11-03-2025
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.
[11-03-2025 16.22] PPM 1: Afternoon session:
54M with metabolic syn phenotype
Both knee osteoarthritis with fixed flexion deformity since years.
Six months back developed severe pain and blackening of left lower limb followed by Doppler showing blocked lower limb arteries
Now admitted with us with pain abdomen and CECT suggests blocked peripheral renal vessels producing a characteristic pattern (attached)
[11-03-2025 16.42] PPM 1: Given the past limb arterial embolism and current renal arterial embolism I
guess a better look at his echocardiography would become imperative @PPM3?
Bedside: Yesterday's patient of peripheral left leg ischemia and amputation 6 months back and current
left renal multiple infarcts
Bedside to bench: 2D echo no thrombus or vegetation.
[14-03-2025 13.20] PPM 1: https://youtu.be/EE1KmigccJg?si=EA4WI-dhz6t5uxZL
[14-03-2025 13.20] PPM 1: 👆 This video can be showed to the current evaluating team.
This is the same patient's EMR summary:
Age/Gender : 55 Years/Male
Address :
Discharge Type: Relieved
Admission Date: 06/03/2025 11:29 PM
Name of Treating Faculty DR.SHASHIKALA(AP) DR.HIMAJA(PGY3) DR.MANOHITH(PGY2)
DR TUSHARA(PGY2)
Diagnosis
ACUTE PYELONEPHRITIS
ACUTE GASTROENTERITIS (RESOLVED)
S/P: LEFT ABOVE KNEE AMPUTATION 4 MONTHS BACK MULTIPLE RENAL INFARCTS
HBSAG- POSITIVE
Case History and Clinical Findings
C/O 2 EPISODES OF VOMITING SINCE EVENING
C/O 1 EPISODE OF LOOSE STOOLS SINCE EVENING C/O PAIN ABDOMEN SINCE EVENING
HOPI:
PATIENT WAS APPARENTLY NORMAL TILL EVENING
THEN HE DEVELOPED 2EPISODES AT VOMITING, SUDDEN ONSET, CONTAINING FOOD PARTICLES WATER AS CONTENT, NON PROJECTILE, NON BLOOD TINGED
C/O 1 EPISDODE OF LOOSE STOOLS, WATERY IN CONSISTENCY, NON MUCOID, NON BLOOD STAINED, NON FOUL SMELLING
C/O PAIN IN THE UMBILICAL REGION, NON TENDER NO AGGREVATING AND RELIEVING FACTORS
NO H/O FEVER, COUGH, COLD, CHEST PAIN, PALPITATIONS, SEIZURES, CONSTIPATION, LOC
PAST HISTORY:
NOT K/C/O DM, HTN, TB, ASTHMA, EPILEPSY, CVA, CAD AND THYROID DISORDERS H/O LEFT ABOVE KNEE AMPUTATION SECONDARY TO ?NECROTING FASCITIS PERSONAL HISTORY:
DIET-MIXED APPETITE- NORMAL
BOWEL MOVEMENTS- IRREGULAR(1EPISODE OF LOOSE STOOLS) BLADDER- NORMAL
SLEEP- ADEQUATE
ADDICTIONS: CHRONIC ALCOHOLIC 10 YEARS AGO, STOPPED 10 YEARS AGO FAMILY HISTORY : NOT SIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA BP:120/80MMHG
PR:62BPM RR:19CPM SPO2:99%@ RA GRBS :142MG/DL
SYSTEMIC EXAMINATION: CVS:S1 S2 HEARD ,NO MURMURS RS:BAE +,NVBS HEARD PA:SOFT,NON TENDER CNS:NFND
GCS: E4V5M6 RT LT
TONE UL NORMAL NORMAL LL NORMAL -
POWER UL 4/5 4/5 LL 4/5 -
REFLEXES B 2+ 2+
T 1+ 1+ S - -
K 2+ -
A 1+ - P F
-SURGERY REFFERAL DONE ON 8/3/25ADVISED UPPER GI ENDOSCOPYSERUM AMYLASE AND SERUM LIPASE
X RAY ERECT ABDOMEN
GASTRO REFERRAL DONE ON 11/3/25 AND ADVISED WITH FIBROSCAN LIVER
AFP
HBV DNA QUANTITATIVE HEPATITIS B ENVELOPE ANTIGEN ANTI HBC ANTIBODY
UGI ENDOSCOPY FASTING
NEPHRO REFERRAL DONE ON 12/3/25 AND ADVISED RENAL ARTERY DOPPLER
Investigation Name Value Range Name Value Range
HEMOGRAM ProvisionalTest Result Units Normal Range MethodHAEMOGLOBIN 11.1 gm/dl 13.0 -
17.0 Colorimetric LOX -PAPTOTAL COUNT 16,900 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 78 % 40 - 80 Light MicroscopyLYMPHOCYTES 14 % 20 - 40 Light
MicroscopyEOSINOPHILS 03 % 01 - 06 Light MicroscopyMONOCYTES 05 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 32.9 vol % 40 - 50 CalculationM C V 79.0 fl
83 - 101 CalculationM C H 26.7 pg 27 - 32 CalculationM C H C 33.8 % 31.5 - 34.5 CalculationRDW-
CV 14.2 % 11.6 - 14.0 HistogramRDW-SD 43.3 fl 39.0-46.0 HistogramRBC COUNT 4.16
millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 3.55 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC Increased on smear Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic withleucocytosisBLOOD UREA 07-03-2025 12:48:AM 40 mg/dl 42-12 mg/dl
FBS 76 mg/dl 70 - 110 GOD - POD
SERUM CREATININE 07-03-2025 12:48:AM 0.8 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) 07-03-2025 12:48:AMSODIUM 141 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5
mmol/LCHLORIDE 106 mmol/L 98-107 mmol/L
LIVER FUNCTION TEST (LFT) 07-03-2025 12:48:AMTotal Bilurubin 0.82 mg/dl 1-0 mg/dlDirect Bilurubin 0.19 mg/dl 0.2-0.0 mg/dlSGOT(AST) 137 IU/L 35-0 IU/LSGPT(ALT) 70 IU/L 45-0
IU/LALKALINE PHOSPHATASE 123 IU/L 280-53 IU/LTOTAL PROTEINS 5.5 gm/dl 8.3-6.4
gm/dlALBUMIN 3.2 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.40
ABG 07-03-2025 12:59:AMPH 7.42PCO2 26.1PO2 125HCO3 16.7St.HCO3 19.3BEB -6.2BEecf -
6.9TCO2 34.5O2 Sat 98.9O2 Count 14.4
HIV 1/2 Rapid Test Non Reactive ImmunoChromatography
HBsAg-RAPID 07-03-2025 01:00:AM PositiveAnti HCV Antibodies - RAPID 07-03-2025 01:00:AM
Non Reactive
SERUM ELECTROLYTES (Na, K, C l) 07-03-2025 07:54:PMSODIUM 135 mmol/L 145-136
mmol/LPOTASSIUM 3.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/LBLOOD UREA
07-03-2025 07:54:PM 37 mg/dl 42-12 mg/dl
SERUM CREATININE 07-03-2025 07:54:PM 1.2 mg/dl 1.3-0.9 mg/dl
LIPID PROFILETest Result Units Normal Range MethodTotal Cholesterol 180 mg/dl Child
:Desirable:<170Borderline high:170-199High : >199Adult :Desirable:<200Borderline high:200- 239High : >239CHOD/PODTriglycerides 128 mg/dl 0 - 150 GPO-POD WithESPASHDL Cholesterol 44 mg/dl 40 - 60 Direct EnzymaticLDL Cholesterol 106 mg/dl. 0 - 100 Direct EnzymaticVLDL * 25.6 mg/dl 12-40 mg/dl Direct Enzymatic
08/03/25
HEMOGRAM ProvisionalTest Result Units Normal Range MethodHAEMOGLOBIN 12.5 gm/dl 13.0 -
17.0 Colorimetric LOX -PAPTOTAL COUNT 23,500 cells/cumm 4000 - 10000
ImpedenceNEUTROPHILS 78 % 40 - 80 Light MicroscopyLYMPHOCYTES 10 % 20 - 40 Light
MicroscopyEOSINOPHILS 06 % 01 - 06 Light MicroscopyMONOCYTES 06 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 36.1 vol % 40 - 50 CalculationM C V 78.3 fl
83 - 101 CalculationM C H 27.1 pg 27 - 32 CalculationM C H C 34.6 % 31.5 - 34.5 CalculationRDW-
CV 14.2 % 11.6 - 14.0 HistogramRDW-SD 43.4 fl 39.0-46.0 HistogramRBC COUNT 4.61
millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 2.9 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC increased counts on smear Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic bloodpicture with leucocytosis
Blood Urea 37 mg/dl 12 - 42 Urease-GLDH
Serum Creatinine 1.2 mg/dl 0.9 - 1.3 Modified Jaffe's
SODIUM 135 mmol/L 136 - 145 Ion SelectiveElectrodePOTASSIUM 3.7 mmol/L 3.5 - 5.1 Ion
SelectiveElectrodeCHLORIDE 99 mmol/L 98 - 107 Ion SelectiveElectrodeCALCIUM IONIZED 1.12 mmol/L Cord Blood : 1.30 - 1.602Hrs : 1.21 - 1.4624Hrs : 1.10 - 1.363Days : 1.15 - 1.425Days : 1.22 -
1.48Adults : 1.16 - 1.32Ion SelectiveElectrode
WIDAL TEST : NEGATIVE 12/3/25
HAEMOGLOBIN 11. 2gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 14,000 cells/cumm
4000 - 10000 ImpedenceNEUTROPHILS 60 % 40 - 80 Light MicroscopyLYMPHOCYTES 15 % 20 -
40 Light MicroscopyEOSINOPHILS 18 % 01 - 06 Light MicroscopyMONOCYTES 07 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 32.9 vol % 40 - 50 CalculationM C V 78.7 fl
83 - 101 CalculationM C H 26.8 pg 27 - 32 CalculationM C H C 34.0 % 31.5 - 34.5 CalculationRDW-
CV 14.5 % 11.6 - 14.0 HistogramRDW-SD 43.9 fl 39.0-46.0 HistogramRBC COUNT 4.18
millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 3.46 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light Microscopy
USG ABDOMEN PELVIS VWAS DONE ON 7.03.2025 IMPRESSION: RIGHT RENAL CALCULI
GRADE 1 FATTY LIVER
REVIEW USG WAS DONE 8.03.2025
IMPRESSION: HYPOECHOIC CIRCUMFERENTIAL EDEMATOUS WALL THICKENING OF DUODENUM MEASURING 11mm. LIKELY INFECTIVE/INFLAMMATORY CAUSE.
E/O 11mm FOCAL CALCIFICATION NOTED IN THE MIDPOLE OF RIGHT KIDNEY. FOCAL CORTICAL SCARRING WITH CALCIFICATION
CECT DONE ON 9/3/25 IMPRESSION
MULTIPLE PERIPHERAL HYPODENSE NON ENHANCING LESIONS IN LEFT KIDNEY F/S/O MULTIPLE RENAL INFARCTS
BLOOD FOR BACTERIAL CULTURE AND SENSITIVITY 10/3/25 NO GROWTH AFTER 48 HRS OF AEROBIC INCUBATION URINE FOR CULTURE AND SENSITIVITY 11/3/25
NO BACTERIAL GROWTH
NO PUS CELLS SEEN ON WET MOUNT
Treatment Given(Enter only Generic Name) INJ. MEROPENEM 500MG IV/BD X 4 DAYS GIVEN IVF NS/RL @100ML/HR
INJ PAN 80MG IV/STAT INJ ZOFER 4MG IV/STAT
INJ METROGYL 500MG IV/TID X 3DAYS INJ THIAMINE 200MG IV/STAT
INJ OPTINEURON 1AMP IN 300ML NS IV/OD INJ BUSCOPAN 1AM IM/SOS
INJ CIPROFLOXACIN 100MG IV/BD X 4DAYS INJ NEOMOL 1GM IV/SOS (IF TEMO >101 F) TAB PCM 650MG PO/TID
ORS SACHETS (1 SACHET IN 1 LITRE OF WATER 1 GLASS AFTER EACH EPISODE)
Advice at Discharge
TAB FAROPENUM 200MG PO/BD X 5 DAYS TAB .PAN 40MG PO/OD X5DAYS TAB.THIAMINE 100MG PO /BDX 2DAYS TAB PCM 650MG PO/TIDX 3DAYS
TAB ZOFER 4MG PO/SOS
SYP. ARISTOZYME PO/TID X 2DAYS
Follow Up
REVIEW TO GM OPD AFTER 2WEEKS /SOS WITH GASTRO REPORTS FIBROSCAN LIVER
AFP
HBV DNA QUANTITATIVE HEPATITIS B ENVELOPE ANTIGEN ANTI HBC ANTIBODY
UGIE FASTING
RENAL ARTERY DOPPLER
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 Date: 12/03/25 Ward: MMW
Unit: IV
Interactions showing current challenges of digitization acceptance:
[16/03, 11:11] Patient Advocate: 54M Arterial gangrene patient advocate says they have taken him to GMC where they were asked to take the scanning again as we have not given them the films but only theory report. Now the patient is experiencing some allergy and has some infection.
[16/03, 11:20] pn: After getting the scan done again?
[16/03, 11:21]pm: GMC people didn't see the case reported and YouTube linked CT films?
[16/03, 11:21] Patient Advocate: No they were asking for hard copies.
[16/03, 11:22]pm: Hard copies of the Film?
[16/03, 11:22] Patient Advocate: Yes
[16/03, 11:25] pm: This is a fresh problem of digitization! Digitization happened so that one center
could access the films and all data easily but currently it appears that even after our digitising whatever
possible, other centers are more interested in seeing the paper and film based hard copies!
https://pajrcasereporter.blogspot.com/2025/03/54m-with-metabolic-syn-phenotype.html?m=1
[25-03-2025 14:55] Caretaker: Can you give me CT scan video sir
[25-03-2025 14:58] PPM 1: It was already shared here with @~Caretaker
[25-03-2025 14:59] PPM 1: Also available in his case report link in the description box
[25-03-2025 15:05] Caretaker: In that link only pdf summary is seen.
We want CT scan video sir
[25-03-2025 15:05] Caretaker: Here in Gandhi they are asking for CT scan video sir.
[25-03-2025 15:22] CR: I have sent it again.
[25-03-2025 15:34] Caretaker: Okay sir tqs
[25-03-2025 16:29] PPM 1: In that link there is a link to the CT video.
@CR can guide you to access the link to the video
[25-03-2025 16:30] PPM 1: Is he still in Gandhi?
How is he now?
Can you ask the Gandhi people to share some of his current issues?
@~PPM 3 are you still in Gandhi?
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