. TAB DOLO 650 MG PO/SOS

 4. MGSO4 GLYCERIN DRESSING

5. B/L LOWER LIMB CREPE BANDAGE AF

67YEAR OLD MALE PRESENTED WITH CHEIF COMPLAINTS ABDOMINAL DISTENSION SINCE

2 MONTHS, PEDAL EDEMA SINCE 2 MONTHSSOB SINCE 20 DAYS AND K/C/O CHRONIC SMOKER AND OCCASSIONAL ALCOHOLIC. NECESSORY INVESTIGATIONS WERE SENT AND BED SIDE 2DECHO WAS DONE SHOWING DILATED RIGHT ATRIUM AND DILATED RIGHT VENTRICLE WITH NON COLLAPSING IVC AND WAS DIAGONSED AS COR PULMONALE

PATIENT WAS STARTED ON LASIX, THIAMINE AND ANTIBIOTICS. PATIENT HAD SWELLING ON LEFT LOWER LIMB AND SURGERY REFERRAL WAS TAKEN AND DIAGNOSED AS LEFT LOWER LIMB CELLULITIS AND RIGHT SIDED CHRONIC HYDROCELE FOR WHICH SUPPORTIVE MANAGEMENT WAS GIVEN. 2DECHO WAS DONE SHOWED EF 61% WITH GOOD LV SYSTOLIC FUNCTION, DILATED RA, RV WITH DILATED IV. ASCITIC TAP WAS DONE WHICH SHOWED HIGH SAAG AND HIGH PROTEIN AND SUPPORTIVE MANAGEMENT WAS GIVEN. PATIENT WAS IMPROVED CLINICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.

Investigation

Anti HCV Antibodies - RAPID 17-01-2025 07:59:PM Non Reactive HBsAg-RAPID 17-01-2025 07:59:PM Negative

SERUM ELECTROLYTES (Na, K, C l) 18-01-2025 12:44:AM SODIUM 133 mmol/L 145-136

mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 101 mmol/L 98-107 mmol/L

BLOOD UREA 18-01-2025 07:37:AM 79 mg/dl 50-17 mg/dl SERUM CREATININE 18-01-2025

07:37:AM 1.2 mg/dl 1.3-0.8 mg/dl SERUM ALBUMIN ON 18/1/25- 3.7 g/dl

ABG 18-01-2025 07:37:AMPH 7.36PCO2 25.4PO2 60.7HCO3 14.3St.HCO3 17.4BEB -8.8BEecf - 10.0TCO2 27.1O2 Sat 89.0O2 Count 21.7

RFT 20-01-2025 12:08:AM UREA 55 mg/dl 50-17 mg/dl CREATININE 1.3 mg/dl 1.3-0.8 mg/ dl URICACID 9.3 mmol/L 7.2-3.5 mmol/LCALCIUM 9.0 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.8 mg/dl 4.5-

2.5 mg/dl SODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

104 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 20-01-2025 12:08:AM Total Bilurubin 4.20 mg/dl 1-0 mg/dl Direct Bilurubin 1.26 mg/dl 0.2-0.0 mg/dl SGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 14 IU/L 45-0

IU/LALKALINE PHOSPHATASE 228 IU/L 119-56 IU/LTOTAL PROTEINS 5.9 gm/dl 8.3-6.4

gm/dl ALBUMIN 2.9 gm/dl 4.6-3.2 gm/dl A/G RATIO 0.94

 RFT 20-01-2025 11:00:PM UREA 55 mg/dl 50-17 mg/dl CREATININE 1.5 mg/dl 1.3-0.8 mg/dl URIC

ACID 8.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 3.7 mg/dl 4.5-

2.5 mg/dl SODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.1 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

98 mmol/L 98-107 mmol/L

APTT TEST ON 20/1/25- 33 SEC PT TIME/INR ON 20/1/25

Prothrombin Time 17 SECINR 1.2 HS-TROPONIN I ON 20/1/25 TROPONIN-I 27.7 pg/ml

USG DONE ON 17/1/25 IMPRESSION

-ALTERED ECHOTEXTURE OF LIVER

-MILD TO MODERATE ASCITIS HEMOGRAM ON 20/1/25

HAEMOGLOBIN 16.5 gm/dl TOTAL COUNT 12,400 cells/cumm NEUTROPHILS 76 % LYMPHOCYTES 20 % EOSINOPHILS 02 % MONOCYTES 02 % BASOPHILS 00 % PCV 50.2 vol % M C V 81.8 fl M C H 26.9 pg M C H C 32.9 % RDW-CV 17.2 % RDW-SD 51.2 fl RBC COUNT 6.1

millions/cumm PLATELET COUNT 1.5 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC leukocytosis Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic with leukocytosis

HEMOGRAM ON 21/1/25

HAEMOGLOBIN 16.6 gm/dl TOTAL COUNT 12,300 cells/cumm NEUTROPHILS 78 % LYMPHOCYTES 11 % EOSINOPHILS 01 % MONOCYTES 10 % BASOPHILS 00 % PCV 49.7 vol % M C V 80.7 fl M C H 27.0 pg M C H C 33.5 % RDW-CV 18.0 % RDW-SD 54.3 fl RBC COUNT 6.15

millions/cumm PLATELET COUNT 1.5 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC leukocytosis Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic blood picture with leukocytosis

HEMOGRAM ON 22/1/25

 HAEMOGLOBIN 16.6 gm/dl TOTAL COUNT 11,000 cells/cumm NEUTROPHILS 79 % LYMPHOCYTES 13 %EOSINOPHILS 01 % MONOCYTES 07 % BASOPHILS 00 % PCV 49.6 vol % M C V 80.8 fl M C H 27.0 pg M C H C 33.4 % RDW-CV 18.0 % RDW-SD 54.4 flRBC COUNT 6.14

millions/cumm PLATELET COUNT 1.50 lakhs/cu.mm SMEAR

RBC Normocytic normochromic Light Microscopy WBC With in normal limits Light Microscopy

PLATELETS Adeqaute Light Microscopy

HEMOPARASITES No hemoparasites seen Light Microscopy

IMPRESSION Normocytic normochromic blood picture

LFT ON 22/1/25

Total Bilurubin 3.67 mg/dl Direct Bilurubin 1.55 mg/dl SGOT(AST) 16 IU/L SGPT(ALT) 10 IU/L ALKALINE PHOSPHATASE 206 IU/L TOTAL PROTEINS 6.1 gm/dl ALBUMIN 2.9 gm/dl A/G RATIO 0.89

RFT ON 22/1/25

UREA 58 mg/dl CREATININE 1.3 mg/dl URIC ACID 8.3 mmol/L CALCIUM 9.8 mg/dl

PHOSPHOROUS 2.9 mg/dl SODIUM 133 mmol/L POTASSIUM 3.5 mmol/L. CHLORIDE 97 mmol/L ASCITIC TAP REPORTS-

ASCITIC FLUID PROTEIN SUGAR:

SUGAR 121 mg/dl PROTEIN 2.9 g/dl ASCITIC FLUID AMYLASE

Ascitic Fluid Amylase-17 IU/L ASCITIC FLUID FOR LDH LDH 130 IU/L

SAAG

Serum Albumin 3.3 gm/dl Ascitic Albumin 1.7 gm/dl SAAG 1.6

2D ECHO WAS DONE ON 18/01/25 REPORT:

- 'D' SHAPE LV

- MODERATE TR+ WITH PAH

- TRIVIAL MR+; NO AR; MILD PR+

- SCLEROTIC AV; NO AS/MS; IAS - INTACT

- EF = 61% GOOD LV SYSTOLIC FUNCTION

- GRADE I DIASTOLIC DYSFUNCTION+

- IVC SIZE (1.90CM) DILATED NON COLLAPSING

- DILATED -> RA/RV MPA - SIZE 2.5CM

- MILD PE+; NO LV CLOT

 

Treatment Given (Enter only Generic Name)

1. SALT RESTRICTION <2 G/DAY

2. O2 SUPPLEMENTATION >SPO2 92%

3. INJ AUGMENTIN 1.2GM IV/TID FOR 5DAYS

4. INJ LASIX IV/BD 40MG---X---20MG

5. INJ CLEXANE 40MG S.C/OD

6. INJ THIAMINE 200MG IV/BD

7. TAB. MET-XL 25MG PO/BD

8. TAB.PCM 40 MG PO/OD

9. TAB.REJUNEX CD3 PO/OD

10. TAB.UDILIV 300MG PO/BD

11. STRICT I/O CHARTING

12. MONITORING VITALS AND INFORM SOS

Advice at Discharge

SALT RESTRICTION <2 G/DAY FLUID RESTRICTION <2L/DAY

HOME O2 / CPAP SUPPLEMENTATION >SPO2 92% TAB DYTOR PLUS 20/50MG PO OD FOR 1 MONTH TAB THIAMINE 100MG PO/BD FOR 1MONTH

TAB. MET-XL 25MG PO/OD TO CONTINUE TAB.PAN-D 40 MG PO/OD FOR 1MONTH TAB.REJUNEX CD3 PO/OD FOR 1MONTH TAB.UDILIV 300MG PO/BD FOR 1MONTH

TAB ECOSPRIN AV 75/10MG PO OD TO CONTINUE TAB.IVABRAD 5MG PO/BD X15DAYS

OINT.T-BACT L/A TID WITH DRESSINGS OVER LEFT LOWER LIMB COMPLETE ALCOCHOL ABSTIENCE

Follow Up

REVIEW TO GM OPD AFTER 2WEEK WITH HEMOGRAM, RFT AND LFT REPORTS.

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

 AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:  For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date: 22/1/25 Ward: ICU

Unit: V

 

PPM 1 - 68M with COPD acute exacerbation and Himalayan "p pulmonale" on ECG reducing in height after recovery!

55M CKD 2 Hypertension Diabetic Andhra PaJR

 

16-01-2025

This is an Online E Log Book  to discuss our patient's de-identified health data shared after his signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

PA - Patient history of Sugar & BP 

From Dec 2012

250 was sugar, 

Glymer/Glycomet 1000mg tablet (from 2012 to 2022) 

Telsarten/Telimstar - 40 mg (both times) (2012 to jun 2024) 

Nebivolal - (2022 to jun 2024) 

From Jun 2024 (only if BP is more than 150/90 - Nicardia 20 mg)

PPM 1- What are his current requirements from us?

To be able to decide that we need you to:

describe your patient's sequence of events that led to the current problems. Please begin the sequence of events from the time your patient had absolutely no problems at all. 

Please describe your patient's hourly routine over 24 hours when he was perfectly alright 

Next please describe what happened to his hourly 24 hour routine once the disease took hold on his life 

Please mention specifically which part of the patient's hourly routine was disrupted 

 If we had to give him a single medicine which problem would they prefer it to address?

Please post the patient's clinical photo of abdomen and arm muscle as demonstrated below in the image here:

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

PPM 1 - Also ask him to share his daily urine output here.

PA - What is the current requirement 👇

Need to cure his CKD disease and get him out of dialysis (he went through 3 dialysis as of now) 

Sequence of events which lead to this 👇

- 12 years of Sugar and BP and medication used

- Admitted for Covid Treatment @ Dec 2020 and treated with steroids

- Took voluntary retirement June 2023

- Went through Stress and mental tension due to family situations from (sep 2023 to Aug 2024) 

Patient @ 24 hrs from 1991 to Jun 2023 👇🏻

 

Approx - 7:30 am or 8 am wakeup

Freshing up and bathing immediately and going to the office 

Breakfast in house (idly & dosa) 

Reach the office by 10 am 

Lunch taken from home @ 2pm

Desk job and Working on the computer till 7 pm in Blue lights  (computers came in 2010) 

30% of the days.. Walking 1 hr

Any other home work and watching TV 

And sleeping by 11 pm 

Patient 24 hrs from jun 2023 till now 

24 hrs @ After voluntary retirement 👇🏻

Waking up not fixed.. Anytime at 9 or 10 

Sometimes breakfast and sometimes no

Lunch 

Sleeping in afternoons and other times also 

50% walking 1 hr

Watching TV

And sleeping 

When disease took over @ 24 hrs 👇

- Mostly not so much active 

- feeling weak 

Which hourly routine is affected ? 👇

Night sleep.. Most of the times night sleep is not possible... So he use to sleep in the morning and he lost his appetite also 

If only 1 medicine is given? 👇🏻

He is asking for over all health (But kidney should become good for now)

PPM 1 - 👍

PPM 2 - 👍

PA - Will send the below details by night 

- CKD details and Medication used during CKD 

- Photos required 

- Other Scans and test done

PPM 1 - Was seeing a similar patient right now in the ward and I have shared his details in the collective group @PPM2, @CR.

PA - Recent Scan report.

PA - Recent 2D Echo. 👇

PA - Recent RFT. After Dialysis. 👇

PA - Free Light Chain latest report. 👇

PA - RFT before 3rd Dialysis. 👇

17-01-2025

PPM 1 - What medications is he currently taking for his diabetes and hypertension and at what time?

Please share his regular food plates as shown by other patient advocates in their case reports

 here 👇

https://pajrcasereporter.blogspot.com/2024/10/80m-diabetes-hypertension-30yrs-ckd.html?m=1

PA - 

PA - He went through 3 dialysis and 

Before dialysis.. His Creatine hit to 23 and urea was at 250

Now.. his creatine is at 9 and urea is at 125.

PPM 1 - Thanks for sharing.

When have the local doctors there planned his next dialysis?

PA - Not yet informed... They said weekly twice.

Maybe day after tomorrow.

As of now.. He doesn't have edema and any water accumulation.

PPM 1 - 👆his hands look swollen here.

PA - Because of canla.

PA - 

Current symptoms

- Heavy cough 

- Breathlessness if he walks for more time 

- Mucus in the mouth

- Vision little less or blur

Improvement

Appetite is good

No pedal edema

No nausea, fatigue or dizziness.

PPM 1 - Any recent chest X-ray image?

PA - This was done after 1st dialysis on 10th.

PA - 

My question is

What makes docs say.. To stabilise creatine at 5 with dialysis 

And what makes them decide.... If a patient wants weekly once or twice? .. Is it symptoms and fluid accumulation or numbers 

And Generally, Urea leads to uremic symptoms right? 

Then... Why dialysis is not based on urea count

Because I have seen my patient with creatine 10 and his urea came down to 75 and he was alright without any symptoms

And one more question... Is there any chance that... If we make a patient accustomed with one frequency (say twice a week dialysis) .. Will his body get used to it?

PPM 1 - Good questions👏👏

1) Symptoms is the main guide in dialysis decision making as dialysis is not curative but simply a symptomatic life saving support

2) Creatinine is a better marker of severity of uremia than urea as urea levels are more variable depending on other factors other than renal function

3) This has been tried in many centers in the past and wasn't a great success in terms of outcomes.

PA - 

And as a person stays long on dialysis.. 

Is there a chance that his kidney will further deteriorate as it's work is done by outside machine.. 

Like it will become lazy and stop even little bit functioning?

Is that the reason.. People won't urinate after certain dialysis?

PPM 1 - Yes you are right!

Continued dialysis eventually makes the person's own kidney deteriorate in terms of function.

Absolutely well observed.

PA - 🙏

I really want my patient to be coming under your guidance as to how much of dialysis he require.. 

Will it be possible to make the process quick and 

If require.. I can bring the patient to your hospital.

🙏🙏🙏

I am afraid... As these people without any deep. Understanding told... For dialysis twice a week

@PPM1 sir, please guide.. If required.. I can physically bring the patient tomorrow to your hospital. 🙏

Because I don't want not even one unnecessary dialysis for the patient 🙏

I hope last 3 dialysis didn't so much deteriorate his kidneys 🙏

PPM 1 - Well it's a very difficult and challenging situation but yes nothing is impossible if there's a person like you who can really dig deep into all the current available data around this and then work with the caregivers to design a better data driven optimal management strategy tailored to the requirements of the patient.

But just to provide a whiff of how challenging and complex this is take a look at this paper 👇

https://pmc.ncbi.nlm.nih.gov/articles/PMC5260570/#:~:text=Residual%20renal%20function%20(RRF)%2C,sized%20molecules%20and%20protein%2Dbound

And after reading it share your learnings and best possible strategy for your patient that you would want your current caregivers in your city to go by.

I don't think you need to come here but if you can share all the data from your nearest center we can work together to guide you in a data driven manner.

PPM 1 - @PPM3 is my student from Bangalore. Still the nephrologist @PPM4 working there in Vijayawada or has he left?

PPM 3 - He is still working there and Associate of the Nephrology department sir.

PA - @PPM4 is treating the patient.

PPM 1 - 👍Let's hope we can all work together as a team along with @PPM4.

PPM 3 - 👍

PA - That would be super cool sir 🙏

Patient is feeling terrible after removing canla 

Is there anything we can do about this pain 🙏

Sorry for asking this silly question 🙏

PPM 1 - This is a most important question

Can apply thrombophob gel locally.

PA - Got and applied.. Thank you doc.

PPM 1 - 👍

PA - 

Docs have recommended these many medicines... I am against some of it

Sodocel 3 times.. His sodium is always in the bracket from past 4 months

Febutat.... His current uric acid is stable from past 4 reports 

Shavelmar 800 mg (twice) his inorganic phosphorus is 5.7

I am. Not sure.. If ecosprin is really required... As the blood will be already in diluted form because of fuilds

Cilnidipine and prazopress and nebimac for BP... Patient is very accustomed with nicardia 20 from 6 months.. That we will give only if his BP is more than 150/90

Dytor.. (No comments on this.. But Pedal edema is not there from 2 days) 

Fersome - His blood is at 6.9 .. I hope this will improve it

PA - @PPM1 sir  can u please guide.. What is must and what I can eliminate 🙏

PPM 1 - 👍

PA - If these many medicines are going inside... Patient  was only frustrated and asked for Pantoprezol 😅 (which doctors didn't recommend initially 😅😅)

PPM 1 - Yes unfortunately if we dig into the scientific evidence of efficacy for most of our drugs we may always find that the evidence is marginal.

While these drugs are a routine strategy for most such similar patients it would be important to review and audit the data around each patient 's outcomes while on these multiple drugs and how may one attribute causality to each drug intervention and their expected outcome.

18-01-2025

PA - 

TRACKER OF VALUES FROM JULY 2024 TILL JAN 2025 ⚡

Creatine 🌳 

7th July - 8.6 

8th July Morning - 6.5 

8th July evening - 7.8 (Kamineni)

12th July - 9.42

16th July - 9.78

19th July - 6.9 (AIIMS) 

20th July - 7.6 (AIIMS) 

21st July - 7.2 (AIIMS) 

Ist August - 11.77 

7th August - 11.9

13th August - 14.9

9th Sep - 11.4

19th Sep - 10.3

4th Oct - 10.3

14th Oct - 9.4

18th Nov - 13.5

27th Nov - 11.6

5th Dec - 12.7

28th Dec - 18.7

1st Jan - 17.8

5th Jan - 18.3

9th Jan - 23 (before HD) 

10th Jan - 18.9 (Next day after 1st HD) 

12th Jan - 9.9 (Next day after 2nd HD) 

15th Jan - 13.7 (before 3rd HD) 

16th Jan - 9.1 (Next day after 3rd HD) 

Urea 🪴

7th July - 107.7 (Vij lab) 

8th July - Not Tested (Kamineni) 

12th July - 118.39 (before hiims) 

16th July- 122.92 (4 days of hiims)

19th July -130 (AIIMS) 

20th July - 129 (AIIMS)

21st July - 126 (AIIMS)

Ist August - 175.5

7th August - 163

13th August - 156

9th Sep - 113.7

19th Sep - 117.1

4th Oct - 115.5

14th Oct - 86.2

18th Nov - 147.5

27th Nov - 157.3

5th Dec - 169.3

28th Dec - 207.5

1st Jan - 209

5th Jan - 230

9th Jan - 256 (before HD) 

10th Jan - 202

12th Jan - 105 (Next day after 2nd HD) 

15th Jan - 123 (before 3rd HD) 

16th Jan - 81 (Next day after 3rd HD) 

Uric Acid🍁 

7th July- 8.1 (vij lab) 

8th July- Not Tested (Kamineni) 

12th July - 7.5(before hiims) 

16th July- 8.2 (4 days of hiims)

19th July - 5.9 (AIIMS) 

Ist August - 8.3

7th August - 8.9

13th August - 7.8

9th Sep - 7.4

19th Sep - 7.4

4th Oct - 8.4

14th Oct - NA

18th Nov - 6.4

27th Nov - 6.8

5th Dec - 7.6

28th Dec - 10.5

1st Jan - 9.7

5th Jan - 10.5

9th Jan - NA

10th Jan - NA

12th Jan - NA

15th Jan - 5.7

16th Jan - NA

Haemoglobin (Blood understand) 🌹 

7th July - 12.4 (Vij lab) 

8th July- 11.5 (Kamineni) 

12th July - 10.3 (before hiims) 

16th July - 10.4 (4 days of hiims)

Ist August - 13.4

7th August - 10.5

13th August - 10.3

9th Sep - 10.8

19th Sep - 11.0

4th Oct - 9.9

14th Oct - 9.8

18th Nov - 8.6

27th Nov - 9.5

5th Dec - 7.6

28th Dec - 7.3

1st Jan - 6.9

5th Jan - NA

9th Jan - 6.7 (before 1st HD

10th Jan - 6.9 

12th Jan - 6.9 (After 2nd HD)

15th Jan - NA

16th Jan - NA

PPM 1 - Well done!

Will be interested to also see brief texts around the numbers depicting the life events of the patient in parallel to give more meaning to those numbers.

PA - I will. Be giving a detailed explanations of series of events happened in the patient's life, Medicines he used, treatment he was taking care, and various other things.. 

During every increase and decrease of values 🙏

This was my work from past 6 months... Everyone including Many neurologists laughed at what I am doing... 

I am happy that.. Finally it's getting used and happy to know that this will help in treating the patient further 🙏

Can u add our physician to the group ..she also saw the detailed patient journey... It will. Be good to have her here.

And there are various docs and health experts interfered in between and helped for the patient health in many ways

Will acknowledge all of them in detailed report by EOD

And let me know... If we can add some of them.. Who would be interested to help us.. Even right now 🙏

PPM 1 - Yes please go ahead and add them. We need to scale ASAP through like minded people.

PA - 🙏

Namaskaram everyone, 

This group is created by PaJR team.. 

They are helping me to understand my patient's health issue and the Source of the problem behind it.. 

I have added you all because.. You have been the people.. Helped my patient in his treatment at various levels 🙏

Hope this case study will help you to treat further patients 🙏

This is headed by @PPM1 Who is HOD of a reputed hospital in Telangana 🙏

The first one is a health scientist and he had done an extensive work and protocols in treating many people's health.

The second one is a MD Cardio vascular surgen turned to be an Ayurvedic Doctor with MD in ayurveda and naturopathy and Founded of SGP an Poly scientific Ayurveda Hospital and he got thousands of End stage disease people out of their problems.

The third one is based out of Chandigarh and she is BAMS Holder and Head of IP in HIIMS Chandigar and Founder of Namo Hospital and brings many people out of CKD 🙏

The fourth one, He is a Naturopathy practitioner from last 20 years and associated 

The fifth one, she is a Psychology grad and have been together for 6 months and understands the patient's journey 🙏

@PPM1 sir, Please have a brief introduction for your methodology and your team 🙏

I will post the remaining data and we will get into the full case study ASAP 🙏

PPM 1 - I'm just a physician.

We just try to help people using data and call the process "medical cognition" as an important component of data driven healthcare

More about our methodology archived here:

https://userdrivenhealthcare.blogspot.com/2022/10/medical-cognition-tools-to-resolve.html?m=1

PPM 2 - Was a kidney biopsy done after this free light chain test report?

PPM 1 - 👍

PA - No, not done.

PPM 2 - Should strongly consider getting one - if the suspected diagnosis is indeed Amyloidosis (from free light chain deposition in kidneys)

PA - Exactly I felt... But the nephrologist said... His report is alright and He will go for liver endoscopy in future.

PPM 2 - Which report? The free light chains one?

PA - Yes.

PPM 2 - Also why did the doctor ask for a liver test / endoscopy?

PA - I think... For future transplantation or probable correlation of it with kidney problem.

TRACKER & EVENTS ⚡

1. Pre Actute-CKD Events 👇(2012 to 2022) 

- BP and Diabetes from Dec 2012

- Covid Treatment with steroids Dec 2020 

2. Risk of Kidney Disease (Dec 2022) 👇 

Creatinine was 1.7 on Dec 2022 (Coimbatore) during his regular checkup and Doc little bit warned about risk of kidney disease in future

3. Voluntary Retirement and Fear of Kidney disease👇(June 2023 - July 2024) 

The patient took his retirement in June 2023 and his life style has changed completely without any activity (In between this period he was scared and didn't check with the doc at all) 

And with fear he used Neeri Juice (atleast 10 bottles) and vrukka doshantaka vati (Without any doc Consultation on his own) 

4. Found Creatinine at 8 (July 2024) 👇

After 10 days of pedal edema, forced to take a RFT and found creatine to be 8 

5. HIIMS Treatment @ Chandigarh 👇

Dates - 10th July to 17th July

Creatinine - 9.42 to 6.9

Treatment Done

- Ayurveda medicine

- Hot Water Tub (Water Dialysis) 

- Panchakarma

- Lape for Pedal Edema

- And few Allopathy medication also

6. Admitted to AIIMS

Dates - 19th July to 22nd July

Creatinine - 6.9 to 7.2

Treatment - Allopathy Medicines (lasix inj) and declares this as Acute CKD

Note - There is a theory that.. This report in AIIMS is wrong (as for the first report they told.. For everyone numbers got wrong in lab) 

7.Treatment with a Health Scientist 👇

Dates - 19th July to 13th Aug 

Creatinine - 11.7 to 14.9

Treatment -

- Punarnava juice and wheat grass

- Type of water (alkaline) quantity per serve very less

- And Food and walking and exercise

8. Restarted Water Dialysis & Siddha medication 👇

Dates - Aug 17th to Sep 9th

Creatinine - 14.9 to 11.4

Treatment - Water tub and siddha medication

9. MD Ayurvedic Doctor Treatment (Ayurveda) 👇

Duration - Sep 5th to Dec 5

Creatinine Values 

9th Sep - 11.4

19th Sep - 10.3

4th Oct - 10.3

14th Oct - 9.4

18th Nov - 13.5

27th Nov - 11.6

5th Dec - 12.7

Treatment 

- Ayurveda Medicines

- Oil Application to body

- Exercises and Asanas

- Breath Exercises

- Food restrictions and no sour or spice at all (reduced patient appetite and interest to words food) 

On our own we did Water Dialysis treatment

And water tub was missed from Nov 2nd to Nov 18th and due to demise of patients sister in law and there is a unusual spike in creatine (My understanding) 

10. No Medication and Nothing 👇

Duration - 5th Dec to Dec 28th 

Creatinine - 12.7 to 18.7

Treatment - Nothing 

Condition and event - Patient developed a heavy cough and mucus in lungs and couldn't follow Ayurveda protocol and didn't do even water dialysis treatment

And his mother was hospitalised and died on 26 Dec

11. Dialysis period 👇🏻

Duration - 9th Jan to 16th Jan

9th Jan - 23 (Creatinine) (morning) 

9th Jan Evening

1st Dialysis of 2000 UF in 3hrs (for water) 

10th Jan - 18.9 (Creatinine) 

11th Jan - 2nd Dialysis of 3000 UF for 6 hours 

12th Jan - 9.9 Creatinine

15th Jan - 13.7 (Creatinine) (morning) 

15th Jan - 3rd Dialysis of 2000 UF for 4 hours 

And Iron injection of 100ml was given 

16th Jan - 9.1 is the latest creatinine report 

12. Present Status ❤👇

- Patient is with Dialysis tube on neck

- Taking sun regularly

- Taking allopathy medication

- Restarted Siddha medicine and Hot water dialysis

- And eating food with very good appetite 

- Patient still has Occasional cough and mucus

🙏🙏🙏🙏

PA - 30% Vision is feeling blurred for the patient

PPM 2 - Can we explore why he took alternative medicine like Ayurveda and Siddha etc?

PPM 1 - Thanks for sharing the sequence of events so very well 👏👏

One of the most interesting features in this case report is surely the convergence of various systems of medicine in one patient that is perhaps much more frequent than it is actually reported.

It would be important to be able to nurture these confluences without conflict to achieve the best possible outcomes of what is currently termed "integrative medicine"

PA - I only have taken that decision.. 

Because I haven't found a proper nephrologist.. Who study's the problem in depth instead he is only eager to do dialysis even without symptoms.. 

The nephrologist in AIIMS.. When my dad creatinine is at 7 .. Was telling.. Anyway in future we need to start dialysis... Why don't we start today itself... This was the approach they had.. 

I am. Not against the dialysis.. But I am against if it's unnecessarily done.. If there is no need.

PPM 2 - I understand your perspective, however not finding a good nephrologist should not push us towards non evidence based practices?

Did those alternative medicine practitioners study the patient's problem in depth?

PA - I guess.. They understand the human system in a different way... And depth differs from system to system

While Allopathy deals with Human Chemistry and it's changes 

Other systems observe them differently

For example ayurveda dwells with Vatta, pitta and kapha and their balance 

And disease is an Imbalance of these Factors

While naturopathy has a different approach and understanding on human system

They see the human to be naturally health if they are insync with nature they understand..

And diseases are reasons and problems which disturbs that sync..

PPM 1 - 👍

PA - I am not saying that allopathy is not seeing things in deep.. 

I am just expressing the problem... 

Because of having a focused view on a particular organ which sometimes removes the eye to see the human as an entire person (organism) 

And sometimes Due to Following the same protocols without seeing every case as different and new.

PPM 1 - 👍

PA - @PPM1 sir Doctor requesting you to guide the patients further steps 

And further understanding the source of the disease and what would be the possible treatment protocol Or diagnosis needs to be done 🙏

PPM 1 - From the dominant mainstream medicine perspective, I guess the next step is renal transplant but from the other systems perspective it would be trying other systems approaches along with dialysis sos.

Wish I knew more about other systems approaches. As pointed out by @PPM2 our training in general medicine doesn't cover these other approaches well enough as the evidence generated for these other approaches currently don't make it to the mainstream but I have added @PPM3 here who has been a collaborator with us in our attempts to learn more about how to integrate all these approaches and I shall be looking forward to his inputs.

PA - Do you think.. Biopsy is required and any other views on the Kidney effects ? 

And can u guide as to.. How we decide the dialysis frequency is it based on number or symptoms?

PPM 2 - I would recommend you to check out The Liver Doctor.

PPM 1 - For mainstream medicine it's useful to be able to visualise the anatomical location of the problem at a microscopic level by taking a tissue sample aka biopsy although it may not change the current treatment plan and one of the reasons it's difficult to decide about whether we should test or not is because there's an old adage suggesting that if we know that the treatment doesn't change with a test result then the test may not have been necessary in the first place. 

Having said that biopsy is a necessity in academic centres as it would help us to gather a collective shared understanding of the problem in micro anatomical terms.

In the article on what are the mainstream approaches to preserve residual renal function that I shared above earlier, there's some mention of twice daily dialysis as one approach along with meticulous avoidance of any triggers toward further renal injury and the article more or less well covers all mainstream medicine may have to offer in this situation.

PPM 3 - December 2022 to July 2024 appears to be the period when Creatinine spiked to 8. Was he evaluated/followed up during that period as to why was it escalating ?

The narrative says he used some ayurvedic medicine during that period on self, and after that pedal edema and spiked creatinine to 8 (prior to that 1.7). Any other creatinine values just before starting that self medication and immediately after can give us a picture if the the initial assault could be DIKI (Drug Induced Kidney Injury)?. I just happened to see a similiar case last week where patient landed into DIKI post usage of a unnamed herbal decoction from a folklore healer.

PPM 1 - 👍

PA - No values in that period nor he went to any doctor.

PPM 3 - Okay.

PPM 2 - In your critical thought - what do you think are the pitfalls or harms of alternative medicine?

You've clearly highlighted the ones with modern medicine. Curious to hear your views.

19-01-2025

PPM 1 - An AI assisted attempt to integrate mainstream and alternative pathways to patient centered care 👇

Looking forward to real world critiques:

[19/01, 08:37]: Can we think of the complement activation system and it's alternative pathways analogous to the connection between mainstream medicine and alternative medicine?

[19/01, 08:37] Meta AI: What an intriguing idea!

The complement activation system, a part of the innate immune system, can be seen as analogous to the relationship between mainstream medicine and alternative medicine in several ways:

Classical Pathway (Mainstream Medicine)

1. Triggered by specific antigens: Mainstream medicine is often triggered by specific, evidence-based diagnoses and treatments.

2. Well-defined and regulated: Mainstream medicine follows established guidelines, regulations, and standards of care.

3. Activation leads to a coordinated response: Mainstream medicine involves a coordinated response from healthcare professionals, following established protocols.

Alternative Pathway (Alternative Medicine)

1. Triggered by non-specific factors: Alternative medicine may be triggered by non-specific factors, such as patient preferences, cultural influences, or personal experiences.

2. Less defined and regulated: Alternative medicine often operates outside of mainstream medical regulations and standards.

3. Activation leads to a diverse response: Alternative medicine encompasses a wide range of practices, such as acupuncture, herbalism, and homeopathy, which may not be universally accepted or evidence-based.

Lectin Pathway (Integrative Medicine)

1. Bridges the classical and alternative pathways: Integrative medicine aims to combine mainstream medical practices with evidence-based alternative therapies.

2. Recognizes the importance of both pathways: Integrative medicine acknowledges the value of both mainstream and alternative approaches, seeking to integrate the best of both worlds.

This analogy highlights the complex relationships between mainstream medicine, alternative medicine, and integrative medicine. While mainstream medicine provides a foundation for evidence-based care, alternative medicine offers diverse perspectives and approaches. Integrative medicine seeks to bridge the gap between these two pathways, promoting patient-centered approach to healthcare.

26-01-2025

PA - Pregabalin Methylcobalamin Capsules. This medicine was suggested by doctor for leg burning in Feb 2023.. And used for 2 months.

Made patient so drowsy and he eventually stopped it.

PPM 1 - Yes that's a bad side effect

I guess he's good since stopping it from May 2023?

27-01-2025

PA - Namaskaram everyone, 

My dad's hemoglobin is at 6

And till now 2 (500ml) of fcm iron injections were givenfrom past 2 weeks

But hemoglobin.. Didn't get increased

When some one suggested to do blood transfusion

There is resistance.. I don't know why? 

Some one told me that.. We should do blood transfusion.. If u r going for transplantation in future.. 

Any one knows why?

Want to Tell you very openly something patient creatinine level went to 23 and even before that for 6 months the creatinine values were above 10 but right now the value is 10 constant but because of the dialysis the symptoms that he is facing is so much...he is having constant cough and his very restless 

 What happened in past 2 weeks for him is more troubling than what happened in 6 months. 

 Only the number got down from 23 to 10 but the symptoms got increased.

And there is a theory that.. If hemoglobin or blood increases in the body.. 

The creatinine and urea in the blood will also look low.. Because of the quantity of blood getting increased.. 

Like a proportionate decrease happens?

PPM 3 - Is anytime Erythropoietin advised or used by him?

PA - Yes sir, he has used the erythropoietin in the past.

After every dialysis.. They are giving Erythropoietin.

PPM 3 - Okay.

PPM 1 - To answer your question regarding efficacy of blood transfusion before renal transplant here's a longish answer:

Historical Context

In the 1970s and 1980s, blood transfusions were commonly used to modulate the immune system and improve graft survival in renal transplant patients. The idea was that blood transfusions would induce a state of immune tolerance, reducing the risk of rejection.

Efficacy:

Numerous studies have investigated the efficacy of pre-renal transplant blood transfusion. A meta-analysis published in the New England Journal of Medicine in 1999 found that:

- Blood transfusions reduced the risk of acute rejection by 27%

- Blood transfusions improved graft survival at 1 year by 12%

- Blood transfusions had no significant effect on patient survival

However, a more recent Cochrane Review published in 2011 found that:

- There was no significant difference in graft survival or acute rejection rates between patients who received blood transfusions and those who did not

- Blood transfusions may actually increase the risk of certain adverse events, such as transfusion-related infections and malignancies

Current Practice

Given the mixed evidence and potential risks associated with blood transfusions, this practice is no longer widely recommended or used as an immunomodulatory strategy in renal transplantation.

Instead, modern immunosuppressive regimens and desensitization protocols have become the standard of care for managing immune responses in renal transplant patients.

In summary, while pre-renal transplant blood transfusion was once thought to be beneficial, the current evidence suggests that its efficacy is limited, and it is no longer a recommended practice.

PPM 3 - 👍

PPM 1 - To answer the question as to why his hemoglobin isn't improving, we may have to confirm if the team has addressed all the issues enumerated below:

Also we need to see his Hb trends since when he was first diagnosed 

1. Erythropoietin deficiency: Erythropoietin (EPO) is a hormone produced by the kidneys that stimulates red blood cell production. In CRF, EPO production is reduced, leading to decreased red blood cell production.

2. Iron deficiency: Iron is essential for hemoglobin production. In CRF, iron deficiency can occur due to blood loss during dialysis, reduced dietary iron intake, or increased iron requirements.

3. Chronic inflammation: Chronic inflammation is common in CRF and can lead to anemia by reducing EPO production, increasing hepcidin levels (which reduces iron absorption), and promoting the production of inflammatory cytokines that suppress erythropoiesis.

4. Vitamin deficiencies: Deficiencies in vitamins such as B12 and folate can contribute to anemia in CRF.

5. Blood loss: Blood loss during dialysis or due to gastrointestinal bleeding can contribute to anemia.

6. Bone marrow suppression: Certain medications used to treat CRF, such as ACE inhibitors and NSAIDs, can suppress bone marrow function, leading to anemia.

Diagnostic Approach

1. Complete Blood Count (CBC): To evaluate hemoglobin, hematocrit, and red blood cell indices.

2. Iron studies: To assess iron deficiency, including serum iron, transferrin saturation, and ferritin levels.

3. Erythropoietin (EPO) level: To evaluate EPO production.

4. Vitamin B12 and folate levels: To assess for deficiencies.

5. Bone marrow biopsy: To evaluate bone marrow function and morphology.

Therapeutic Approach

1. Erythropoiesis-stimulating agents (ESAs): To stimulate red blood cell production, such as epoetin alfa or darbepoetin alfa.

2. Iron supplementation: To address iron deficiency, either orally or intravenously.

3. Vitamin supplementation: To address vitamin deficiencies, such as vitamin B12 or folate.

4. Blood transfusions: To rapidly increase red blood cell count in severe anemia.

5. Addressing chronic inflammation: Through medications or lifestyle modifications to reduce inflammation and promote erythropoiesis.

6. Dialysis optimization: To minimize blood loss and optimize dialysis treatment.

The therapeutic approach should be individualized based on the underlying cause of anemia, the patient's clinical status, and the presence of any comorbidities.

PA - 

Free Light Chain latest report.

Is this light chain test.. Something to do with bone marrow?

If yes.. Why did we talk about bone marrow biopsy?

PPM 1 - It's a test used to look for multiple myeloma in patients of renal failure.

However it cannot totally alone confirm multiple myeloma as for that bone marrow will be necessary.

As in your patient it was negative the matter may not have been pursued further and rightly so.

We have another 57 year old patient on follow up of another PaJR Team member here where this ratio was strongly positive that helped in her diagnosis of multiple myeloma 👇

https://medicineprudence.blogspot.com/2025/01/high-risk-kappa-light-chain-multiple.html?m=1