55M Homelessness With Psychoendoneuroimmunologic Social Determinants of Health TG PaJR

 

28-02-2025

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.

Chest X-ray

03-03-2025

PPM 1 - This is an additional diagnosis of the patient 👇

19F With Type 1 Diabetes Telangana PaJR

25-02-2025

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 ONLINECOMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BET EVIDENCE BASED INPUTS.

Afternoon ward:

19F with Type 1 Diabetes, diabetic ketoacidosis and lower limb cellulitis 

Mother lost both her limbs by amputation due to diabetic foot a year back although mother had developed diabetes just two years ago.

25-02-2025

PPM 2 - Early changes of Charcot visible here. Loss of hair on legs, skin changes, almost flat foot arches, LMN type of wasting (minimally) all pointing to poor glycemic control and long duration of diabetes.

What's the current HbA1c and long term management plan?

PPM 1 - @PPM3 please check the data on file to answer these.

PPM 3 - HbA1c is 7.3 sir 

She was non complaint to treatment.

Her history is suggestive of Type 1 DM sir, planning to discharge her on injectable insulin after DKA subsides.

PPM 1 - Any reasons the treating team found for her non concordance with the treatment?

PPM 3 - She herself told that she was on OHAs and she used to not take them regularly sir.

PPM 1 - Oh! Since when was she on OHAs? How long is her diabetes?

PPM 3 - Since 6yrs she’s having sir, i.e from the age of 13/14yrs.She was on OHAs since only 1 year and non complaint to medication.

PPM 1 - From age 13 to till 1 year back what was she taking for her diabetes?

PPM 3 - She did not take anything sir

Since 6 years she has complaints of polyuria, polyphagia and polydypsia 

And since 1 year she is using medication occasionally 

There was no apparent reason why she decided to go to hospital 1 year ago for treatment sir.

PPM 1 - Very interesting!

Then it couldn't have been a type 1 since 6 years although it now looks like a type one with ketoacidosis! @PPM2?

PPM 3 - Why couldn’t it be type 1 sir?

PPM 1 - Type 1 essentially means completely destroyed beta cells and hence prone to ketoacidosis and death if left untreated with insulin!

However there's a possibility that her beta cells behaved like type 2 initially with just 60-70% destruction and took 6 years to get totally destroyed producing severe insulinopenia enough to generate ketoacidosis!

But then the above scenario would be labeled rapidly progressive type 2. What other labels can one use from the diabetes ontology for a similar scenario @PPM2?

PPM 2 - I don't believe that HbA1c for half a second.

PPM 3 - Our hospital  lab generally gives a lesser value than outside labs sir

It will be around 9/10, if our lab gives HbA1c as 7.3.

PPM 2 - It is very likely a Type 1 with a long honeymoon phase.

While that is the pathophysiology, Type 1 is now basically diagnosed with a C-peptide level of <200 pmol/l paired with a serum glucose of 72mg/dl or above and either Anti GAD, Anti IAA2, Anti Zn8 or any Anti ICA antibodies.

Can happen that she was teetering along the borders of these numbers for quite a while (honeymoon phase)

This is euphemism for "our hospital lab is incredibly corrupt and immoral in that in several cases it calculates the HbA1c by using a formula with fasting blood glucose and also does not upgrade itself to perform HPLC and still performs enzymatic based tests"

I've been there and done that.

Ambedkar, our biochemistry in house lab tech told me this when I probed on this issue. He himself gets his and his family tests done elsewhere, inspite of having KAP.

PPM 1 - This is a 19 year old girl with a younger brother and a mother with two amputated limbs and a long dead father and no one else in this world other than us (for the time being)! Even while giving consent in the file for something it was she who had to painfully write using the cardiac table in her ICU bed even as she continued her acidotic breathing as her brother looking after her in the ICU is just a minor.

While our departmental fund and devotion may tackle her issues we need to gear up foundationally to work around expensive lab test driven diabetes ontologies and develop our own low resource settings ontology for diabetes classification @PPM4.

PPM 1 - Yes, none of those tests will add any value to her current clinical condition.

However, what insulin she will be put on matters and I'm curious to know.

I also believe a thorough and detailed neurological and vascular examination would be excellent value addition to her care.

PPM 1 - We have discussed this with the Principal who used to be from Biochemistry department and the HOD biochemistry who agreed that our latex agglutination approach to Hba1c isn't great but we must remember again that we work in a low resource setting with sparse manpower and resources and have to make do with other perhaps even better current PaJR portable means of blood sugar control assessment than expensive Hba1c.

Mixtard 50:50 sponsored by "we the people"/tax payers/government.

Yes that's not difficult. Can be easily done and maintained on PaJR follow up.

PPM 2 - It's a solid bet and should be as good as those Lispros and Levemirs.

If anyone of the interested PGs can kindly share a head to head trial on this for further discussion and optimisation of treatment.

PPM 1 - 👍

[10-03-2025 10:25] PA: Doctor, this patient is having breathlessness and is in Gandhi Hospital.

[10-03-2025 10:32] PPM 1: Oh!

Why Gandhi?

Why not here?

[10-03-2025 10:45] PA: Don't know, casually called her about updating her health.

[10-03-2025 10:59] PPM 1: Alright

[10-03-2025 13:00] PA: She is still waiting there with nobody attending. She didn't come to Kamineni

 for financial reasons.

[10-03-2025 13:06] PPM 1: Alright but how much did she have to spend with us last time? Oh now I

 remember the treating unit had probably asked for some expensive antibiotics to continue which they

 couldn't afford.

[10-03-2025 13:07] PA: Now how can we help her?

[10-03-2025 13:15] PPM 1: We need to know what are her current pressing issues.

How is her lower limb wound?

How is her sugar control?

Can she check her sugars every two hours after her meal and allow us to guide the dosage of her

 insulin?

@PPM2 may agree that it's the non evidence based over-testing and overtreatment that she has received

 till now (whatever may be the reason) that is perhaps the reason for her running out of resources

Even the government PHC also has adequate resources to manage her only there are no trained doctors

[10-03-2025 13.18] PPM 2: 👍

[10-03-2025 13:19] PA: Now they are attending to her and according to her brother her wound is okay

 and sugar under control. will call her after some time and update.

 

37M With Tubercular Meningitis Altered Sensorium Telangana PaJR

 22-02-2025

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.

Afternoon ward new patient:

37 year old man with PUO since 1 month and altered sensorium since one week. Admitted on Saturday evening and recovered into nearly normal sensorium for an hour after which again slid into coma. On examination there's right sided conjugate eye deviation making it difficult to elicit the oculocephalic reflexes. No meningeal signs. We did the meningeal tap anyways and struck gold!

@PPM2 @PPM3 @PPM4 I recall you were the first ones to share and document and review these patients with tubercular meningitis with normal cell count with just hypoglycorrhaceia and increased proteins! Can you share those previous patient case reports here or even the reviews? I have lost all that previous data from my previous phone. @PPM5 any similar patients in your tubercular project data? 

His CSF:

[24/02, 15:06] PPM7: CSF- Cell count 🔬

Only 1 cell 

Lymphocyte

[24/02, 15:06] PPM7: CSF- Biochem reports.

PPM 1 - His brain imaging:

Nothing very impressive except mild hydrocephalus consistent with raised ICP due to his tubercular involvement that is peculiar in showing normal cell count!

Update: Anisocoria and progressive hypoxia.

Getting connected to ventilator.

Chest X-ray today.

29F Pain Abdomen Endometriosis Looming Infertility WB PaJR

 

20-02-2025

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.

PPM 1 - Bedside curbside PaJR patient data shared with PaJR patient team advocate on 👇

 [2/19, 9:02 PM]: On December 25, 2024, a 29-year-old female experienced severe lower abdominal pain, making it difficult for her to stand. Initially, doctors suspected a urinary tract infection, but further tests, including several blood tests, multiple USG tests, a CT scan, and an MRI, revealed complexities like internal bleeding or endometriosis. Several doctors recommended surgery to remove a cyst from her right ovary, which might affect her fertility. She then went to Bangalore, where doctors prescribed medication for a month and advised a follow-up visit to determine if surgery is needed.

[2/19, 9:06 PM]: The patient recently got married and she doesn't have any child. She wants pregnancy in near future.

[2/19, 9:37 PM]: *Medication for 3 months

[2/19, 9:40 PM]: She never had any symptoms like pain or any irregularities in her menstrual bleeding before. And even afterwards she didn't have any pain during her period in January 28th.

[2/19, 9:42 PM]: But after few days of taking medicine, she finds red spotting and mild continuous bleeding throughout the month. She is taking DINOGEST tablet's from approximately one month.

[2/19, 9:48 PM]: All her test reports and prescriptions are sent here. Kindly consider reviewing once as the patient and patient party is in a big panic mode.

PPM 1 - @PA Please add the patient's immediate advocate here to discuss her problems and also share the deidentified file containing the patient's report data so that our case reporter can quickly collate her case report and share the link in the description box where we have already pasted her initial history as shared earlier by the patient's immediate advocate. Consent form has been shared in the case reporter group to email and archive safely in the informedconsent@gmail.com address.

PA - Patient case report 

On December 25, 2024, a 29-year-old female experienced severe lower abdominal pain, making it difficult for her to stand. Initially, doctors suspected a urinary tract infection, but further tests, including several blood tests, multiple USG tests, a CT scan, and an MRI, revealed complexities like internal bleeding or endometriosis. Several doctors recommended surgery to remove a cyst from her right ovary, which might affect her fertility. She then went to Bangalore, where doctors prescribed medication for a month and advised a follow-up visit to determine if surgery is needed.

The patient recently got married and she doesn't have any child. She wants pregnancy in near future.

*Medication for 3 months

She never had any symptoms like pain or any irregularities in her menstrual bleeding before. And even afterwards she didn't have any pain during her period on January 28th.

But after few days of taking medicine, she finds red spotting and mild continuous bleeding throughout the month. She is taking DINOGEST tablet's from approximately one month.

All her test reports and prescriptions are sent here. Kindly consider reviewing once as the patient and patient party is in a big panic mode.

27-02-2025

PPM 1 - @PPM2 can you comment on this obstetric endocrine issue particularly the progestin preparation dinogestin DNG that she's taking?

PA - 

PPM 1 - Please tell us what happened to the pain after it began on December 25, 2024. How long did it continue? How did it stop? Did it happen again? How is her pain currently?

PA - Pain lasted for 9/ 10 days. 

The patient used some painkillers for the first 4/5 days and had relief from pain.

The patient did not experience pain for a long time.

After that she never had any pain. The patient had brownish bleeding through out the month and her regular monthly periods were also on time.

She's fine now. No abdominal pain, no cramping, no bloating or any heaviness.

Patients Query - Should she try to conceive in this condition?

28-02-2025

PPM 1 - Yes she can try to conceive.

Once she feels better we can stop the tablet dienogest and then her chances of returning to be able to conceive may happen in a month.

To quote from a study on patients taking the same medicine,

"studies describe a prompt return to fertility (eg, mean about 30 days) and include cases of successful pregnancy in women with endometriosis following the cessation of dienogest treatment 2 mg daily for durations up to one year.

https://pmc.ncbi.nlm.nih.gov/articles/PMC3140813/

[12-03-2025 18:06] PA: Patients concern -"Good Afternoon Dr

My periods started on 20th Feb and still it is continuing. Everyday I use 1 pad. Before that spoting was

 there but now period is flowing."

[12-03-2025 20:09] PPM 1: Is she on dienogest? If not then when was it stopped?

[12-03-2025 20:10] PPM 1: When was the date of the period prior to that?

[12-03-2025 20:13] PA: Yes. She still taking DINOGEST.

Her period started on 26th Feb. And prior to that it was on 28 th January.

[12-03-2025 20:14] PA: *20 th Feb.

[12-03-2025 20:24] PPM 1: When was her last hemogram done and when was it done

 before that? Can you share those after deidentification?

[12-03-2025 20:31] PA: This was done approximately 2 months before

[12-03-2025 20:38] PPM 1: Can this be repeated now?

Is she on any iron tablets?

[12-03-2025 20:43] PA: She's not taking iron tablets. 

Sure, she'll repeat the test.

May be another USG be also done within few days. 

However, she is taking medicine for hypothyroidism, thyroxin sodium 37.5 mcg for last one month.

[12-03-2025 20.45] PPM 1: 👍

[17-03-2025 20:12] PA: With due respect, I would like to bring to your kind attention that the patient

 underwent another pelvic ultrasound today. The report is provided here for your review.

[17-03-2025 20:14] PA: CA 125, complete hemogram and TSH level test also have been done and

 reports will come by tomorrow

[17-03-2025 20:44] PPM 1: Strangely none of these fibroids were visible in her uterus in the December

 2024 ultrasound!

[17-03-2025 20:45] PA: Yes Sir! Should she do another Ultrasound?

[17-03-2025 20:50] PPM 1: Was the previous ultrasound done by the same sonologist?

[17-03-2025 20:51] PA: Yes Sir.

[17-03-2025 20:58] PPM 1: Did he comment that the fibroid weren't noticed earlier?

[17-03-2025 21.00] PA: Does this MRI scan of January suggest any kind of uterine fibroids?

[17-03-2025 21:02] PA: He mentioned it wasn't detectable on USG before.

[18-03-2025 10:19] PPM 1: Yes it does! 

Very well spotted👏👏

[21-03-2025 06:49] PA: CA 125 value 51

[21-03-2025 06:51] PA: TSH and other blood parameters are more or less normal.

[21-03-2025 06:51] PA: I shall send the reports by this evening.

[21-03-2025 06:52] PPM 1: Levels above 35 U/mL may be associated with ovarian cancer, but can also

 be elevated due to other conditions like endometriosis, fibroids etc

https://ocrahope.org/for-patients/gynecologic-cancers/ovarian-cancer/detection-diagnosis/#:~:text=Generally%20speaking%2C%20the%20normal%20range,or%20other%20suspicious%20clinical%20findings.

[21-03-2025 06:53] PA: She consulted with two Doctors. Their suggestions are contradicting each

 others. She's getting confused.

[21-03-2025 07:00] PA: One of them suggested to continue the DINOGEST 2mg for another month

 more at every night. And also gave some progesterone to take each day in the morning. And avoid

 pregnancy for this 1 month to avoid further complications.

But doctor 2 Suggested to stop all medicine and for immediate trying for pregnancy. 

So will you kindly share your views in this regard, please?

[22-03-2025 16.57] PPM 1: Logically speaking, things are not going to be different unless she stops the

 dinogest and for her desired pregnancy, she will have to stop the dinogest at some point of time.

 Stopping it now or stopping it after a month should not make much difference.

[28-03-2025 19:07] PA:  Good evening,

Since February 20th, her periods have started and are still continuing. Every day, she has to use one pad.

 Last week, on Friday, she consulted a doctor, who prescribed Pause 500 mg (three times a day) for five

 days. During those days, the bleeding was minimal, with only a few drops. However, today, she

 suddenly experienced heavy bleeding along with blood clots. She has been taking Dienogest 2 mg

 tablets since January 23rd.

[28-03-2025 19:28] PPM 1: When was her last period before Feb 28?

[28-03-2025 19:31] PA: January 24th

[28-03-2025 19:37] PPM 1: What was the duration and how many pads per day at that time?

[28-03-2025 20:07] PA: 2nd day tey 3 ta lage . 3rd day tey 2 ta. Onno din ektai

[28-03-2025 20:07] PA: Other days 1 pad only.

[14-05-2025 20:08] PPM 1: Please share her current updates

[14-05-2025 20:13] PA: Stopped every medicine. No recurrence of symptoms. However the usg is not done in recent time. And the doctor suggested to plan for pregnancy. Now she is suggested to do several follicular usg tests.

[14-05-2025 20:18] PPM 1: Good to hear that she's symptom free

[14-05-2025 20:19] PA: Yes sir. Now the goal is pregnancy.

PPM 1: 👍