10-02-2025
This is an Online E Log Book to discuss our patient's de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.
Ward afternoon session:
22F with Crohn's colitis and cachexia since 3 years
On budesonide 3 mg capsules SR once daily for 3 years with intermittent breaks when the medicines go out of stock.
Incidentally we had another similar age patient visiting us in the OPD at the same time right now with a similar hemoglobin but notice the differences in the nails (the middle one being that of our other intern serving as a nail control). This other patient's anemia is due to her Crohn's disease and that makes her nails clubbed where we can expect a high ferritin level while Latisha's patient's anemia is likely due to iron deficiency and you can check out her flat nails!
PPM 1 - 👆We also started empirical antitubercular therapy for the current patient of Crohn's and as per her weight band she needs 2 tablets per day @PPM3.
PPM 1 - Crohn's or intestinal tuberculosis daughter with marked cachexia and sarcopenia in comparison to her current normal healthy mother in one frame.
PPM 2 - Addisons!!
PPM 1 - 👆From today we will try to capture and archive her macroscopic stool images as this may also provide valuable clues to monitor her bowel inflammation
19-02-2025
PPM 1 - Congratulations intern for this remarkable patient centered learning contribution in a young patient with neck flutter where because of your good clinical skills (inspite of my bad ones going contrary) you persisted in your diagnosis of anemia to explain her neck flutter due to hyperdynamic circulation and also did a small study with more controls to study the reason for neck flutter when most of her investigational hemodynamic parameters came normal! 👏👏
Incidentally we had another similar age patient visiting us in the OPD at the same time right now with a similar hemoglobin but notice the differences in the nails (the middle one being that of our other intern serving as a nail control). This other patient's anemia is due to her Crohn's disease and that makes her nails clubbed where we can expect a high ferritin level while Latisha's patient's anemia is likely due to iron deficiency and you can check out her flat nails!
19-02-2025
PPM 1 - Day 2 stool update 👆
20-02-2025
PPM 1 - Day 3 stool update. Will be discharging her tomorrow.
01-03-2025
PPM 1 - Update on our previously reported patient of suspected crohn's vs intestinal tuberculosis started on antitubercular therapy who came back with fever and pancytopenia after 10 days of starting antitubercular therapy!
Yesterday she went into hypotension. Antibiotics escalated and inotropes instituted. Still holding on with a finger!
The only current source of her sepsis appears to be this urinary E Coli while her blood culture is sterile.
Her serial ECGs since admission. Any correlation with the serial serum potassium trends visible in the daily investigation timeline shared above?
What are these ECG artifacts?
01-03-2025
Non contrast CT Abdomen
03-03-2025
Afternoon ward:
22F with Crohn's and drug induced pancytopenia and sepsis today had severe guarding and rigidity in her abdomen suggestion a perforation peritonitis, which was imaged at the bedside and fluid aspirated.
04-03-2025
Afternoon Update 22F
Bedside: Crohn's, drug induced pancytopenia, sepsis, hypotension and recent peritonitis, altered sensorium since yesterday
Bench: Ascitic fluid 300 cells all lymphocytes
Also ascitic fluid shows an organism morphologically resembling pepto streptococcus
[04-03-2025 18:44] PPM 2 - Long term steroids?
[04-03-2025 20:57] PPM 3: Sir does it require surgical intervention?
[04-03-2025 20:59] PPM 1: Was on budesonide intermittently since her Crohn's diagnosis
[04-03-2025 20:59] PPM 1: Would be very risky to provide anesthesia in her current
critically ill state
[04-03-2025 21:00] PPM 3: Yes Sir.
05-03-2025
PPM 1 - She died yesterday! It was her birthday today!
Sometimes I feel we doctors should also get an opportunity to cry once each one of our patient dies. It
could be possible I guess on making home visits after meeting the family and sharing the grief with
them. Perhaps that was possible in the past when doctors used to make home visits and always kept in
touch with the families of their patients.
06-03-2025
[06-03-2025 16:05] PPM 3: Gram positive bacilli sir.
[06-03-2025 16:05] PPM 3: If you look at the above picture you can see gram positive cocci also sir
(few in singles)
[06-03-2025 16:05] PPM 3: In this field you can see gram positive cells and mononuclear cells also sir
[06-03-2025 16:08] PPM 1: Microscopic examination of her peritoneal fluid revealed these organisms
suggestive of anerobic gut bacteria.
[06-03-2025 16.25] PPM 2 - The only 2 clinically relevant Gram positive bacillii I know are Neisseria
and Moraxella
But if chronic,
Actinomyces, Nocardia and our old friend TB come to mind.
[06-03-2025 16:41] PPM 2: But if anaerobic then Bacterioides fragilis is the commonest
[06-03-2025 16:44] PPM 1: And considering that it may have come from the gut, which one would it
be?
[06-03-2025 16:46] PPM 4: E coli?
[06-03-2025 16:52] PPM 1: The four dominant bacterial phyla in the human gut are Bacillota
(Firmicutes), Bacteroidota, Actinomycetota, and Pseudomonadota.[23] Most bacteria belong to the
genera Bacteroides, Clostridium, Faecalibacterium,[6][7] Eubacterium, Ruminococcus, Peptococcus,
Peptostreptococcus, and Bifidobacterium.[6][7] Other genera, such as Escherichia and Lactobacillus,
are present to a lesser extent.[6] Species from the genus Bacteroides alone constitute about 30% of all
bacteria in the gut, suggesting that this genus is especially important in the functioning of the host.
Unquote
https://en.m.wikipedia.org/wiki/Gut_microbiota
[06-03-2025 17:00] PPM 2: Micro or macroperforation. Especially in the background of IBD Crohn
[06-03-2025 17:02] PPM 1: Clinically macro
[06-03-2025 17:20] PPM 2: Then needs exploratory laparotomy and repair.
[06-03-2025 21.48] PPM 1: She had severe hypotension, was on inotropes due to her neutropenic
sepsis.
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