29-03-2025
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.
[29-03-2025 09.31] PA: "The patient is vomiting blood after drinking water. If this vomiting stops, we will take the patient to the hospital. If there is any emergency, please let us know."
[29-03-2025 09:33] PPM 1: Oshudh noi
Local daktar ke diye ryles tube poriye bleeding ta monitor kora dorkar ebong endoscopic variceal
ligation er proyojon hote pare jodi na bleeding bondho hoi
[29-03-2025 09:37] PA 2: এখানে তো এত কিছু সুবিধা নেই দেখা যাক কি করা যায়।
[29-03-2025 17:30] PA 1: Eai injection debe 👆
[29-03-2025 19:51] PPM 1: Aekhono blood vomiting hocche?
BP ta ekbar shuye ebong ekbar 3 minute baade dariye kimba boshiye koto ache janate parle bhalo hoto.
Uni ki local PHC te bhorti hoyechen?
[29-03-2025 19:57] PA 2: এখানে এই ব্যবস্থা গুলো নেই, শিলিগুড়ি নার্সিংহোমে ভর্তি করতে হয়েছে
রোগীকে।
[29-03-2025 21:22] PPM 1: 👍
[01-04-2025 11:01] PA 2: বহু কষ্ট করে নার্সিংহোম থেকে বের করে আনা হয়েছে, তাদের কাছে যাওয়া হয়েছিল আপনি যে দুটো টেস্ট করতে দিয়েছিলেন, সেই দুটো করতে। আমাদের ব্যাতিব্যস্ত করে দেওয়া হয়েছে। তারপরেও আপনার দেওয়া ওষুধ দুটোই বন্ধ করে দিয়েছেওষুধ দুটোই বন্ধ করে দিয়েছে ওরা। এখন বলুন প্রেসক্রিপশনের ওষুধ গুলো কি খাওয়াবো আপনার ওখানে যাওয়া পর্যন্ত অপেক্ষা করব।
[01-04-2025 11:02] PA 2: এই মুহূর্তে পেসেন্ট মোটামুটি স্বাভাবিক আছে কিন্তু কিছু ঘুষখুসে কাশি আছে কিন্তু কোন কফ বেরোচ্ছে না। এর জন্য কি কোন ওষুধের প্রয়োজন আছে?
[01-04-2025 16:17] PPM 1: 👆@CR deidentifying these could be tricky as @PA2 has missed that the patient's name is written in the middle of the document!
[01-04-2025 16:18] CR: No issues, will do it.
[01-04-2025 16:19] PPM 1: 👆 Even here the identifier has been missed by the patient advocate during
the process of deidentification @PPM9Here's where AI could be more efficient than humans?
[01-04-2025 16:21] PPM 1: 👆 identifiers visible here too
[01-04-2025 16:21] PPM 1: Aer jonye unar chest X-ray film ta dekha dorkar
[01-04-2025 16:22] PPM 1: Amar 2016 te dewa oshudh!
[01-04-2025 16:24] PPM 1: @~PPM 3 wish we had some way to textually engage with the local
treating team in an academic non adversarial manner. @PPM9 do you think fhir and abdm tech
interfaces will help to resolve these human adversarial issues
[01-04-2025 16:27] PPM 1: In this context an nejm paper 👇
Source: NEJM AI
A new open-source tool called LLM-Anonymizer has been developed to securely deidentify patient information from medical documents using local, privacy-preserving large language models (LLMs) without the need for internet access or programming skills.
Tested on 250 real-world clinical letters, the tool achieved high accuracy (up to 99.2%) in removing personal identifiers like names, addresses, and patient IDs while preserving essential clinical information.
It operates on local hardware via a simple browser interface, making it practical for hospitals and researchers to anonymize sensitive data in compliance with privacy regulations like GDPR. The tool outperformed existing solutions and is available for free use and further research.
[01-04-2025 16:46] PPM 3: I would try the referral letter route. Digital systems? Perhaps a digital
medical record app? This can be made to accept FHIR messages.
[01-04-2025 16:48] PPM 1: Currently that digital medical records app is WhatsApp!
[01-04-2025 16:50] PPM 3: Neither DPDP Act nor standards compliant.
[01-04-2025 17.00] PPM 1: 👍
[01-04-2025 20:08] PA 2: হ্যাঁ, সে কথাই রুগিনি বলতে চেয়েছেন।
[01-04-2025 20:14] PA 2: দাঁতে আবার সমস্যা হচ্ছিল, সেজন্য লোকাল দাঁতের ডাক্তার দেখানো হলো। এইমাত্র এই ওষুধ কি রোগী এখন খেতে পারবে?
[01-04-2025 21:09] PA 2: ৩০ তারিখ যখন দাঁতের ব্যথা হয়েছিল তখন এই ওষুধটা খাওয়ানো হয়েছিল তারপর থেকে রক্ত বমি শুরু হয়।
[01-04-2025 21:29] PPM 1: Na khawai bhalo
[01-04-2025 22:10] PA 1: Sir aldectone=100
Betacap tr =40
Continue korb ki na ektu janaben please.
[03-04-2025 08.38] PA:
[03-04-2025 11.25] PA:
[04-04-2025 07:03] PPM 1: Hain korun
[04-04-2025 07:03] PPM 1: Khawa dawa dekhe mone hocche uni abar normal hoye uthechen
[04-04-2025 08:38] PA: Sir ajke mornig e abar olpo rokto beriache.
[04-04-2025 08:45] PPM 1: Ki beriyeche shetar chobi ta share korte parle bhalo hoto
[04-04-2025 08:48] PA: Ektu chaka chaka rokto
[04-04-2025 08:51] PA: 2 din pore ajke latrine holo.bathrom normal hochilo.
[04-04-2025 08:51] PPM 1: Unar BP ta ekbar shuye tarpor abar teen minute baade dar koriye ekbar dekhe janan. Dorkar hole @~PA 44F apnake ae bishoye guide korte paren
[04-04-2025 08:51] PPM 1: Otar o chobi share kora uchit chilo
[04-04-2025 09:03] PA: Sueatola BP 103/62 PR 93
[04-04-2025 09:07] PA: Ekhon eta dine2 bar kore. CIRROSAM 400 Tab.
[04-04-2025 09:09] PA: Dar koriye
[04-04-2025 09:09] PA: Sokale Khali pete BP 115/65 PR 117
PANTACID 40, HENZOVIT CAPSULES
[04-04-2025 09:10] PA: Dine 2bar kabar por
[04-04-2025 09:11] PA: Dine 1bar FOLVITE TABLETS
[04-04-2025 09:13] PA: Dine 4bar khabar age SUCRAFIL
[04-04-2025 09:29] PPM 1: 👍bhalo
[04-04-2025 21:03] PA: 2 bar bhomik holo
[04-04-2025 21:27] PPM 1: Unar chest X-ray film ta share korun. Bomi hoyechilo naki kashir moton hoyechilo?
[04-04-2025 21:35] PPM 1: Eta kobekar?
[04-04-2025 21:36] PA: 30/03/25
[04-04-2025 21:46] PA: Glucon D ki khete parbe ki.
[05-04-2025 07:07] PPM 1: Dorkar nei. Ota khele baki jinish khawa mushkil habe
[05-04-2025 07:08] PPM 1: Rokto ta dekhe thik variceal bleed mone hocche na. Lungs thekeo aashar sombhabona royeche.
[05-04-2025 07:11] PA: Sir akhon ki kono medicine er projon ache
[05-04-2025 07:11] PA: Amra joto tari tari sombhob apner okhane aschi.
[05-04-2025 11:09] PA: Sir Amra to Monday te jabo kinu rokto ta ektu bondho korar kono upay bolen.rokto t bondho na hole ki kore niye jai.
[05-04-2025 11:19] PA: Soril khub durbol hoye ashe.khub tenson korche.
[05-04-2025 13:04] PPM 1: Eta ki bomi holo?
[05-04-2025 13:05] PA: Ha sir
[05-04-2025 13:05] PA: Pore tai nomi holo kintu rokto ber hoyni
[05-04-2025 13:07] PPM 1: Unake locally admit kore porikkha kora dorkar
Hourly BP monitoring
Supine BP and BP after 3 minutes of standing
Hourly pulse rate, respiratory rate, SpO2
Ryles tube aspiration with hourly lavage
Evaluation with endoscopy and other modalities
[05-04-2025 13:09] pa: Endos copy kora hoyche kintu report ekhono daine
[05-04-2025 13:11] PPM 1: Sheki! Sheta to immediately dewar kotha!
[05-04-2025 13:11] PPM 1: Kabe kora hoyeche?
[05-04-2025 13:12] PPM 1: 30/3/25
[05-04-2025 13:13] PA: Sir local hospital a ki admit korbo.naki by air Monday apnar o khane niye asbo.
[05-04-2025 13:15] PA: Ektu jodi bomi tar babosta kore den.tahole Monday te amra apnar o khane jete pari.
[05-04-2025 13:59] PPM 1: Local hospital, nearest health centre a admit korun.
Ami jeguno suggest korlam oguno odhikansho hospital aei kora sombhob. Ekhane aeto dure aana tao ektu risky hoye jai
[05-04-2025 14:01] PPM 1: Preferably government primary health centre a.
@~PA2 okhane kono daktar ke jodi aei group a add kore dite paren to bhalo hoi.
@~Dr. PM do you know anyone from Mathabhanga primary health centre or sub divisional hospital?
[05-04-2025 14:03] PA: Na sir kono doctor er sathe sei babhe porichoy nei.
[05-04-2025 14:05] PPM 1: @PA2 cheshta korte paren
[05-04-2025 14:06] PPM 1: 👆best habe jodi nearest primary health centre kimba sub divisional hospital a bhorti kore aei guno korano jai
[05-04-2025 14:10] PA: Sir rogi ekhon bomi korlo Khali caugh ber holoBut patient bolche ager theke aktu valo lagcheAmra apnar okhane niye jete chai
[05-04-2025 18:29] Dr.PM: Unfortunately no sir but will check surely
[05-04-2025 18:48] PPM 1: Cough tar saathe ki rokto o chilo?
[05-04-2025 18:48] PPM 1: Otar chobi?
[05-04-2025 19:09] PA: Na sir Khali cough chilo
Rokto chilo na.
[05-04-2025 19:22] PPM 1: Jai thakuk na keno chobi oti oboshyoi pathaben
[05-04-2025 19:24] PA: Thik ache sir Patient's BP 91/41, PR 88
[06-04-2025 11:37] PPM 1: Hourly BP monitoring
Supine BP and BP after 3 minutes of standing
Hourly pulse rate, respiratory rate, SpO2
Ryles tube aspiration with hourly lavage
Evaluation with endoscopy and other modalities
[06-04-2025 11:37] PPM 1: Looking forward to it Dr. PM
[06-04-2025 11:43] PA: Patient had pomegranate. Ryles tube ta ekhne shombhob na.sir ota apner okhane giye korbo.appatoto B.P ta 1ghanta por por monetring korchie.
[06-04-2025 11:57] PPM 1: Shuye ebong dariye teen minute bade mepe janaben
[06-04-2025 12:25] PA 44F Lateral: BP monitoring sue o darie check korar khetre kono osubidha hole ami bole dite pari sir apni jodi bolen ...
[06-04-2025 12:32] PA: BP 89/45, PR 79. Shuye
[06-04-2025 12:55] PPM 1: Eta ki onyo arekta instrument diyeo mepe dekha jabe? Er aage amader arekjon patient er instrument a kom dekhacchilo kintu amader hospitaler onyo instrument a aeki saathe dekhar somoy beshi dekhacchilo
[07-04-2025 08.55] PA: Breakfast rice with 2 boiled eggs.
[07-04-2025 11.00] PA: Sir apni ki Saturday te thakben.amar tahole Saturday te pouchabo.
[07-04-2025 13.07] PA: At present she is receiving following medications.
1. Inj. PIPZO 4.5gm IV thrice daily D3
2. Inj. PANTOCID 40mg IV twice daily
3. Syp. SUCRAFIL 2tsf four times daily
4. Tab. CIRROSAM 400mg twice daily.
5. Tab. HENZOVIT one tab once daily
6. HEPSURE SACHET 1 such thrice daily
7. ALBUZEST HEPA 2 scoops orally twice daily
8. Tab. FOLVITE 5mg one tab once daily
9. Syp. DEXORANGE 10ml twice daily
10. Inj. TERLIPRESSIN 1mg IV 6th hourly
11. IVF NS @ 80ml/hr
[07-04-2025 13:08] PA: Sir ai medicine gulo continue korbo.
[07-04-2025 13:13] PPM 1: Aekhon ki continue korechilen?
[07-04-2025 13:13] PPM 1: Kabe theke continue? Bari te ki bhabe dewa hocchilo?
[07-04-2025 13:16] PA: Eta sir nursing home doctor deachilo.
[07-04-2025 13:20] PPM 1: Bari te ki continue korechilen?
[07-04-2025 13:21] PA: Hospital theke asar por 2 din dwa hoye chilo
[07-04-2025 13:23] PPM 1: Aekhon koto din bondho?
[07-04-2025 13:25] PA: Kalke night a ses hoyeche.
[07-04-2025 13:29] PPM 1: Terlipressin injection ta to ICU chara aei bhabe dewa jai na!
[07-04-2025 13:31] PA: Na sir Khali medicine gulo
[07-04-2025 13:32] PPM 1: Injection shob bondho chilo?
[07-04-2025 13:33] PA: Ha sir
[07-04-2025 13:33] PPM 1: Tahole shob bondho thakte pare
[07-04-2025 13:35] +91 75860 53704: Eai gulo
[07-04-2025 13:40] PA: Sir ai report gulo pending ache.report gulo 10/04/25 date debe.ai report gulo niea asbo naki report chara chole asbo.
[07-04-2025 13:54] PPM 1: Niye ashle bhalo hoi. Upper GI endoscopy ta bishesh kore
[07-04-2025 13:54] PPM 1: Temon dorkar nei
[08-04-2025 10.03] PA: Rice with 2 boiled eggs.
[09-04-2025 21.23] PA: 87/45 PR 80
[09-04-2025 21:23] PA: Sue tola
[09-04-2025 21:24] PA: Sir rogi bari normal khbar khete chai.
[09-04-2025 21.27] PA: 93/38, PR 82
[09-04-2025 21:27] PA: Darie nea
[09-04-2025 21:29] PA: Milk jatio kono kichu khabe ki na.
[10-04-2025 10.30]PA: BP 96/54 PR 75
[10-04-2025 10:30] PA: Dariye nea
[10-04-2025 10.41] PA: BP 90/46 PR76
[10-04-2025 10:41] PA: Sua nea
[10-04-2025 16:23] PPM 1: Eta showar por teen minute dariye newar kotha
[10-04-2025 21.43] PA 2:
PPM 1: This was very useful to see 👏👏. Thanks Sir 🙂🙏
[10-04-2025 22.26] PA: BP 96/54 PR80 Sariye.
[11-04-2025 10.13] PA:
[11-04-2025 20:31] PPM 1: 👍
[11-04-2025 21:53] PA: Dinner=aloobhaja. dim bowl. Ghee. koas aalo sobji.
[12-04-2025 07:19] PPM 1: 👍Daranor teen minute baade to?
[12-04-2025 08:43] PA: Ha sir
[12-04-2025 10:32] PA: Dal seddo
Koas seddo
Aloo seddo
Sojna seddo
[12-04-2025 10:32] PA: Vendi seddo
[12-04-2025 11:46] PPM 1: 👍
[12-04-2025 22:20] PA: Dinner=aloo. potol. swaben er sobji.
[13-04-2025 08:32] PA: Date=12/04/25
[13-04-2025 09:18] PPM 1: Well done 👏👏 Appears good.
Please share her hourly activities of yesterday
[13-04-2025 10:09] PA 2: ১২/০৪/২০২৫ মোটামুটি সারা দিনের activity নিম্নরূপ ঃ
রোগী সকাল ন'টা নাগাদ ঘুম থেকে উঠেন।
প্রাতকৃত্যাদির পর সাড়ে নটা নাগাদ জলখাবার (সেদ্ধ সহযোগে)
তারপর বেলা এগারোটা পর্যন্ত রোগীনি শুয়েছিলেন।
এগারোটার সময় একটা মুসাম্বি ফল খান।
এরপর বারোটা সাড়ে বারোটা পর্যন্ত দেবর ভাইয়ের বাচ্চার সঙ্গে সময় কাটানো হয়।
এবার স্নান ও দুপুরের খাওয়া।
এবার দেড়টা পর্যন্ত বিশ্রাম ও একটা আপেল খাওয়া।
বেলা চারটা পর্যন্ত কিছুটা ঘুম ও বিশ্রাম।
তারপর বেলা পাঁচটা পর্যন্ত বাড়িতেই হাঁটাহাঁটি।
পাঁচটা নাগাদ সামান্য টিফিন (ওটস)।
এরপর সাড়ে নটা পর্যন্ত কিছু ঘরের কাজ, টিভি দেখা, হাঁটাহাঁটি ও রাতের খাওয়া।
এবার শুয়ে বসে কিছুটা সময় কাটিয়ে সাড়ে দশটা নাগাদ ওষুধ সেবন (Bitacap TR 40, Aldectone 100)।
রাত এগারোটা নাগাদ রোগিনী ঘুমিয়ে পড়েন।
[13-04-2025 10:17] PPM 1: @Meta AI can you translate the content here from Bengali to English for our multilingual audience here:
১২/০৪/২০২৫ মোটামুটি সারা দিনের activity নিম্নরূপ ঃ
রোগী সকাল ন'টা নাগাদ ঘুম থেকে উঠেন।
প্রাতকৃত্যাদির পর সাড়ে নটা নাগাদ জলখাবার (সেদ্ধ সহযোগে)
তারপর বেলা এগারোটা পর্যন্ত রোগীনি শুয়েছিলেন।
এগারোটার সময় একটা মুসাম্বি ফল খান।
এরপর বারোটা সাড়ে বারোটা পর্যন্ত দেবর ভাইয়ের বাচ্চার সঙ্গে সময় কাটানো হয়।
এবার স্নান ও দুপুরের খাওয়া।
এবার দেড়টা পর্যন্ত বিশ্রাম ও একটা আপেল খাওয়া।
বেলা চারটা পর্যন্ত কিছুটা ঘুম ও বিশ্রাম।
তারপর বেলা পাঁচটা পর্যন্ত বাড়িতেই হাঁটাহাঁটি।
পাঁচটা নাগাদ সামান্য টিফিন (ওটস)।
এরপর সাড়ে নটা পর্যন্ত কিছু ঘরের কাজ, টিভি দেখা, হাঁটাহাঁটি ও রাতের খাওয়া।
এবার শুয়ে বসে কিছুটা সময় কাটিয়ে সাড়ে দশটা নাগাদ ওষুধ সেবন (Bitacap TR 40, Aldectone 100)।
রাত এগারোটা নাগাদ রোগিনী ঘুমিয়ে পড়েন।
[13-04-2025 10:17] Meta AI: Here's the translation from Bengali to English:
April 12, 2025, the activities for the day are roughly as follows:
The patient woke up around 9 am. After morning routines, she had a snack (with boiled eggs) around 9:30 am. Then she rested till 11 am. At 11 am, she ate a sweet lime (Mosambi). From 11 am to 12:30 pm, she spent time with her brother-in-law's child. After that, she took a bath and had lunch. She rested till 1:30 pm and ate an apple. She slept and rested a bit from 1:30 pm to 4 pm. Then she walked around the house till 5 pm. At 5 pm, she had a light snack (oats). After that, she did some household chores, watched TV, walked around, and had dinner till 9:30 pm. She spent some time sitting and lying down, took her medication (Bitacap TR 40, Aldectone 100) around 10:30 pm. The patient fell asleep around 11 pm.
[13-04-2025 10:18] PPM 1: @Meta AI that's amazing hourly activity considering the fact that she's recovering from a bout of upper GI bleed due to her cirrhosis of liver
[13-04-2025 10:18] Meta AI: Given her medical condition, it's impressive that she's able to maintain such a regular and gentle routine. The activities seem carefully planned to avoid putting too much strain on her body, which is important for recovery. The inclusion of rest periods, light snacks, and gentle exercises like walking around the house suggests a thoughtful approach to managing her health.
[13-04-2025 10:47] PA: Aloo,koas,jhinga dea sobji.
[13-04-2025 12:33] PA: Sir rogi alpo chiken khete chiche.debo ki.
[13-04-2025 13:40] PA: Sag vaga,aloo@bagun vaga,magur mach potol,jhinga,aloo,koash diye jhol.
PPM 1: 👍
[13-04-2025 20:09] PA: Sir Amra agami 17/04/25 thurs day anumanik sondya 6pm nagar nalgonda station a nabo.sedin ki admit@cabin er babostha kora jabe.
[13-04-2025 21:44] PA: Paneer,aloo,capsicum diye jhol.
[13-04-2025 23:37] PA: Date=13/04/25
[14-04-2025 07:21] PPM 1: 👍
[15-04-2025 09.20] PA:
[15-04-2025 10.02] PA: Aloo seddo,pepe seddo,dim
PPM 1- 👍
[15-04-2025 16:53] PPM 1: This patient will arrive in the evening of 17/4. Any idea who will be in the casualty on that day and can admit them into SS ward from there? @~PPM7 @~PPM5 @~PPM3 @~PPM6
[15-04-2025 16:57] PPM 3: I will be there on 17 th sir
[17-04-2025 12:03] PA: Train late cholche anumik time=8to8.30 pm nalgonda station pouchabe.
[17-04-2025 12:10] PPM 1: No problem 👍@~PPM 3 they may reach late tonight
[17-04-2025 21:48] PA: Just nalgonda station a namlam ekhon ki jabar kono babosta ache.
[17-04-2025 21:57] PPM 3: Ok sir
[17-04-2025 21:58] PPM 1: Have they reached casualty? They appear to have reached Nalgonda. Can admit them now from casualty
[17-04-2025 21:59] PPM 1: Chole ashun. Bhorti kore newa habe. Auto niye chole ashun
[17-04-2025 22:11] PA: Sir onek besi Vara diye nal gonda bus stand Aslam.kintu kono auto jete chisena tai bus stand er ek lodge achi.kal early mornig amra chole asbo.
[17-04-2025 22:12] PPM 1: Nalgonda station theke bus stand? Koto bhara nilo?
[17-04-2025 22:13] PA: Per head rs 40
[17-04-2025 22:16] PPM 1: Apnara ko jone achen? Lodge a koto niyeche?
[17-04-2025 22:17] PA: Amra 3jon achi Rent1000
[17-04-2025 22:17] PPM 1: They are staying the night at a lodge in Nalgonda and will reach here tomorrow morning @~PPM 3
[17-04-2025 22:29] Co-ordinator: Spoke to patient they are settled going for dinner
[17-04-2025 22:29] Co-ordinator: They will meet PPM 1 sir tomorrow morning 9am
[18-04-2025 06:11] PPM 3: Ok sir
[18-04-2025 06:49] PA: Sir rogi ki brekfast korte parbe.
[18-04-2025 07:24] Co-ordinator: Spoke to patient patient starting from nalgonda will be available at opd at 9am
[18-04-2025 09:13] PA: Amra apnar chamber er samne bose achi sir.
[18-04-2025 09:20] PPM 1: Aashchi
[18-04-2025 10.50] PPM 1: OPD now:
Reviewing this 39F with gestational portal hypertension and cirrhosis of Liver who I first met in 2016 in Bhopal and she was doing fairly well till few weeks back when she developed sudden blood vomiting due to her portal hypertensive varicieal rupture for which local doctors did an endoscopic variceal band ligation recently.
Her first tryst with her illness was when she found that her post partum abdominal size wasn't reducing and she waited from 2014 to 2016 before consulting in sskm, Kolkata when doctors there found her esophageal varices!
Currently on examination:
Liver and spleen palpable (with difficulty and soft, will review the ultrasound personally with POCUS in the afternoon.
Details available here:
https://pajrcasereporter.blogspot.com/2025/04/39f-cirrhosis-of-liver-2016-now-blood.html?m=1
Question to our Web 3.0 champion:
What may have caused her gestational portal hypertension? What can we do to help her at present?
[18-04-2025 12:55] PA: Sir superspecelity ward a transfer korche.
[18-04-2025 12:57] PPM 1: Okhane Gastro keo dekhiye neben. Dupure 2:30PM ami ICU te ultrasound ta korbo
[18-04-2025 14:04] PA: Sir ICU koto no room@ Kon floor jabo.
[18-04-2025 14:05] PA: Amra apner chamber er samne bose achi.
[18-04-2025 14:07] PA: Room akhono pai nai .Bolche doctor na asle hobe na.
[18-04-2025 14:35] PPM 1: Ami ICU te
[18-04-2025 14:37] PPM 1: @~PPM4 @~PPM5 can you check why the patient is unable to get their SS room yet?
If when free send them before 3 to ICU for the ultrasound
[18-04-2025 14:38] PPM 4: Taking history sir
[18-04-2025 17.48] PA: Eai test gulo kora Bo ki.
[18-04-2025 18:36] PPM 1: Hain
[18-04-2025 22:26] PA: Date=08/04/2016
[18-04-2025 22:27] PA: 2015 USG report jalpaiguri.
[19-04-2025 10:09] PPM 1: Need her hourly BP charting and current timing and dose of propranolol to optimise her current treatment plan @~PPM 4
In this context:
"95 consecutive patients recruited from our prospective database. After hepatic venous pressure gradient measurement, patients received propranolol 10 mg, twice daily increased 10 mg daily until to 80 or 120 mg/day. Secondary hepatic venous pressure gradient was also measured. For nonresponders at 80 mg/day, propranolol was titrated to 120 mg/day.
Results
For 58 patients, propranolol was titrated to 80 mg/day, whereas for 37 patients, it was titrated to 120 mg/day. Hemodynamic response was similar in both groups (50 vs. 54.1%, P=0.700). Eighteen of the 29 nonresponders at propranolol 80 mg/day received a dose of 120 mg/day. Two patients achieved a hemodynamic response, but two could not tolerate the dose. Nine (15.5%) patients achieved the target dose of propranolol at 80 mg/day, whereas 16 (43.2%) patients at 120 mg/day achieved this (P=0.003). The difference in patients achieving the target dose between responders and nonresponders was not significant (14 vs. 14, P=0.642). Reduction or discontinuation was required by two (6.9%) patients using 80 mg/day propranolol and six (30%) patients using 120 mg/day propranolol (P=0.032).
Conclusion
There is no dose-dependent effect of 80–120 mg/day of propranolol on the hemodynamic response in cirrhotic patients with gastroesophageal varices. This indicates that low-dose propranolol below the target dose might lead to a considerable hemodynamic response and is much safer and well tolerated."
[19-04-2025 10:12] PA: Sir apni ki chole eschen
[19-04-2025 10:24] PPM 1: Hain
[19-04-2025 10:25] PA: Ektu dekha kortam
[19-04-2025 10.54] PPM 1: @~PPM8 get the tests other than these
[19-04-2025 19:26] PPM 1: Please mention the dose of propranolol and time taken
[19-04-2025 20:14] PPM 3: Sir she is taking tab. Betacap 40 mg after dinner
[19-04-2025 20:15] PPM 3: And also Aldactone 100mg
[19-04-2025 20:23] PPM 1: Let's add another betacap after breakfast and continue the BP charting to see how much it's affected
[19-04-2025 20:37] PPM 3: Ok sir
[20-04-2025 12:22] PA: Medicine ta ki Debo.
[20-04-2025 12:58] PPM 1: Hain
BP ta ekhane ghontai ghontai maapchen?
[20-04-2025 13:02] PA: Sir ota to hospital nurse ra niye jache.aaj sokale Dr Naveen ekbar b.p chek kore gache.
[20-04-2025 13:03] PPM 1: @~PPM 3 please share her BP chart including the medicine dose times
[20-04-2025 13:03] PPM 1: Our plan was to increase the dose and add the tablet betacap 40 also in the morning
[20-04-2025 13:04] PA: Ta hole ekhon Debo na ajke.
[20-04-2025 13:05] PPM 1: Deben
[20-04-2025 13:06] PPM 1: Deben kintu BP tao ghontai ghontai dekha dorkar. Sombhob hole ekta electronic BP instrument kine nije nije dekha tai shob theke bhalo hobe
[20-04-2025 13:07] PA: Sir ekhane B.P machine pawa jabe.
[20-04-2025 13:27] PPM 3: Yes sir it got late to reach the ward as I was in rounds in ICU. Morning dose was missed. Tmrw mrng I will make sure she will take it before breakfast
[20-04-2025 13:37] PPM 1: Can give it now. Share the BP chart and guide him to buy an electronic BP monitor with warranty from our pharmacy or Apollo pharmacy
[20-04-2025 13:38] PPM 3: Ok sir. Today's BP charting sir.
[20-04-2025 14:25] PPM 1: Always mention the time of administration and dose of the medicines in all BP charts
[20-04-2025 14:29] PPM 3: Ok sir
[21-04-2025 10:23] PPM 1: Any reports pending and not shared here?
Please share here after deidentification if that's the case
[21-04-2025 10:26] PPM 1: Please share the dental notes ASAP
[21-04-2025 11:32] PPM 1: Check out the pancytopenia here @~~PPM 9 and share your thoughts on why
[21-04-2025 11:44] PA: Sir diet chart.
[21-04-2025 13:22] PPM 1: https://medicinedepartment.blogspot.com/2023/09/the-healthy-plate-diet-in-bengali-telegu.html?m=1
[21-04-2025 14:08] PPM 9: Okay sir
[21-04-2025 14:17] PPM 9: Spenomegaly ?
[21-04-2025 14:25] PPM 9: Since viral causes for infection are negative on serology (HIV, Hep B, C), what else could be the cause?
Long standing cirrhosis can lead to HCC but it’s ruled out I guess ? Any possibility of parvo viral infection?
[21-04-2025 14.28] PPM 9: INR is understandable secondary to liver dysfunction..
[21-04-2025 14:28] PPM 9: Is there any prescribed drug which could be leading to this?
[21-04-2025 15.33] PPM 3: This is review on right hepatic vein and ivc
[21-04-2025 15:40] PPM 1: Yes her spleen size is nearly 20 cms
[21-04-2025 15:43] PPM 1: Current final diagnosis for the EMR summary:
Gestational portal hypertension noticed after delivery with massive splenomegaly detected since 10 years
Recent upper GI bleed due to NSAID intake due to dental pain
Esophageal varices grade II EVL done outside
[21-04-2025 16:28] PPM 9: 👍 okay sir
[27-04-2025 13:05] PA: Sir rogie khabar ruchie nai@ gas hoyche bolche . Kono medicine ki deben.
[27-04-2025 13:28] PPM 1: Kabe theke ruchi nei?
Ruchi nei naki khawar icche sotteo khele pet fule jacche?
[27-04-2025 13:43] PA: Aaj ke sakal theke.
Khabar icche nai.pet fule jacche.
[27-04-2025 13:44] PA: Pet fule acche tai kabhar kono ruchhi nai.
[27-04-2025 13:52] PPM 1: Aer aage thik aeki bhabe last kabe pet fulechilo?
[27-04-2025 13:55] PA: Soril kharap hober motamuti 6 mash age.thokhon ekta gas er medicine pantocid 40 khey chilo.
[27-04-2025 14:53] PPM 1: Tokhon somosya ta koto din chilo?
Aekhon haatha chola kemon hocche?
[27-04-2025 14:55] PA: 2 dose khabar por kome gechilo.
Sir Amra kalke pouchalam.ajj ke theke hatta chola suru koreche normaly.
[27-04-2025 15:39] PPM 1: Haathleo aneker kome jai
[02-05-2025 23.26] PA: 
[17-05-2025 08.33] PA: 
[19-05-2025 17.01] PPM 1: Shorir folar kono chobi share korte parben?
[15-05-2025 21:25] PA: Kintu sir soril ta phule jachhe.
[15-05-2025 21:29] PA: Baly Tao ager theke onek ta boro hoye gache@ soril ta o onek ta phule gache. Kintu normal kwadwa korche.
[15-05-2025 22:37] PPM 1: Are daily ojon ta janacchen na?
[16-05-2025 08:33] PA: Ojon 81 kg
[16-05-2025 08:47] PPM 1: Aer aager din guno?
[16-05-2025 09:04] PA: Age to sei bhabe ojon mapa hoy ni.khali b.p ta mapa hoye chilo.
[16-05-2025 09:48] PPM 1: Aebar theke roj ojon mepe janaben
[16-05-2025 10:00] PA: Ok sir
[17-05-2025 09:48] PPM 1: Aajker ojon?
[17-05-2025 10:04] PA: Sir ajke machine nea ase ojon kore pathbo.
[18-05-2025 15:21] PA: Ajke onno machine ojon 75.8 kg dakache.
[18-05-2025 15:21] PA: BP=111-61-78
[18-05-2025 15.25] PPM 1: 👍
[19-05-2025 15:46] PA: Weight - 76.1
BP-104 /56
P-84 time-3.40
[19-05-2025 16:20] PPM 1: Bortomane ki ki oshudh khacchen ektu ogunor chobi share korun
[19-05-2025 16:36] PA: Sudhu Betacap tr=40
Dine 2 bar kacche.
Jemon payer chobi ekhane 👇
[19-05-2025 17.13] PA: 
[19-05-2025 23.23] PA: BP-118/64
P- 94 Time- 10.50
[20-05-2025 15.07] PA: Weight - 76.6
[20-05-2025 18.26] PA: BP-104/83P-75
[20-05-2025 19:17] PPM 1: Pa er chobi?
[20-05-2025 19:41] PPM 1: Tablet Lasix kalke sokal theke 40 mg dine ekbar kore teen din.
[20-05-2025 20:06] PA: Sir eai osud ta
[20-05-2025 20:07] PA: Khabar age na pore khabe.
[20-05-2025 20:11] PPM 1: Sokale khabar por
[21-05-2025 15.08] PA: WEIGHT-75.9 TIME - 3.00
[22-05-2025 14.34] PA: WEIGHT- 72.4, TIME- 2.27, BP104/50, PR 85 TIME 2.40PM
[22-05-2025 17:02] PPM 1: 👍
[23-05-2025 15:00] PA: Weight- 74.2
BP - 102/56
P- 92 TIME- 2.58
[23-05-2025 16:13] PPM 1: 👆Tablet Lasix jeta khawar kotha roj sokale sheta sokale kotai khacchen?
[23-05-2025 16:19] PA: Sokal=10 am After breakfast.
[23-05-2025 16:21] +91 75860 53704: Sir kono liver er ayurvedic medicine ki dewa jabe.
[23-05-2025 16:24] PPM 1: Na dilei bhalo keno ki ogunor side effect sombondhe amader jana nei
Unar tablet lasix 40mg ta sokale 8:00AM ekbar ebong dupure 12:00 PM arekbar dewa jete pare.
[23-05-2025 16:26] PA: Lasix ta continue korbe.
[23-05-2025 16:27] PPM 1: Unar tablet lasix 40mg ta continue korbe
sokale 8:00AM ekbar
ebong
dupure 12:00 PM arekbar
[23-05-2025 16:28] PA: Thik ache sir
[23-05-2025 16:28] PA: Kal rat theke Kasi hoyeche.
[23-05-2025 16.32] PA: Cough ache kintu ber hocche na.
[23-05-2025 16:35] PPM 1: Respiratory rate tao dekhe janaben.👇
[24-05-2025 14:31] PA: WEIGHT-72 .9 KG
BP101/53
P-82 TIME-2.29
[24-05-2025 17:21] PA: Sir hotat kore tol pet tai halka pain hoche.
[24-05-2025 19:48] PPM 1: Local daktar er saathe alochona kore Ultrasound kore jodi jol thake tahole ekbar baar kore test kore dekha jete pare
[25-05-2025 15.46] PA: Weight=72
BP=117/61
P=86
[25-05-2025 19.54] PPM 1: Kalke theke tablet lasix suudhu ekta sokale.
[26-05-2025 14.43] PA: Weight- 71kg, BP-110/62, P-86
PPM 1: 👍
[27-05-2025 15.42] PA: Weight-71k.g, BP-105/57, P-86
[28-05-2025 15.44] PA: Weight-70k.g, BP-113/63, P-91
PPM 1: 👍
[29-05-2025 15.40] PA: Weight-70 K.G, BP-98/62, P-89
[29-05-2025 16:09] PPM 1: Chobi?
[30-05-2025 07:17] PPM 1: Aekhon lasix sokale ekta kore khacchen?
Aebar ekdin chere arek din khete paren
[30-05-2025 09:14] PA: Ha sir
[30-05-2025 15:45] PA: WEIGHT-71k.g, BP-111/65, P-94
[30-05-2025 16:18] PPM 1: Aajke lasix khanni?
[30-05-2025 16:21] PA: Ha sir sokale 1bar
[30-05-2025 15.52] PA: Weight-70 K.G, BP-103/56, P-85
[01-06-2025 19.13] PA: Weight=70kg, BP=108/61, P=88
[02-06-2025 18:50] PA: Weight=71 kg, BP=112/63, P=89
[02-06-2025 22:35] PA: Sir Kasi ta to komche na
[03-06-2025 08:24] PPM 1: 👆23rd May theke 3rd June er modhye kashir prokop ta ki komar deeke naki barar deeke?
[03-06-2025 08:26] PA: Ager thake ektu komeche.
[03-06-2025 22:42] PA: Weight=75 kg, BP=113/62, BP=94
[04-06-2025 08:55] PA: Weight=72kg, BP=113/62, BP=94
[04-06-2025 16:39] PPM 1: Tablet lasix 40 mg ki ekta kore sokale khacchen?
[04-06-2025 17:56] PA: Ha sir
[04-06-2025 18:51] PA: Weight=72 kg, BP=103/62, P=78
[05-06-2025 19:50] PA: Weight=71 kg, BP=100/55, P=79
[05-06-2025 19:58] PPM 1: 👍
[07-06-2025 19.38] PA: Weight=70 kg, Bp100/54, P=78
[08-06-2025 19:14] PA: Weight=69 .5kg, BP=103/60, P.=82
[08-06-2025 21:19] PPM 1: 👍
[09-06-2025 21.05] PA: Weight=69.5 kg, BP=104/60, P=78
[10-06-2025 21.22] PA: Weight=69 kg, BP=98/56, P=80
[11-06-2025 23.18] PA: Weight=69.5, BP=101/68, P=77
[12-06-2025 22:43] PA: Weight=70, BP=106/65, P=79
[13-06-2025 08:42] PPM 1: @PPM10 can we get deepseek to restructure the case report here https://pajrcasereporter.blogspot.com/2025/04/39f-cirrhosis-of-liver-2016-now-blood.html for our recently joined gastro team?
[13-06-2025 10:33] PPM 10: ### Restructured Case Report for Gastro Team
---
#### *Patient Summary*
- *Age/Gender*: 39-year-old female
- *Primary Diagnosis*: Cirrhosis of liver (diagnosed 2016)
- *Key Complication*: Acute variceal bleed with hematemesis (March 2025)
- *Etiology*: Gestational portal hypertension post-delivery → cirrhosis with massive splenomegaly
- *Current Status*: Stable on medical management after endoscopic variceal ligation (EVL)
---
#### *Timeline of Critical Events*
1. *29 Mar 2025*:
- Hematemesis after water intake.
- Initial home management; advised Ryle’s tube monitoring and urgent EVL.
- Transferred to Siliguri Nursing Home due to lack of local facilities.
2. *30 Mar 2025*:
- Dental pain triggered NSAID use → worsened bleeding.
- Endoscopy performed (report delayed).
3. *05 Apr 2025*:
- Recurrent bleeding with hypotension (BP 89/45 mmHg).
- ICU admission advised; patient opted for transfer to tertiary center.
4. *17–18 Apr 2025*:
- Admitted to tertiary center.
- *Findings*:
- Splenomegaly (20 cm on ultrasound), pancytopenia.
- Esophageal varices grade II (post-EVL).
- *Diagnosis*: Portal hypertensive bleed exacerbated by NSAIDs.
5. *Apr–Jun 2025*:
- Diuretic optimization (furosemide 40 mg BID + spironolactone 100 mg) for ascites/edema.
- Weight reduction: 76 kg → 69 kg.
- Persistent dry cough; no active bleeding.
---
#### *Key Clinical Data*
| *Parameter* | *Findings* |
|---------------------|-----------------------------------------------------------------------------|
| *Vitals* | BP: 90–115/45–65 mmHg, HR: 75–94 bpm, RR: 16–20/min |
| *Lab (Apr 2025)* | Hb: 8.9 g/dL, WBC: 2,900/µL, Plt: 69,000/µL, INR: 1.5 |
| *Imaging* | Ultrasound: Cirrhosis + splenomegaly (20 cm); IVC patent |
| *Endoscopy* | EVL performed externally; no active bleeding at admission |
---
#### *Management Evolution*
1. *Acute Bleed (Mar 2025)*:
- Terlipressin, pantoprazole, IV antibiotics.
- EVL at local facility.
2. *Medical Therapy*:
- *Propranolol*: Titrated to 40 mg BID (target HR reduction).
- *Diuretics*: Furosemide + spironolactone for fluid overload.
- *Avoided*: NSAIDs, hepatotoxic agents.
3. *Stabilization Phase (May–Jun 2025)*:
- Daily weight/BP monitoring.
- Diet: High-protein, low-salt, small frequent meals (e.g., boiled eggs, oats, vegetables).
- Resolved ascites; minimal edema.
---
#### *Unresolved Issues*
1. *Etiology of Pancytopenia*:
- Hypersplenism vs. drug effect (investigate if progression occurs).
2. *Persistent Cough*:
- Dry, non-productive; consider hepatic hydrothorax or GERD.
3. *Dental Comorbidity*:
- NSAID use triggered bleed; require dental liaison for safe analgesia.
---
#### *Learning Points*
1. *Triggers for Decompensation*:
- NSAIDs → catastrophic in cirrhosis. *Avoid strictly*.
2. *Remote Monitoring*:
- WhatsApp-enabled BP/weight logs aided stabilization.
3. *Resource-Limited Settings*:
- Delayed endoscopy reports; emphasize patient-held records.
4. *Beta-Blocker Titration*:
- Propranolol 40–80 mg/day effective without dose-dependent response (per PMC study).
---
#### *Action Plan for Gastro Team*
1. *Surveillance*:
- Quarterly endoscopy (varices), USG (liver/spleen).
2. *Medication Review*:
- Optimize propranolol (target HR 55–60 bpm).
- Screen for diuretic-induced electrolyte imbalances.
3. *Patient Education*:
- Emergency protocol for rebleed (avoid NSAIDs, immediate BP monitoring).
- Dietitian input for protein/calorie goals.
---
*Report Ends*
Source: De-identified from [PaJR Case Report](https://pajrcasereporter.blogspot.com/2025/04/39f-cirrhosis-of-liver-2016-now-blood.html).
Note: All identifiers removed per privacy protocols.
[13-06-2025 21.11] PA: Weight=70, BP=100/55, P=79
[14-06-2025 22.24] PA: Weight=69, BP=100/69, P=81
PPM 1: 👍
[15-06-2025 21.13] PA: Weight=70kg, BP=111/58, P=82
[17-06-2025 08.21] PA: Weight=70kg, BP=98/58, P=82
[17-06-2025 21.16] PA: Weight=70kg, BP=100/58, P=79
PPM 1: 👍
[18-06-2025 07.20] PPM 1: Olpo ache.
[18-06-2025 19.30] PA: Weight=70, Bp=99/58, P=79
[19-06-2025 20.54] PA: Weight=70 kg, BP=113/64, P80
[20-06-2025 20.48] PA: Weight=70, BP=100/65, P80
[21-06-2025 20.27] PA: Weight=70 kg, Bp=98/55, P=80
[22-06-2025 20.34] PA: Weight=70kg, BP=99/58, P=80
[23-06-2025 21:40] PA: Weight=70kg, BP=99/58, P=76
[24-06-2025 21:10] PA: Weight=70, BP=100/60, P=80
[25-06-2025 21.26] PA: Weight=70 kg, BP=104/62, P79
[26-06-2025 21.06] PA: Weight=70kg, BP=104/59, P=73
[27-06-2025 21.15] PA: Weight=70 kg, BP=98/58, P=78
[28-06-2025 21.08] PA: Weight=70 kg, BP=104/60, P72
[30-06-2025 10.38] PA: Weight=69 kg, BP=102/58, P69[30-06-2025 21.01] PA: Weight=69 kg, BP=98/54, P=79
[01-07-2025 21.30] PA: Weight=69 kg, BP=104/56, P=79
[02-07-2025 22.08] PA: Weight=69kg, BP=100/57, P=75PPM 1: 👍
[03-07-2025 20.59] PA: Weight=69, BP=98/55, P=80
[04-07-2025 21.06] PA: Weight=69, BP=112/64, P=84
[07-07-2025 21:45] PA: Weight=69, BP=101/60, P=76
[08-07-2025 21:24] PA: BP=103/58, P=78, Weight=69
[09-07-2025 19.54] PA: Weight=69, BP=103/62, P=79
PPM 1: 👍
[10-07-2025 20.52] PA: Weight=69, BP=100/60, P=78
[11-07-2025 21.24] PA: BP=102/59, P=79, Weight=69
[13-07-2025 20.57] PA: BP=107/59, P=80, Weight=71
[14-07-2025 21.06] PA: BP=106/64, P=82, Weight=71
[15-07-2025 20.57] PA: BP=102/59, Weight=70, P=75
[16-07-2025 21.26] PA: BP=106/54, P=76, Weight=70
[17-07-2025 21.44] PA: BP=100/57, P=79, Weight=70
[18-07-2025 22.50] PA: BP=110/58, P=81, Weight=70
[19-07-2025 07:25] PPM 1: Oshudher bortoman dose ebong time tao roj janaben
[19-07-2025 08:45] PA: Sir
Betacap tr=40 sokal 7am khali pete.
Lasix40=sokal 10.30 am khabar por
Betacap tr 40 =rate 10 pm dinner er age.
PPM 1: 👍
[19-07-2025 22:57] PA: BP: 110/58
P=83
Weight=70
[19-07-2025 22:59] PA: Betacap tr=40 sokal 7.15am khali pete.
Lasix40=sokal 10.25am khabar por
Betacap tr 40 =rate 10.20 pm dinner er age.
PPM 1: 👍
[20-07-2025 22:39] PA: BP-108-63
P-80
[20-07-2025 22:40] PA: Betacap tr=40 sokal 8.10am khali pete.
Lasix40=sokal 10.54am khabar por
Betacap tr 40 =rate 10.22 pm dinner er age.
[20-07-2025 22:41] PPM 1: Weight?
[20-07-2025 22:41] PA: Weight=70kg
[21-07-2025 22:20] PA: BP-102-54
P-84
[21-07-2025 22:21] PA: Weight=70
[21-07-2025 22:22] PA: Betacap tr=40 sokal 7.40am khali pete.
Lasix40=sokal 10.05 khabar por
Betacap tr 40 =rate 10.08 pm dinner er age.
[22-07-2025 22:26] PA: BP-104/61, P-84, Weight=70
[22-07-2025 22:31] PA: Betacap tr=40 sokal 8.00am khali pete.
Lasix40=sokal 10.25 khabar por
Betacap tr 40 =rate 10.20 pm dinner er age.
[23-07-2025 22.07] PA: BP-108-56, P-85
Betacap tr=40 sokal 7.00am khali pete.
Lasix40=sokal 10.00 khabar por
Betacap tr 40 =rate 10.00 pm dinner er age.
[24-07-2025 08:41] PPM 1: Weight?
[24-07-2025 09:13] PA: 70 kg
[24-07-2025 22.26] PA: BP 112/67, 88, weight 70
[25-07-2025 23.31] PA: BP=107/6, P=87, Weight=70
Betacap tr=40 sokal 6.30am khali pete.
Lasix40=sokal 9.38am khabar por
Betacap tr 40 =rate 10.00 pm dinner er age.
[27-07-2025 22:12] PA: BP=111/58, P=86, Weight=70
[27-07-2025 22:13] PA: Betacap tr=40 sokal 7.15am khali pete.
Lasix40=sokal 9.00m khabar por
Betacap tr 40 =rate 9.40pm dinner er age.
[28-07-2025 21:50] PA: BP=103/64, P=86, Weight=71
[28-07-2025 21:51] PA: Betacap tr=40 sokal 7.50am khali pete.
Lasix40=sokal 9.400m khabar por
Betacap tr 40 =rate 9.50pm dinner er age.
[29-07-2025 22:20] PA: BP=100/64, P=82, Weight=71
[29-07-2025 22:22] PA: Betacap tr=40 sokal 7.15am khali pete.
Lasix40=sokal 9.15 am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[30-07-2025 20:56] PA: BP=108/62, P=80, Weight=71
[30-07-2025 20:57] PA: Betacap tr=40 sokal 6.55am khali pete.
Lasix40=sokal 8.30 am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[31-07-2025 21:57] PA: BP=113/71, P=83, Weight=71
[31-07-2025 21:57] PA: Betacap tr=40 sokal 7.05am khali pete.
Lasix40=sokal 8.30 am khabar por
Betacap tr 40 =rate 09.55pm dinner er age.
[01-08-2025 20:54] PA: BP=100/69, P=82, Weight=71
[01-08-2025 20:55] PA: Betacap tr=40 sokal 6.50am khali pete.
Lasix40=sokal 8.00 am khabar por
Betacap tr 40 =rate 09.55pm dinner er age.
[02-08-2025 20:34] PA: BP=109/62, P=78, Weight=71
[02-08-2025 20:35] PA: Betacap tr=40 sokal 7.22am khali pete.
Lasix40=sokal 8.40 am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[03-08-2025 21:04] PA: BP=105/62, P=78, Weight=71 kg
[03-08-2025 21:04] PA: Betacap tr=40 sokal 7.50am khali pete.
Lasix40=sokal 9.05am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[04-08-2025 22:09] PA: BP=102/67, P=73, Weight=71
[04-08-2025 22:10] PA: Betacap tr=40 sokal 8.02am khali pete.
Lasix40=sokal 9.28m khabar por
Betacap tr 40 =rate 9.50pm dinner er age.
[05-08-2025 10:27] PA: Sir sokal theke halka fever@ gola ta khus khus korche@ halka pain o korche.songe Kasi o hoyche.kintu cough ber hocche na.
[05-08-2025 10:30] PPM 1: Please unar temperature ta proti char char ghontai record kore ekhane janaben
[05-08-2025 10:54] PPM 11: I had some time last night and went through the entire case history.
I have a few questions:
1. How was the diagnosis of cirrhosis made? We have clinical evidence of portal hypertension only. Can it be NCPF? Her albumin and INR are remarkably normal. Her enzymes are normal (burnt out cirrhosis may have normal enzymes but albumin and INR would have been affected) Transient ascites post bleed can be seen in NCPF too.
2. If cirrhosis, what is the etiology? We don't have IgG, ASMA and LKM, which should be done, and if positive she needs to be started on definitive treatment for AIH.
[05-08-2025 14:40] PPM 1: Great inputs 👏👏
Quoting from the case report documented on "18-04-2025 10.50]
PPM 1: OPD now:
Reviewing this 39F with gestational portal hypertension (neologism perhaps on my part) and cirrhosis of Liver who I first met in 2016 in Bhopal and she was doing fairly well till few weeks back when she developed sudden blood vomiting due to her portal hypertensive variceal rupture for which local doctors did an endoscopic variceal band ligation recently.
Her first tryst with her illness was when she found that her post partum abdominal size wasn't reducing and she waited from 2014 to 2016 before consulting in SSKM, Kolkata when doctors there found her esophageal varices!
Currently on examination:
Liver and spleen palpable (with difficulty and soft, will review the ultrasound personally with POCUS in the afternoon."
Unquote
So unexplained portal hypertension since 10 years on no treatment is perhaps more consistent with NCPF than AIH?
Perhaps a liver biopsy may help if done at an appropriate place with good pathology back up?
[05-08-2025 15.06] PPM 11: Yes sir, a liver biopsy will be essential.
In absence of liver biopsy, we can try LSM, SSM and LSM/SSM ratio. A high SSM with near normal LSM would favor a non cirrhotic etiology of the portal Htn.
I would tend to think this is non cirrhotic portal hypertension (cirrhosis will be the second in the list of differentials). That she hasn't developed ascites (except post bleed), and maintained her synthetic functions and enzymes throughout is also pointing towards non cirrhotic portal Htn.
[05-08-2025 15.09] PPM 1: 👍
[05-08-2025 21:16] PA: BP=116/69, P=83, Weight=71
[05-08-2025 21:17] PA: Betacap tr=40 sokal 7.32am khali pete.
Lasix40=sokal 9.50m khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[06-08-2025 21:10] PA: BP=102/60, P=74, Weight=71
[06-08-2025 21:11] PA: Betacap tr=40 sokal 8.05am khali pete.
Lasix40=sokal 10.20pm khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[07-08-2025 22:52] PA: BP=103/56, P=76, Weight=71
[07-08-2025 22:53] PA: Betacap tr=40 sokal 8.30am khali pete.
Lasix40=sokal 10.35am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[08-08-2025 20:48] PA: BP=98/58, P=73, Weight=71
[08-08-2025 20:55] PA: Betacap tr=40 sokal 7.40am khali pete.
Lasix40=sokal 10.05am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[09-08-2025 20:53] PA: BP=100/58, P=72, Weight=71
[09-08-2025 20:54] PA: Betacap tr=40 sokal 7.00am khali pete.
Lasix40=sokal 09.05am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[10-08-2025 21:17] PA: BP=106/58, P=72, Weight=71
[10-08-2025 21:18] PA: Betacap tr=40 sokal 7.10am khali pete.
Lasix40=sokal 08.40am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[11-08-2025 21:11] PA: BP=106/63
Weight=71
P=78
[11-08-2025 21:11] PA: Betacap tr=40 sokal 8.05am khali pete.
Lasix40=sokal 09.45am khabar por
Betacap tr 40 =rate 10.00pm dinner er age.
[12-08-2025 09:27] PPM 1: Doesn't appear to be completely dry.
However one can always stop and check.
@PA ebar kichu din lasix ta bondho kore dekha jaak payer fola ta kemon thake
[12-08-2025 11:22] PPM 11: Okay sir. We can ask her to get just a USG screening for free fluid (not the full USG abdomen) locally at maybe two monthly interval? Any local USG center can do it. Keeping her on prolonged diuretics might cause sudden dyselectrolytemia in cases of fasting or intercurrent diarrhea/vomiting etc
[12-08-2025 12:28] PPM 1: @PA last ultrasound ta kabe hoyechilo?
Ektu patient er naam na dekha jai moton abar ekhane share korte parben?
[12-08-2025 20.48] PA: 31/03/2025
[12-08-2025 21:01] PA: BP=101/57, P=68, Weight=71
[12-08-2025 21:02] PA: Betacap tr=40 sokal 7.50am khali pete.
Betacap tr 40 =rate 10.00pm dinner er age.
[12-08-2025 22:15] PA: Sir ekbar abar ultrasound ki lokaly kore apnake report pathabo.ager theke ektu pet (splin) ta ektu boro hoye che.
[12-08-2025 22:19] PA: Amni normaly routine life cholche.kintu maje maje pulse ta ajke thake kome gache.
[12-08-2025 22:23] PPM 11: The pulse may be low because of beta blockers. How much is the pulse rate?
[12-08-2025 22:28] PA: Right now=72
[12-08-2025 22:31] PPM 11: This seems okay. What is her normal pulse rate?
[12-08-2025 22:37] PA: Normally 75 to 80
[13-08-2025 10:33] PPM 1: Hain (PA: Sir ekbar abar ultrasound ki lokaly kore apnake report pathabo.ager theke ektu pet (splin) ta ektu boro hoye che.)
[13-08-2025 10:35] PPM 1: We have a daily meticulous archive of her pulse rate in her case report in the description box of this group.
[13-08-2025 23:00] PA: BP=103/58, P=68, Weight=71
[13-08-2025 23:02] PA: Betacap tr=40 sokal 8.30am khali pete.
Betacap tr 40 =rate 10.20pm dinner er age.
[14-08-2025 21:03] PA: BP=106/68, P=70, Weight=71
[14-08-2025 21:04] PA: Betacap tr=40 sokal 07.15am khali pete.
Betacap tr 40 =rate 10.00pm dinner er age.
[15-08-2025 20:48] PA: BP=100/57, P=68, Weight=74
[15-08-2025 20:48] PA: Betacap tr=40 sokal 07.55am khali pete.
Betacap tr 40 =rate 10.00pm dinner er age.
[16-08-2025 22:54] PA: BP=109/58, P=84, Weight=71
[16-08-2025 22:55] PA: Betacap tr=40 sokal 8.20am khali pete.
Betacap tr 40 =rate 10.20pm dinner er age.
[17-08-2025 09:57] PPM 1: 👆@CR @PPM12 can we add some of our pedal edema patients here for them to appreciate how this patient's advocate is regularly sharing her edema progress?
[17-08-2025 10:00] PPM 12: okay sir
[17-08-2025 10:22] PPM 1: Also do explain it to them beforehand as to why they are being added in other groups. Also try to add them in groups where the etiology of the clinical findings also match
[17-08-2025 10:57] PPM 12: yes sir.. I did explain them about the objective.. to follow how the edema decreases over time with therapy.
will add them to similar etiology groups too sir
[17-08-2025 13:23] PPM 11: I have a doubt here. In any DCLD, ascites comes first and then (in some patients) anasarca. Will all ascites patients have pedal edema, unless they have concomitant hypoalbuminemia?
[17-08-2025 13:37] PPM 1: @Meta AI @PPM 10 a doubt here. In any DCLD, ascites comes first and then (in some patients) anasarca. Will all ascites patients have pedal edema, unless they have concomitant hypoalbuminemia?
[17-08-2025 13:37] Meta AI: In decompensated chronic liver disease (DCLD), ascites is one of the hallmark features, and it generally develops due to portal hypertension and sodium-water retention. Pedal edema may or may not accompany ascites in all cases. Here's the breakdown:
1. Ascites without Pedal Edema: It's possible to have ascites without significant pedal edema, especially in the early stages of fluid accumulation. This is because ascites is driven primarily by portal hypertension, while pedal edema is more influenced by systemic factors like hypoalbuminemia or venous congestion.
2. Pedal Edema with Hypoalbuminemia: Hypoalbuminemia, which is common in advanced liver disease, reduces oncotic pressure and predisposes patients to generalized edema, including pedal edema. So, if hypoalbuminemia is present, pedal edema is more likely.
3. Pedal Edema Without Hypoalbuminemia: Even in the absence of hypoalbuminemia, severe ascites can impair venous return from the lower extremities due to raised intra-abdominal pressure, leading to pedal edema.
In summary, not all patients with ascites will have pedal edema unless additional factors like hypoalbuminemia or venous congestion play a role. Would you like to discuss more about the pathophysiology or clinical management of these conditions?
[17-08-2025 13:40] PPM 11: Yeah, once pedal edema develops, and if the patient is not malnourished (or otherwise hypoalbuminemic), we check for back veins because venous obstruction may be present
[17-08-2025 13:42] PPM 10: That's an excellent question about the sequence of fluid accumulation in decompensated chronic liver disease (DCLD). Here's the breakdown:
1. *Typical Sequence:* You're correct that *ascites usually develops BEFORE anasarca (generalized edema) or isolated pedal edema* in DCLD. This sequence reflects the underlying pathophysiology:
* *Portal Hypertension:* The initial and primary driver is portal hypertension, causing splanchnic (gut) vasodilation.
* *Splanchnic Vasodilation:* This leads to arterial underfilling in the splanchnic circulation.
* *Neurohormonal Activation:* The body senses this relative hypovolemia, activating the Renin-Angiotensin-Aldosterone System (RAAS), sympathetic nervous system (SNS), and antidiuretic hormone (ADH/vasopressin).
* *Sodium & Water Retention:* These systems cause massive sodium and water retention by the kidneys.
* *Ascites Formation FIRST:* Due to the portal hypertension and the specific anatomy/hydrostatic pressures, this retained fluid initially accumulates preferentially in the peritoneal cavity, forming *ascites*.
* *Peripheral Edema LATER:* As sodium and water retention becomes even more severe and prolonged, the fluid eventually "overflows" into the peripheral tissues (like the lower extremities), causing *pedal edema* and potentially progressing to *anasarca*.
2. *Do ALL ascites patients have pedal edema? NO.*
* It's *common* for patients with significant ascites to also have pedal edema, especially as the disease progresses.
* However, *it's perfectly possible to have ascites WITHOUT pedal edema, particularly in the **earlier stages of decompensation*.
* The key factor is the *degree of sodium retention* and the *predominant site of fluid distribution*. Early on, the retained sodium/water is largely confined to the peritoneal space by portal hypertension.
3. *Role of Hypoalbuminemia:*
* *Hypoalbuminemia IS a contributing factor* to edema formation. It reduces plasma oncotic pressure, making it easier for fluid to leak out of capillaries into the tissues.
* *However, it is NOT the *primary driver in DCLD-related ascites/edema.** Portal hypertension and neurohormonal activation are the main culprits.
* *It is NOT necessary for a patient to have "concomitant hypoalbuminemia" to develop pedal edema once ascites is present.* Even patients with relatively preserved albumin can develop pedal edema if sodium retention is severe enough due to portal hypertension and neurohormonal activation.
* Conversely, a patient with significant hypoalbuminemia and ascites is *more likely* to also have pedal edema, as the low oncotic pressure facilitates fluid leakage systemically. But the trigger is still the portal hypertension/sodium retention.
*In Summary:*
* *Ascites precedes pedal edema/anasarca* in DCLD due to the initial effects of portal hypertension.
* *Not all patients with ascites have pedal edema.* Isolated ascites is common, especially early on.
* *Hypoalbuminemia facilitates edema formation* by lowering oncotic pressure.
* *Hypoalbuminemia is NOT required* for pedal edema to develop in a patient with ascites. The primary drivers are portal hypertension, severe sodium retention, and neurohormonal activation. Pedal edema occurs when sodium retention is so profound that it overflows beyond the peritoneal cavity.
* *Hypoalbuminemia makes pedal edema MORE likely* in a patient with ascites, but it's not the sole determinant or a prerequisite.
So, to answer your core question: *No, not all ascites patients will have pedal edema.* Pedal edema develops later as sodium retention worsens, and while hypoalbuminemia makes it more likely, it is not absolutely required for pedal edema to occur.
[17-08-2025 22:18] PA: BP=106/63, P=69, Weight=71
Betacap tr 40 =rate 10.15pm dinner er age.
[17-08-2025 22:22] PA: Sir right pa ta ektu phole gache .Kasi ta Kom chena. Kono medicine ki deya jabe. Ghum ta hocche na.
[18-08-2025 10:38] PPM 1: Kabe theke?
[18-08-2025 10:40] PA: Kasi ta 3 din holo ghus ghuse Kasi coufgh ber hocche na.
[18-08-2025 22:28] PA: BP=104/62, P=75, Weight=71
[18-08-2025 22:28] PA: Betacap tr=40 sokal 07.50m khali pete.
Betacap tr 40 =rate 10.10pm dinner er age.
[18-08-2025 22:32] PA: Sir pet ta onek ta phulle che.are nicher dike neme gache.nicher dike money hocche kichu ek ta jome acche.onek ta ballon er moto.
[18-08-2025 23:36] PPM 11: I think stopping the diuretic has led to reaccumulation of fluid @Rakesh Biswas Sir. She needs to be started back on diuretics.
Why didn't we consider adding aldactone earlier? Any issue with potassium?
[19-08-2025 08:56] PPM 1: Agree!
Can't recall why not aldactone earlier unless it's there in the archived PaJR case report discussion.
Yes let's start her on:
Tablet Aldactone 100 mg once daily
Tablet lasix 40 mg in the morning
[19-08-2025 08:56] PPM 1: Pet er last ultrasound kabe kora hoyechilo?
[19-08-2025 09:01] PA: Sir aapnader okhane.
[19-08-2025 09:03] PPM 1: Tahole arekta bortomane apnader okhan theke koriye nin. Unara report chara jodi video tao share korte paren tahole bhalo hoi
[19-08-2025 09:08] PA: Aldactone 100 ki aaj ke diye suru korbe.
[19-08-2025 14:49] PPM 1: Hain
[19-08-2025 20:56] 60M DM2 PA: আল্ট্রাসনোগ্রাফি কোন পজিশনে করার কথা বলতে হবে।
[19-08-2025 21:10] PPM 1: Ultrasound jini korben uni oboshyo janben
[19-08-2025 22:17] PA: BP=112/66, P=81, Weight=71
[19-08-2025 22:19] PA: Betacap tr=40 sokal 07.25m khali pete.
Lasix40=8.55am
Betacap tr 40 =rate 09.50pm dinner er age.
Aldectone100=10.15pm
[20-08-2025 22:21] PA: BP=104/61, P=75, Weight=71
[20-08-2025 22:23] PA: Betacap tr=40 sokal 07.50m khali pete.
Lasix40=09.15am
aldactone100=02.00 pm
Betacap tr 40=10.00 dinner age.
[21-08-2025 22:19] PA: BP=104/62, P=67, Weight=71
[21-08-2025 22:20] +91 75860 53704: Betacap tr=40 sokal 08.25m khali pete.
Lasix40=09.35am
aldactone100=02.30 pm
Betacap tr 40=9.45 dinner age.
[22-08-2025 23:12] PA: BP=104/62, P=65, Weight=71
[22-08-2025 23:13] +91 75860 53704: Betacap tr=40 sokal 08.00m khali pete.
Lasix40=09.20am
aldactone100=02.30 pm
Betacap tr 40=10.25 dinner age.
[23-08-2025 22:05] PA: BP=112/65, P=70, Weight=73
[23-08-2025 22:07] PA: Betacap tr=40 sokal 08.30m khali pete.
Lasix40=09.30am
aldactone100=02.15pm
Betacap tr 40=09.50 dinner age.
[24-08-2025 22:31] PA: BP=100/54,P=64,Weight=73
[24-08-2025 22:33] PA: Betacap tr=40 sokal 08.25m khali pete.
Lasix40=09.45am
aldactone100=12.00pm
Betacap tr 40=10.05 dinner age.
[25-08-2025 09:29] PPM 1: 👍
[25-08-2025 22:03] PA: BP=107/55, P=70, Weight=73
[25-08-2025 22:04] PA: Betacap tr=40 sokal 7.48m khali pete.
Lasix40=10.05am
aldactone100=02.25pm
Betacap tr 40=10.01 dinner age.
[26-08-2025 21:29] PA: BP=109/58, P=74, Weight=73
[26-08-2025 21:30] PA: Betacap tr=40 sokal 7..55am khali pete.
Lasix40=09.50am
aldactone100=02.00pm
Betacap tr 40=09.25 dinner age.
[27-08-2025 22:12] PA: BP=100/54, P=64, Weight=73
[27-08-2025 22:13] PA: Betacap tr=40 sokal 8.00am khali pete.
Lasix40=09.15am
aldactone100=02.15pm
Betacap tr 40=09.55 dinner age.
[28-08-2025 23:13] PA: BP=102/60, P=68, Weight=73
[28-08-2025 23:14] PA: Betacap tr=40 sokal 8.10am khali pete.
Lasix40=09.45am
aldactone100=02.15pm
Betacap tr 40=10.05 dinner age.
[29-08-2025 22:56] PA: BP=102/58, P=67, Weight=73
[29-08-2025 22:57] PA: Betacap tr=40 sokal 8.30am khali pete.
Lasix40=10.05am
aldactone100=02.00 pm
Betacap tr 40=10.00 dinner age
[30-08-2025 15:47] PPM 1: 👍
[30-08-2025 22:06] PA BP=113/67, P=73, Weight=73
[30-08-2025 22:07] PA: Betacap tr=40 sokal 8.10am khali pete.
Lasix40=09.40am
aldactone100=02.00 pm
Betacap tr 40=10.05 dinner age.
[31-08-2025 23:06] PA: BP=109/64 P=72 Weight=72
[31-08-2025 23:07] PA: Betacap tr=40 sokal 07=25am khali pete.
Lasix40=10.05am
aldactone100=01
30 pm
Betacap tr 40=09.40 dinner age.
[02-09-2025 18.07] PA: https://1drv.ms/b/c/83fd19b3363f46cd/Ec6cbod-2iZKjx3v5aiUvB8Bn824_R3ljof6RxckUvxRHw
[02-09-2025 18:09] PA: Sir pet ta onek ta phola acche.
[02-09-2025 22:14] PA: BP=109/58, P=69, Weight=73
[02-09-2025 22:15] PA: Betacap tr=40 sokal 08.10am khali pete.
Lasix40=10.05am
aldactone100=12.45
Betacap tr 40=10.05 dinner age.
[02-09-2025 22:29] PPM 1: @PPM11 is liver transplant the only way out now?
[03-09-2025 09:15] PPM 11: Seems so.
But the only problem is the uncertainty about the primary etiology of cirrhosis. In HBV/HCV/Autoimmune even a proportion of cirrhotics can recompensate once the primary etiology is controlled.
[03-09-2025 09:16] PPM 11: Better would be to consult a center capable of LT, they will be able to do a transjugular liver biopsy also.
[03-09-2025 09:17] PPM 1: Such as your current workplace?
[03-09-2025 09:19] PPM 1: The differentials that you mention are less likely as known viral serology has been done and autoimmune events in terms of intermittent hepatitis was never seen in this patient over the last 10 years when she first presented to us in Bhopal with asymptomatic esophageal varices
[03-09-2025 09:20] PPM 11: I am not in ILBS anymore sir. My course completed a couple of months ago.
But she can definitely consult there.
[03-09-2025 09:21] PPM 11: Yes I saw the viral serologies.
Autoimmune seems less likely given the clinical course, I agree.
Did she ever have jaundice?
[03-09-2025 09:22] PPM 2: Has Wilson's been ever considered?
[03-09-2025 09:25] PPM 11: Wilson is unlikely to present as asymptomatic portal hypertension and once decompensated, unlikely to survive so long without chelation.
But ofcourse, should be ruled out in d/d of any CLD.
[03-09-2025 09:25] PPM 11: I think we had discussed about Wilson last time she bled
[03-09-2025 09:35] PPM 11: Her last albumin which I can see in the PaJR is 3.97 (was it after albumin supplementation?) and INR is normal.
As I said earlier, this seems unlikely to be a parenchymal etiology.
We have to think about other causes of portal Htn.
[03-09-2025 09:35] PPM 1: Yes my initial hunch even 10 years ago was NCPF post gestation
[03-09-2025 09:35] PPM 11: Yes sir.
[03-09-2025 09:36] PPM 1: Never received anything other than EVL 10 years back for asymptomatic varices
[03-09-2025 09:38] PPM 11: Two questions from the history which seem vital:
1. Did she or any of her siblings ever have any pruritus during childbirth or while taking oral contraceptives?
2. Is there any family history or personal history of early gallstones(before 35y of age)?
[03-09-2025 09:40] PPM 11: A rare (but very common to us pediatric hepatologists) cause of insidious portal Htn in young adults is MDR3. They frequently present with only portal Htn and over years slowly progress to ESLD, just like in this patient
[03-09-2025 09:42] PPM 1: 👆@PA uporer aei proshno tar uttor din
[03-09-2025 09:43] PPM 1: @Meta AI translate below to Bengali
Two questions from the history which seem vital:
1. Did she or any of her siblings ever have any pruritus during childbirth or while taking oral contraceptives?
2. Is there any family history or personal history of early gallstones (before 35y of age)?
[03-09-2025 09:43] Meta AI: I don’t understand Bengali yet, but I’m working on it. I will send you a message when we can talk in Bengali.
[03-09-2025 09:43] PPM 1: @Meta AI you've been learning Bengali for last one year and yet you fail us most of the time in translating Bengali!
[03-09-2025 09:43] Meta AI: It sounds like you're passionate about improving communication in Bengali, and I appreciate your dedication! If there's a specific way I can help clarify or improve on translations, feel free to point it out—I'll do my best to assist. How has your Bengali learning journey been so far?
[03-09-2025 09:44] PPM 1: @Meta AI we were talking about your sub optimal Bengali learning journey.
[03-09-2025 09:44] Meta AI: Ah, you're right—my Bengali skills aren't perfect yet, and I appreciate the patience! While I aim to provide accurate translations, there’s definitely room for improvement, and feedback like yours helps me get better. What do you think I can do to make my Bengali translations more reliable?
[03-09-2025 09:50] PPM 11: Proshno tinte holo:
1. Pregnancy r shomoy onar shorirer kono ongshe (specially hat e ba pa e) chulkani r problem dekha giechilo ki?
2. Pregnancy chharao, onyo somoy e kono osudh (jerom contraceptives) khaoyar pore kono chulkani r somoshya dekha giechilo?
3. Onar ba poribarer gall bladder e stone er somoshya ache?
[03-09-2025 09:53] PA: 1 no kono oral contraceptives use hoy ni.
2.rogi ba tar kono family te golblader stone history jana nai.
[03-09-2025 09:53] PPM 11: Ar pregnancy time e shorir e kono itching hoechilo?
[03-09-2025 09:55] PPM 11: Ektu khonj nie janale bhalo hoy.
[03-09-2025 10:03] PA: Na kono itching hoi nai.
[03-09-2025 10:03] PPM 11: Okk
[03-09-2025 10:04] PPM 11: So we still have NCPF as a predominant possibility @Rakesh Biswas Sir
[03-09-2025 10:05] PPM 11: We have to review the indications of LT in NCPF. The latest APASL 2024 guidelines may be a good start
[03-09-2025 10:08] PPM 1: @Meta AI please review the indications of liver transplantation in NCPF particularly look up the latest APASL 2024 guidelines to begin with
[03-09-2025 10:08] Meta AI: The indications for liver transplantation in Non-Cirrhotic Portal Hypertension (NCPF) are nuanced and typically reserved for specific, severe cases. Based on the latest APASL 2024 guidelines, here's what stands out:
### Indications for Liver Transplantation in NCPF:
1. Uncontrolled Variceal Bleeding: Despite optimal medical and endoscopic therapy, patients with recurrent or life-threatening variceal bleeding due to portal hypertension may require transplantation. This is especially true if the bleeding severely impacts quality of life or poses a risk to survival.
2. Progressive Liver Dysfunction: Although NCPF is characterized by preserved liver function in many cases, some patients may develop complications resembling decompensated liver disease (e.g., ascites, encephalopathy) that fail to respond to conventional treatments.
3. Portal Hypertension-Related Complications: Patients with severe portal pressure leading to complications like refractory ascites or spontaneous bacterial peritonitis may be considered for transplantation.
4. Secondary Liver Damage: In rare cases, secondary liver injury (e.g., superimposed infections, thrombosis, or ischemia) may deteriorate liver function to the point where transplantation becomes necessary.
### Key Considerations from APASL:
- NCPF vs Cirrhosis: Unlike cirrhosis, NCPF patients often have preserved synthetic liver function. This makes transplantation less common, but it remains a lifesaving option for those with uncontrollable complications.
- Living Donor Liver Transplantation (LDLT): In the Asia-Pacific region, LDLT is often the preferred method due to limited deceased organ availability. APASL emphasizes the importance of multidisciplinary evaluation before proceeding with transplantation in NCPF cases.¹ ² ³
The guidelines also highlight the importance of individualized decision-making, weighing the risks of surgery against the potential benefits for these patients. Let me know if you’d like further details or clarification!
[03-09-2025 10:08] Meta AI: https://www.aasld.org/practice-guidelines
[03-09-2025 10:08] Meta AI: https://www.journal-of-hepatology.eu/article/s0168-8278(13)00607-7/fulltext
[03-09-2025 10:08] Meta AI: https://link.springer.com/article/10.1007/s12072-023-10629-3
[03-09-2025 10:09] PPM 1: @PPM11 looks like we are on the initial phases of her LT journey if at all necessary
[03-09-2025 10:21] PPM 11: Yes, in NCPF transplant needs to be reserved for specific cases, unlike routine cirrhosis ESLD. Since the synthetic/detoxification function is preserved, the patient is unlikely to develop HE or AKI like cirrhotics. If the bleeds can be tackled with good nearby endoscopy services or if one time TIPS can be attempted from an experienced interventional radiology center?
[03-09-2025 10:23] PPM 11: Then we may never need LT at all and spare the patient a lifetime of immune suppression and post LT complications.
[03-09-2025 10:34] PPM 1: She didn't bleed once in 10 years as far as I can recall without actually revisiting her case report.
Please confirm @PA
[03-09-2025 10:43] PPM 11: But her portal Htn is progressive? Even if we assume her recent bleed was NSAID driven, she has now developed ascites?
[03-09-2025 10:49] PA: Sir bhopal theke asar por last 10 years kono problem hoy nai.
[03-09-2025 11:01] PPM 1: Wish we could find better engineering solutions to reducing portal pressures @PPM9
[03-09-2025 21:58] PA: BP=100/58, P=71, Weight=73
[03-09-2025 22:01] +91 75860 53704: Betacap tr=40 sokal 08.00am khali pete.
Lasix40=11.00m
aldactone100=01.40
Betacap tr 40=09.45 dinner age.
[03-09-2025 22:11] PA: Sir emny kono peta somosa nei .normal life acche .khali pet ta ektu boro hoye che.
[04-09-2025 22:51] PA: BP=106/60, Weight=73, P=72
Lasix40=10.250m
aldactone100=02.05
Betacap tr 40=010.05 dinner age.
[05-09-2025 22:23] PA: BP=100/54, P=74, Weight=72
[05-09-2025 22:24] PA: Betacap tr=40 sokal 08.10am khali pete.
Lasix40=9.40m
aldactone100=01.45
Betacap tr 40=10.15 pm dinner age.
[06-09-2025 22:10] PA: BP=100/51
P=70
Weight=71
[06-09-2025 22:11] PA: Betacap tr=40 sokal 08.15am khali pete.
Lasix40=9.40m
aldactone100=2.30
Betacap tr 40=10.05 pm dinner age.
[07-09-2025 21:51] PA: BP=107/59, P=73, Weight=71
[07-09-2025 21:52] PA: Betacap tr=40 sokal 07.45m khali pete.
Lasix40=9.05m
aldactone100=2.00pm
Betacap tr 40=09.10pm dinner age.
[08-09-2025 22:08] PA: BP=103/52, P=65, Weight=70
[08-09-2025 22:09] PA: Betacap tr=40 sokal 07.20m khali pete.
Lasix40=08.50m
aldactone100=2.00pm
Betacap tr 40=09.45pm dinner age.
[09-09-2025 22:19] PA: Bp=105/59, P=73, Weight=70
[09-09-2025 22:20] PA: Betacap tr=40 sokal 07.30m khali pete.
Lasix40=09.10m
aldactone100=2.30pm
Betacap tr 40=09.55pm dinner age.
[10-09-2025 22:05] PA: BP=105/54, P=69, Weight=69
[10-09-2025 22:05] PA: Betacap tr=40 sokal 07.50m khali pete.
Lasix40=08.35m
aldactone100=1.45pm
Betacap tr 40=09.38pm dinner age.
[10-09-2025 22:05] PA: Sir weight ta kome jache.peter fola ta onek kome gache.
[11-09-2025 06:05] PPM 1: Ebar lasix ta kichudin bondho rakha jete pare
[11-09-2025 23:02] PA: BP=105/55, P=75, Weight=69
[11-09-2025 23:03] PA: Betacap tr=40 sokal 07.50m khali pete.
Lasix40=07.25m, aldactone100=1.50pm, Betacap tr 40=09.45pm dinner age.
[12-09-2025 06:58] PPM 1: Ebar lasix ta kichudin bondho rakha jete pare
[12-09-2025 21:55] PA: BP=104/62, P=77, Weight=69
[12-09-2025 21:57] +91 75860 53704: Betacap tr=40 sokal 08.20m khali pete
aldactone100=1.50pm, Betacap tr 40=09.55pm dinner age.
[13-09-2025 22:09] PA: BP=100/54, P=74, Weight=69
[13-09-2025 22:10] PA: Betacap tr=40 sokal 07.45m khali pete
aldactone100=02.10pm, Betacap tr 40=09.45pm dinner age.
[14-09-2025 21:18] PA: BP=108/56, P=80, Weight=69
[14-09-2025 21:18] PA: Betacap tr=40 sokal 07.55m khali pete, aldactone100=01.50pm
Betacap tr 40=09.15 pm dinner age.
[14-09-2025 21:18] PPM 1: 👍
[15-09-2025 21:15] PA: BP=111/56, P=76, Weight=70
[15-09-2025 21:16] PA: Betacap tr=40 sokal 08.05m khali pete aldactone100=01.45pm
Betacap tr 40=09.10pm dinner age.
[16-09-2025 22:08] PA: BP=105/61, P=73, Weight=73
[16-09-2025 22:08] PA: Betacap tr=40 sokal 07.35m khali pete
aldactone100=01.40pm. Betacap tr 40=09.40pm dinner age.
[17-09-2025 16:32] PPM 1: Abar lasix ta shuru kore din
[17-09-2025 18:14] PA: Sir weight ta 70 kg hobe.bhul kore 73 likhe diye chi.
[17-09-2025 18:38] PPM 1: Okay tahole lasix aekhon start na korleo habe
[17-09-2025 21:17] PA: BP=102/60, P=73, Weight=70
[17-09-2025 21:19] PA: Betacap tr=40 sokal 06.40 am khali pete, aldactone100=01.20 pm
Betacap tr 40=09.10pm dinner age.
[18-09-2025 21:28] PA: BP=108/68, P=74, Weight=70
[18-09-2025 21:28] PA: Betacap tr=40 sokal 007.25am khali pete
aldactone100=01.45pm, Betacap tr 40=09.25pm dinner age.
[18-09-2025 21:33] PPM 1: 👍
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