05-03-2025 22.39
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.
DESCRIPTION
Patient: Male
Age 18 Years
(A Student of Class XI)
Present Problems:
Lethargy,
Unmindful and less interest in study,
Lack of Concentration,
Habit of sleeping late night and awaking up late,
Laziness,
Habits of wasting time unnecessarily.
Family History:
Father is a pre- diabetic (52M Hypertension, Diabetes 5 years WB PaJR )
Mother is a patient of hypertension
Grand Father was a patient of Liver Cirrhosis
Grand Mother was a patient of diabetes and hypertension
Uncle is a patient of Fatty Liver
Medications:
Tablet Levipil 500 (twice daily)
Tablet Tetrafal Plus — Once daily (presently discontinued)
History:
When the patient was 3 (three) years old, suddenly found that his lips were slightly bend, firstly 2/3 times a day, then several times (7 to 10). He seemed to be smiling. One brain tumor was detected after doctor’s investigation. After detecting brain tumor in his right side of parental lobe, surgery done in the year 2010, (NIMHANS — Bangalore) then doctor told that tumor has been removed partially.
Thereafter in the year 2012 symptoms of focal seizures appeared again and Brain Surgery was done again.
One day in the year 2021, December, he had severe pain in his head and became senseless, after being admitted to the hospital; he was in a pre-coma stage and was on ventilation for five days. After investigation Doctor found that lot of blood clotted inside the brain and once again brain surgery was done for the third time. After that left side of his body became paralyzed.
At present he can walk with a little shuffling of his left leg but cannot do the movement of left wrist but he can’t move the fingers of his left hand. Always he keeps the fingers of his left hand folded.
The patient is eagerly waiting to meet you as soon as possible.
Phenotype of the patient
[11-03-2025 20.58] PA: Dinner
[11-03-2025 21:44] PPM 3: 🙏🏻 Any video of walking?
[11-03-2025 21:46] PPM 1: Without patient's face and any other identifiers.
[11-03-2025 21:47] PPM 1: We'll take it once the patient visits us.
[11-03-2025 21:47] PPM 1: When are they visiting us?
[11-03-2025 21:48] PPM 1: Walking away will do.
[11-03-2025 22:11] PA: Sir we are going to your hospital on 13 th March, Thursday morning, and will
reach the Railway Station at 7.20am on that day. I request you to kindly brief how to reach there from the railway station. 🙏
[12-03-2025 07:28] PPM 1: From Nalgonda to our hospital is easiest by auto.
[12-03-2025 07.30] PA: Below is the video of the patient walking.
[12-03-2025 07:29] PPM 1: Managing to climb down the stairs with his left hemiparesis 👏👏
Morning PaJR CBBLE session:
[13/03, 06:48] cm: This long distance patient is visiting us today and will be admitted as inpatient for a few days 👇
What contextual causes and effects can we find in his multi modal data in the link above?
@PPM4 are you working in similar oncology projects at Moffitt?
[13/03, 06:58] PPM 4: I am not working on neuroepithelial tumors sir. In previous job I use to work in neuro-oncology with a focus on brain mets and glioblastoma and in connection to breast cancer. Now working in gynecologic cancers including low grade serous ovarian cancer which is a cousin of breast cancer.
[13/03, 06:58] PPM 4: But I can look up guidelines and other evidence around diagnostic and treatment options
[13/03, 07:02] PPM 1: Yes that would be very useful. What in the current case report available data is useful in terms of contextual causes and effects?
[13/03, 07:07] PPM 4: Contextual Causes and Effects from Multi-Modal Data
1. Primary Neurological Condition:
• Cause: The patient has a history of a right frontal recurrent dysembryoplastic neuroepithelial tumor (DNET) with focal atypical features, hemorrhage, and focal cortical dysplasia.
• Effect: Multiple brain surgeries (2010, 2012, and 2021) were performed for tumor excision and hematoma evacuation, leading to residual neurological deficits, including focal seizures and left-sided paralysis.
2. History of Recurrent Surgeries and Its Effects:
• Cause: The patient underwent three major craniotomies and surgical resections, with the latest in December 2021, after a pre-coma state due to a massive intracranial hemorrhage and blood clot formation.
• Effect:
• Resulted in left-sided paralysis (hemiparesis) and inability to use fingers of the left hand.
• Persistent neurological symptoms, including seizures, requiring antiepileptic drugs (Levipil).
• Likely neurocognitive impairments, seen as lethargy, lack of concentration, and sleep disturbances.
3. Structural Brain Changes and Cognitive Dysfunction:
• Cause: MRI shows:
• Large cystic lesion in the right fronto-parietal region communicating with the lateral ventricle.
• Gliotic changes with hemorrhagic foci in the right fronto-temporal region.
• Old hemorrhage in the occipital horns of the bilateral lateral ventricles.
• Effect:
• The right frontal lobe involvement is strongly linked to cognitive decline, impaired executive function, lack of focus, and behavioral changes.
• Damage to the fronto-temporal regions could explain the lethargy, laziness, and lack of motivation.
4. Post-Surgical Sequelae and Medications:
• Cause: Ongoing need for antiepileptic drugs (Levipil, Tetrafal Plus).
• Effect: Chronic use of antiepileptic drugs may contribute to cognitive slowing, fatigue, and concentration issues.
5. Vitamin D Deficiency and Possible Systemic Impact:
• Cause: Documented low vitamin D levels and mild thrombocytopenia.
• Effect:
• Vitamin D deficiency is associated with fatigue, depression, muscle weakness, and could contribute to sluggishness and reduced motivation.
• Mild thrombocytopenia might be secondary to chronic illness or medication effects.
6. Lifestyle and Sleep-Wake Disturbance:
• Cause: Habit of sleeping late and waking up late.
• Effect: Irregular sleep cycles can exacerbate cognitive dysfunction, emotional instability, and reduced focus.
7. Family History and Genetic Predisposition:
• Cause: Strong family history of metabolic disorders (diabetes, hypertension, fatty liver, liver cirrhosis).
• Effect: Increased risk of metabolic dysregulation, which could further impact neurological recovery and cognition.
Support Credit: ChatGPT LLM.
[13/03, 07:13] PPM 1: Excellent! I guess till the advent of AI LLMs tackling contextual multi-modal causes and effects data may have been a major manual challenge but that has currently changed and AI may have a lot to do with changing the current single cause and effect research paradigm to a multiple complex causes and effects research paradigm? @PPM5.
[13-03-2025 13.02] PPM 1: Reviewed the long distance patient in OPD @PPM4 (earlier case reported
from home as a part of our telemedical EHR development program:
https://pajrcasereporter.blogspot.com/2025/03/18m-right-frontal-lobe-neuroepithelial.html?m=1
Additional interview insights: started at age 2 with frequent falls during running or laughter and the first
time in December 2009 he developed facial partial seizures as if he was having a distorted smile
following which MRI showed the tumor, Nimhans operated but seizures recurred, re-operated in
Kolkata and then in 2021 had an intratumoral bleed (image attached) which was again re operated in
Chennai. His current problems are @PPM3 left hemiparesis stiffness particularly
the perpetually closed fist as in the attached image and reactive depression due to the issues.
@PPM6 please ensure that he gets physiotherapy and psychiatry opinion today
[13-03-2025 13:11] PPM 6: Okay sir
[13-03-2025 13:12] PPM 3: Frequent stretching exercises for finger and wrist flexors. May be
considered for BoNT after showing to local PMR - AIIMS Bibinagar
[13-03-2025 13:13] PPM 1: BoNT?
[13-03-2025 13:13] PPM 1: Would a splint help?
[13-03-2025 13:13] PPM 3: Botulinum Neuro Toxin
[13-03-2025 13:13] PPM 3: May not. Depends how much is spasticity. Exercise will surely help
[13-03-2025 13:15] PPM 3: 4-6 times a day. Cryotherapy is dicy as it may induce Raynauds but may be tried.
[13-03-2025 20:52] PA: Sir ei test গুলো এখন করতে দিয়েছে
Translation - "Sir has now asked to do these tests."
[14-03-2025 10:05] PPM 1: @PPM6 please share the psychiatry notes of this patient especially for
evaluation of his current symptoms of people phobia that could be a result of his traumatic brain injury
over the last few years
[14-03-2025 10:06] PPM 1: @PPM6 send them to the OPD with the file where i shall take care of
sending to their necessary consults and I shall also talk to the psy team in OPD.
[14-03-2025 14.20] PPM 7:
[14-03-2025 14:20] PPM 7: Psychiatry consultation completed sir
[14-03-2025 14:35] PPM 1: Thanks can you summarise the jist of the above here in text?
[14-03-2025 14:45] PPM 7: He was feeling uncomfortable when he meets his group of peers.
He was not able to focus on his studies and he was feeling low about his inability and what others think
about him (social anxiety). he was unable to do on large tasks. but he is good at small tasks. He was
spending much time with phone. He was suffering from adjustment disorder sir.
[14-03-2025 16:20] PPM 1: Well summarised 👏
[14-03-2025 16:31] PA: Sir physiotherapy done
[14-03-2025 16:38] PPM 7: Tq sir
[14-03-2025 17:37] PPM 8: I want to talk to him please
[14-03-2025 19:39] PPM 1: Thanks. Please let @PA please mention when you would be free to
talk to @PPM8. He is our team psychologist. It will be very useful for us to get inputs from him once
he talks to you.
[14-03-2025 20:16] PA: Sir now we are free to talk with him
[14-03-2025 20:25] Rakesh Biswas Sir: 👆@PPM8
[14-03-2025 20:54] PA: স্যার এই মেডিসিনগুলো কি শুরু করে দেবো? (Sir Should i start these
medications)
[14-03-2025 21:00] PPM 1: @PPM8 er saathe kotha bole. Chutir pore shuru korleo cholbe (It's okay to
start after the holiday)
[14-03-2025 21:59] PA: স্যার আমি ওনার সাথে কথা বলেছিলাম মেডিনিনের জন্যে,উনি জানিয়েছেন
যে ওটা আপনি ঠিক করবেন (Sir I spoke with him regarding the medication, and he mentioned that you would decide on that.")
[15-03-2025 07:24] PPM 1: Hain. Unar theke jene nicchi patient er sombondhe unar impression ki
tarpor janacchi. ("Yes. I’m getting to know about the patient from him, and then I will inform you about
his impression.)
@PPM8 can you pm me your impression of the patient's psychological issues after your telephonic
conversation with him?
[15-03-2025 07:38] PPM 8: Yes sir
[15-03-2025 11:19] PA: স্যার আজকে কি আপনি হাসপাতালে আসবেন? ("Sir, will you come to the
hospital today?")
[15-03-2025 11:27] PPM 1: OPD te achi to sokal theke ("I'm at the OPD since morning)
[15-03-2025 11:28] PA: স্যার কতক্ষন আছেন? (Sir, how long will you be there?)
[15-03-2025 11:29] PA: আমরা physiotherapy তে আছি (We are in physiotherapy.)
[15-03-2025 11:30] PA: Physiotherapy হয়ে গেলে আসবো? (I will come after the physiotherapy.")
[17-03-2025 12.27] PPM 1: We want our patient who's currently 10+2 science to become a doctor and I
have added @~PPM9 to this group to facilitate the same and @~PPM3 can share his thoughts on how
to procure a disability certificate for him.
Meanwhile our PG is teaching him how to see BP in OPD
[17-03-2025 12.22] PA: 🙏
[17-03-2025 12.25] PA: 🙏
[17-03-2025 12:44] PPM 3: For all in this group. It is easy to get certified. Fill details and approach the
hospital👇🏻
[17-03-2025 12:45] PPM 3: https://swavlambancard.gov.in/Applyforudid
[17-03-2025 12:49] PPM 1: 👆@~PA please check this
[17-03-2025 15:33] PA: Patient is suffering from running nose and nasal congestion from the last 3 days
[17-03-2025 16:19] PPM 1: Can take tablet fexofenadine 120 mg once daily.
[18-03-2025 14:36] PA: স্যার আজ বিকেল 5.30 এখান থেকে বেরিয়ে যাবো,আমরা এখনো কেবিনেই আছি
[07-04-2025 13:59] PPM 1: @~PA was the above link checked and done?
[07-04-2025 15:04] PA: Yes Sir
[07-04-2025 16:13] PPM 1: Oh that's very good news. Did they provide a certificate?
[07-04-2025 16:14] PA: Yes sir one certificate provided by them
[07-04-2025 16:15] PPM 1: Online?
[07-04-2025 16:19] PA: Yes Sir online certificate along with ID card
[07-04-2025 16:20] PPM 1: Good to hear that!
[07-04-2025 16.20] PA: 🙏
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