50M Chronic Diarrhoea Cough and CKD Hypertension WB PaJR
[05-04-2025 20:49] PPM 1: Currently admitted today in ward.
50y old male came with
c/o greasy stools since 4-5 months
c/o cough since 2 months
c/o pain in epigastrium since 1 month
history of red colored stools 8-9 months back followed by tarry colored stools which subsided 4 months back with medication
now patient had greasy stools on and off
cough since 2 months insidious onset associated with feeling of something stuck in the throat
h/o frothing of urine since 8 months
patient had previous history of blood transfusions
k/c/o chronic kidney disease since 9 months
k/c/o hiatus hernia
k/c/o hypertension since 9 months on tab cilnidipine 20mg po/od (non compliance to medication)
chronic alcoholic daily stopped 8 yrs back
chronic tabacco chewing stopped now
[06-04-2025 11:56] PPM 1: @~PPM 6 eta apnar patient er jonye toiri kora.
Ekhane mone rakhben patient er privacy bojai rakhar jonye kokkhono unar naam ba onyo kichu share korben na jate unake ekhane online identify kora na jete pare. Amra jara patient ke chini ebong unar roger uposhomer jonye kaaj korchi amrao aeki chesta korbo
[06-04-2025 20:03] PPM 1: Looks like chronic glomerular injury CKD with pulmonary kochs left upper lobe Send his sputum AFB and trunat tomorrow
[06-04-2025 20:09] PPM 3: Okay sir
[07-04-2025 20:42] PPM 1: @~PPM3 we forgot to collect his signed informed consent form today to prepare his case report @PPM4 perhaps we can call to OPD tomorrow and gather it?
[07-04-2025 20.44] PPM 1: Afternoon session with him:
Appears to have all began with this skin lesion following which the local doctor informed him that he also had renal failure
[07-04-2025 20:56] PPM 4: Yes sir!
[08-04-2025 08:33] PPM 1: Nothing significant here?
[08-04-2025 08:45] PPM 5: Yes sir It was done in dec
[08-04-2025 08:49] PPM 5: Should we repeat endoscopy today sir
[08-04-2025 08:56] PPM 1: Not sure why?
[08-04-2025 08:57] PPM 5: Yesterday u told to get it done sir
[08-04-2025 09:20] PPM 1: Oh for suspected upper GI bleed in the past?
So they already have a normal scopy report to rule out an upper GI bleed in the past. Perhaps after that they thought his anemia was renal?
Are we suspecting any ongoing recent upper GI bleed? What is his postural BP @~PPM3?
[08-04-2025 11:04] PPM 3: supine - 140/80mmhg, standing -110/80 mmhg sir
[08-04-2025 12:30] PPM 5: Trunaat is negative
[08-04-2025 15:15] PPM 6: Oh that's significant!
When was this?
We need to monitor him more then hourly!
[08-04-2025 15:19] PPM 1: Please check hourly or more frequently if possible
[08-04-2025 15.53] PPM 1: Taking the history again now:
2 years back, one while he started driving his lorry (@~PPM 3 please share his retrovirus report) at 3:00 AM from Mathabhanga and trying to rapidly reach his destination to Siliguri by 7AM to avoid "no entry" he suddenly felt giddy and he stopped the truck and developed altered sensorium and became unresponsive following which bystanders got him admitted at the nearest hospital where he was told to have Hypertension.
Not checked for creatinine then but one year later when he developed his skin lesion which began as a blister he was also told to have high creatinine.
Today's 24 protein appears not significant although his serum creatinine is 5.2 and his urine cue was albumin 3+!
[08-04-2025 18:02] PPM 3: patient is having loose stools sir now -3 times (since morning stools 5 times)
[08-04-2025 18:24] PPM 7: Sir is he diabetic?
[08-04-2025 18:56] PPM 7: Any signs of edema? What are electrolyte levels?
[08-04-2025 18:56] PPM 7: Any weight loss? history
[08-04-2025 20:46] PPM 8: Ecg
[09-04-2025 08:38] PPM 5: They are willing for Hrct sir Should we proceed with it
[09-04-2025 10:30] PPM 1: Would it be fair to make them spend their meager savings unless after the HRCT we will do something differently with than from before the HRCT?
Please share your expectations from the HRCT as to how it will add more value worth his meager savings and also what about his repeat sputum AFB sent to RNTEP?
[09-04-2025 10:31] PPM 1: Not diabetic. Are you 2021 batch?
[09-04-2025 10:32] PPM 1: If you are 2021 batch you are supposed to meet the patient in the ward and take his history in detail and find the answers to these questions. @PPM4 please clarify if she is 2021
[09-04-2025 10:52] PPM 1: Please share the report of USG kub @~PPM3
What other investigations can we do for his renal failure short of renal biopsy.
Please ask @PPM 9 to evaluate him ASAP for renal biopsy if kidney size and other parameters are concordant
[09-04-2025 10:56] PPM 3: patient is sent for USG sir
[09-04-2025 11:03] PPM 7: Yes sir
[09-04-2025 11:07] PPM 1: Tell us his history in detail @PPM7
[09-04-2025 12.04] PPM 3:
[09-04-2025 13:05] PPM 1: Never send sputum culture sensitivities unless you want to get confounded in your management plan more so because someone is having to pay for this meaningless sputum culture sensitivity exercise
[09-04-2025 13:06] PPM 1: Kidneys appear to be shrunken!😨
Why haven't the radiologists mentioned that, please ask! 😳
[09-04-2025 13:31] PPM 3: Okay sir
[09-04-2025 15:51] PPM 1: Chronic diarrhoea 25 years!
Increased gastro colic reflexes every day. Passes normal stools immediately after major meals.
Once every two months he develops watery diarrhoea which lasts for 15 days
[09-04-2025 15:52] PPM 1: From 57 kgs one year back, Currently 40 kgs
[09-04-2025 16:31] PPM 4: Yes sir, she is from 2021 batch.
[09-04-2025 16:56] PPM 1: She asked some good questions around this patient 👏👏
Thanks @~~PPM7
[09-04-2025 18.15] PPM 8: Hrct chest.
https://youtu.be/tA3gj2gPiJM?si=KsuGvEvlD5fmDnN2
[09-04-2025 18.43] PPM 1: Thanks, Here's the main frame
[12-04-2025 18.43] PPM 10: Yes turns out it easily interprets this. ChatGPT answer below.
[13-04-2025 08:18] PPM 1: What's the Bristol grading and reassurance for this one @Meta AI @~PPM 10?
[13-04-2025 08:18] Meta AI: The Bristol Stool Chart (not grading) is a medical aid designed to classify the physical form of human feces into seven categories. Here's a brief overview:
1. Type 1: Separate hard lumps
2. Type 2: Sausage-shaped but lumpy
3. Type 3: Like a sausage but with cracks
4. Type 4: Like a smooth sausage
5. Type 5: Soft blobs with clear-cut edges
6. Type 6: Fluffy pieces with ragged edges
7. Type 7: Liquid consistency
Reassurance would depend on the specific type and individual circumstances. Generally, types 3-5 are considered normal. If you're concerned about your stool or experiencing symptoms, it's best to consult a healthcare professional for personalized advice.
[13-04-2025 08:19] PPM 1: @Meta AI thanks. This patient's looks like 4-5
[13-04-2025 08:19] Meta AI: That's good news. Types 4 and 5 on the Bristol Stool Chart typically indicate a healthy gut and normal bowel movements. Type 4 is like a smooth sausage, and type 5 is soft blobs with clear-cut edges. If the patient is experiencing no other symptoms or issues, this could be a sign of good digestive health.
[13-04-2025 08:22] PPM 1: @~~PPM 11 @~PPM 10 @PPM 2 alk the above data is a part of our project paper: "Optimizing clinical complexity in intestinal disorders utilising AI driven macroscopic stool output pattern recognition."
Will soon blog the intro other than the archival of all of this and above by @CR in this patient's PaJR case report.
[13-04-2025 10.01] PPM 5: Today’s chest Xray
[13-04-2025 10:05] PPM 1: Excellent! Changing lung shadows in chest X-ray indicates an active infection as in mycobacteria or inflammation as in an autoimmune lung disease.
[13-04-2025 11.07] PPM 1: [13/04, 10:21] Pushed1Comm22: That means in tb also there will be changing lung shadows sir
[13/04, 10:23]cm: Yes that used to be a hallmark of active TB in radiological assessment when we were PGs
[13/04, 10:26] Pushed1Comm22: New point for me sir
[13/04, 10:27] Pushed1Comm22: Then shall we start him on emperical att
[13/04, 10:28]cm: What other choice do we have to address his atypical pneumonia?
[13/04, 10:30] Pushed1Comm22: Starting him on antibiotics and see the response sir
[13/04, 10:37]cm: Hasn't he received any antibacterials in the past? Could the antibacterials harm his kidney further?
Alright perhaps oral Azithromycin for 3 days or oral doxycycline for a week or levofloxacin?
[13/04, 11:00] Pushed1Comm22: No sir he didn’t receive any antibiotics. Pulmonologist adviced levoflox. But u told to with hold sir
[13/04, 11:05]cm: Yes I meant before coming here. In that case which antibiotics from the above three options for atypical pneumonia short of antimycobacterials would you like to start. Justify your choice with a mention of which atypical organism you are targeting and why
[13-04-2025 18:18] PPM 2: Incredible. How are we marrying this to outcomes?
[13-04-2025 19:36] PPM 1: We'll need to wait for those in this patient but there is a fabulous example of that in a past patient PaJR created by @CR here and she may be able to summarise the correlation between our stool learning outcomes and his illness outcomes 👇https://24fpatient.blogspot.com/2024/07/28m-abdominal-migraine-1-month-headache.html?m=1
[13-04-2025 20:40] PA44F: What is abdominal migraine?
[13-04-2025 20:51] PPM 1: @Meta AI what is abdominal migraine?
[13-04-2025 20:51] Meta AI: Abdominal migraine is a type of migraine disorder that primarily affects children, but can also occur in adults. It's characterized by recurring episodes of abdominal pain, often accompanied by other symptoms like:
1. Nausea and vomiting
2. Loss of appetite
3. Pallor (pale skin)
4. Headaches (not always present)
The exact cause is unclear, but it's thought to be related to abnormal blood vessel activity and neurotransmitter imbalances. Triggers can include stress, certain foods, or hormonal changes.
Abdominal migraines can be diagnosed based on medical history, symptoms, and ruling out other conditions. Treatment often involves lifestyle changes, dietary modifications, and sometimes medication to manage symptoms.
Would you like more information on managing abdominal migraines or potential treatments?
[14-04-2025 17.11] PPM 3:
@PPM 8 @~PPM5 what's the surgery plan for removal?
[14-04-2025 18:59] PPM 5: We asked brig sirs unit Pg’s to review the case.They will see tomorrow sir
I think they will suggest FNAC first.
[15-04-2025 12.06] PPM 3:
[15-04-2025 16:47] PPM 1: Should we repeat his chest X-ray to see if the shadows are changing or is the apparent change here due to the obliquity of the image capture?
[15-04-2025 16:49] PPM 5: Yes sir it’s better to repeat the xray.
14-04-2025 Reports
When is the FNAC report expected?
[16-04-2025 11:58] PPM 5: Fnac not done yet sir
Pathology team told that they will review today and tell whether they will do fnac or not
As lymph node is near carotid
[16-04-2025 12:32] PPM 3: pathology team said they will do FNAC tomorrow
[16-04-2025 13:05] PPM 1: The patient was saying a needle was passed
[16-04-2025 15:46] PPM 3: not passed sir just counselled him the procedure of FNAC. Repeat Chest X ray.
[16-04-2025 16:06] PPM 1: Thanks. The above chest X-ray was quite useful. Apparently his shadows are changing rapidly. Is it a recovering community acquired pneumonia or evolving tuberculosis? @~PPM 12 @~~PPM11
[16-04-2025 18:55] PPM 11: I'm not sure, might be recovering from community-acquired pneumonia? ( I haven't attended many medicine postings sir especially respiratory😅)
[16-04-2025 20:02] PPM 1: I meant by reviewing the literature
[17-04-2025 08:23] PPM 5: Good morning sir. He is not giving consent for FNAC
[17-04-2025 08:40] PPM 1: Alright. Let's start him on antitubercular therapy today? Please ask the pulmonary physicians to review the rapidly changing chest X-rays for their comments on if that signifies tuberculosis or community acquired pneumonia.
@Meta AI what would be your first differentials for rapidly changing shadows on the chest X-ray in an Indian male immunocompromised by chronic kidney disease stage 4?
@~PPM13what would be your Web 3.0 take on it?
[17-04-2025 08:40] Meta AI: Given the clinical context, here are some differentials for rapidly changing shadows on a chest X-ray in an Indian male with chronic kidney disease stage 4:
1. Pulmonary tuberculosis (TB): Common in India, and immunocompromised patients are more susceptible.
2. Community-acquired pneumonia (CAP): Could be bacterial, viral, or fungal, and might progress rapidly in immunocompromised patients.
3. Fluid overload/pulmonary edema: CKD stage 4 patients are prone to fluid overload, which can cause rapid changes on X-ray.
4. Pulmonary hemorrhage: Possible in CKD patients, especially if there's an underlying vasculitis or bleeding disorder.
Web 3.0 take:
A decentralized approach to managing such patients could involve:
1. Decentralized data sharing: Sharing patient data (e.g., X-rays, lab results) across healthcare providers in real-time.
2. AI-assisted diagnosis: Using machine learning models to analyze X-rays and provide differential diagnoses.
3. Personalized treatment plans: Utilizing genomic and medical history data to tailor treatment to individual patients.
These approaches can enhance patient care, improve outcomes, and facilitate research.
[17-04-2025 08:41] PPM 1: @~PPM 10 @~~PPM 11 that's an interesting take on Web 3.0?
[17-04-2025 08:49] PPM 13: His chest X ray please!
[17-04-2025 08:52] PPM 13: Got it — let's break this down clinically and technologically:
---
### *Clinical Insight (For the Pulmonary Review):*
In an *Indian male with CKD stage 4, rapid changes in chest X-ray findings could point towards **infectious, inflammatory, or even vascular etiologies. Given the context, here are **first-line differentials* to consider:
---
### *Top Differentials for Rapidly Changing Pulmonary Shadows:*
1. *Pulmonary Tuberculosis (TB)*
- Especially *miliary or progressive primary TB* in immunocompromised patients.
- Look for upper zone infiltrates, cavitary lesions, or hilar adenopathy.
2. *Community-Acquired Pneumonia (CAP)*
- Rapid lobar consolidation; can mimic TB but typically with more acute symptoms.
- Look for air bronchograms, pleural effusion.
3. *Pulmonary Edema (Uremic/Volume Overload in CKD)*
- Can cause bilateral perihilar shadowing ("bat-wing" pattern).
- Responsive to dialysis and diuretics.
4. *Fungal Infections (e.g., Aspergillosis)*
- Especially in immunocompromised hosts; check for nodules with halo signs.
5. *Pulmonary Hemorrhage Syndrome (e.g., Goodpasture’s or Vasculitis)*
- Diffuse alveolar infiltrates, hemoptysis, rapid progression.
6. *Metastatic Sepsis / Septic Emboli*
- Common in dialysis patients with vascular access infections.
7. *ARDS*
- Rare but possible in uremic immunocompromised individuals post-infection or transfusion.
---
### *Web 3.0 Take (from @Dr.Abdulsalam’s Angle):*
From a *Web 3.0 perspective*, this scenario could benefit from:
- *Blockchain-enabled patient data exchange*
=> Rapid radiograph access across institutions securely for second opinions.
- *AI diagnostic consensus platforms*
=> Using decentralized models to compare CXR patterns across massive TB-CAP annotated datasets.
- *NFT-based radiological tokenization*
=> Protecting radiologic data integrity while allowing collaborative reviews.
- *Metaverse-based medical simulation*
=> Simulating disease progression scenarios (e.g., TB vs CAP) in virtual environments for rapid diagnostics and consensus-building.
--- Would you like me to fetch recent studies or evidence on differentiating TB from CAP on CXR in immunocompromised Indian patients? I can run a scholar search and present clinical papers too.
---
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[17-04-2025 08:55] PPM 1: 👏👏. Yes to the last question
[17-04-2025 09:01] PPM 13: I am waiting for deep research results of the scholar ChatGPT
[17-04-2025 09:01] PPM 13: It may take few minutes
[17-04-2025 10:14] PPM 13: ### Overview:
Chronic Kidney Disease (CKD), especially in advanced stages like stage 4 and 5, significantly affects the cardiopulmonary system. Chest X-rays (CXRs) are frequently used to monitor associated complications, including *pulmonary edema, pleural effusion, cardiomegaly, and **vascular congestion*. In the Indian context, several studies highlight unique epidemiological and radiological patterns influenced by regional comorbidities, late-stage diagnoses, and limited access to specialized nephrology care.
Below is a synthesis of key studies on this topic.
---
### *Key Research Findings on Chest X-ray & Pulmonary Manifestations in Indian Adults with CKD*
1. *Mani et al. (2023)*
Title: Pulmonary Manifestations at Different Stages in the Chronic Kidney Disease: An Observational Study
- *Findings:* Chest X-ray showed *pulmonary hypertension, pleural effusion, and edema* in stage 4 CKD patients. Pulmonary issues were increasingly prevalent in later stages.
- *Link:* [Read Full PDF](https://www.cureus.com/articles/155364-pulmonary-manifestations-at-different-stages-in-the-chronic-kidney-disease-an-observational-study.pdf)
2. *Shaik et al. (2021)*
Title: A Spectrum of Pulmonary Complications in ESRD Patients on Hemodialysis
- *Findings:* Most common abnormalities on X-ray included *interstitial edema, **cardiomegaly, and **vascular congestion*. Hemodialysis did not eliminate respiratory risks.
- *Link:* [Read Full PDF](https://www.cureus.com/articles/57636-a-spectrum-of-pulmonary-complications-occurring-in-end-stage-renal-disease-patients-on-maintenance-hemodialysis.pdf)
3. *Mogar et al. (2017)*
Title: A Study of Respiratory Manifestations in CKD
- *Findings:* Chest imaging revealed *calcifications, **volume overload, and **pleural effusions*. Sleep apnea and pulmonary calcification were notable in Indian CKD patients.
- *Link:* [PDF Access](https://www.academia.edu/download/53123287/5.3876-10999-4-PB.pdf)
4. *Manjuri et al. (2016)*
Title: Cardiovascular Complications in CKD: A Clinical Study
- *Findings:* CXR showed *cardiomegaly* in 70% of patients. Combined use of X-ray and echocardiography improved cardiovascular assessment.
- *Link:* [PDF Access](https://scholar.archive.org/work/qyoy46agmjgafbb22met2qfswq/access/wayback/http://ijhrmlp.org/pdfs/179.pdf)
5. *Ahmad et al. (2020)*
Title: Imaging Spectrum of Pulmonary Infections in Renal Transplant Patients
- *Findings:* Though focused on transplant patients, it reported *multifocal patchy opacities*, which are also seen in immunocompromised CKD patients.
- *Link:* [Read HTML](https://www.thieme-connect.com/products/ejournals/html/10.4103/ijri.IJRI_357_19)
6. *Suresh et al. (2017)*
Title: Cardiorenal Syndrome Type 4: Cardiovascular Diseases in CKD
- *Findings:* Chest X-ray helped confirm *pulmonary edema* and *left ventricular hypertrophy (LVH)*.
- *Link:* [Full Article](https://www.sciencedirect.com/science/article/pii/S0019483216302632)
7. *Singh et al. (2013)*
Title: Manifestations of Pulmonary Disease in Adults with Congenital Heart Disease
- *Findings:* Observed overlap between congenital heart disease and CKD complications on CXR like *increased cardiothoracic ratio* and *lung fibrosis*.
- *Link:* [PDF Access](https://www.researchgate.net/profile/Arunabh-Talwar/publication/256762959_Manifestations_of_Pulmonary_Disease_in_Adults_with_Congenital_Heart_Disease/links/5745bbbc08ae9ace84241ba6/Manifestations-of-Pulmonary-Disease-in-Adults-with-Congenital-Heart-Disease.pdf)
8. *Anusha et al. (2022)*
Title: Diffuse Parenchymal Lung Disease and Pulmonary Circulation
- *Findings:* Chest X-ray showed *increased cardiothoracic ratio* in advanced CKD. Parenchymal changes often indicated poor outcomes.
- *Link:* [PDF Download](https://journals.lww.com/lungindia/_layouts/15/oaks.journals/downloadpdf.aspx?an=01408641-202203001-00021)
9. *Gembillo et al. (2023)*
Title: Lung Dysfunction and CKD: A Complex Network
- *Findings:* Radiological signs such as *bronchial wall thickening, **reduced lung volume, and **vascular markings* are significant.
- *Link:* [Read Full PDF](https://www.mdpi.com/2075-4426/13/2/286/pdf)
10. *Singal et al. (2016)*
Title: Cardiac Status in CKD Patients: Non-invasive Assessment
- *Findings:* Used CXR for evaluating *LVH* and *alveolar edema*. Confirmed high prevalence of cardiovascular findings.
- *Link:* [Read PDF](https://banglajol.info/index.php/BJMS/article/view/23596/19508)
---
## Common Chest X-Ray Abnormalities in Stage 4 CKD (India)
| Radiological Finding | Frequency & Notes |
|-----------------------------|----------------------------------------------------------|
| Pulmonary Edema | Common in fluid-overloaded states, especially in late CKD |
| Cardiomegaly | Often due to LVH or heart failure; visible on X-ray |
| Pleural Effusion | Frequently bilateral; associated with hypoalbuminemia |
| Interstitial Markings | Suggest pulmonary fibrosis or edema |
| Pulmonary Hypertension Signs| Enlarged pulmonary arteries, visible in advanced stages |
---
If you’d like, I can also *summarize any specific article, **generate a concept map, or help you **extract data for analysis*.
Would you like a *visual summary or structured chart* of these findings?
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[17-04-2025 11:33] PPM 1: Thanks
Also @PPM 8 with whom I had a discussion and @~PPM 6who met me just now in the OPD and pooling everything I feel the chest X-ray changes have progressed too rapidly to attribute to even a mycobacterial etiology @~PPM 5
This may as well be pulmonary edema and my current plan is to repeat his chest X-ray tomorrow and then send him home without any antibacterials including without any antimycobacterials! I'm glad we waited and didn't jump to start antitubercular therapy.
If frusemide is the real hero here (or perhaps its just the bed rest) how much dose of lasix is he currently on? @~PPM 12?
[17-04-2025 11:58] PPM 3: He is not on lasix sir
[17-04-2025 12:10] PPM 1: Let's add 40mg 8:00AM
[17-04-2025 12:12] PPM 8: Okay sir
[17-04-2025 15:31] PPM 11: Yes sir. Will mark this.
[17-04-2025 15:31] PPM 11: Sorry sir, wasn't able to follow-up earlier.
[18-04-2025 06:51] PPM 1: The Web 3.0 review of literature shared by @~Dr.Abdulsalam did influence our medical cognition here as we moved from infectious etiology causality thinking to heart failure causality attribution for his lung shadows! Point to be noted for the medical cognition book.
Now here's another interesting CBBLE discussion with another Medical student regarding our intervention (both causality assessment aka diagnosis vs solution implementation aka treatment )👇
[17/04, 17:27] Medical Student CBBLE: should we start any anemia treatment for 50y ckd with pulmonary edema patient sir
[17/04, 21:55]cm: Treatment for the cause of his anemia yes but then what's the cause of his anemia? CKD alone? Does erythropoietin have better than marginal benefits over placebo?
[17/04, 23:14] Medical Student CBBLE: Erythropoietin (EPO) has shown significant benefits in treating anemia secondary to chronic kidney disease (CKD). Here's what the research suggests:
Benefits of EPO in CKD-related Anemia:
- Improved Hemoglobin Levels: EPO helps increase hemoglobin levels, reducing the need for blood transfusions and associated complications like infections and iron overload.
- Enhanced Quality of Life: By correcting anemia, EPO improves patients' overall quality of life, reducing debilitating symptoms and increasing energy levels.
- Neuroprotective Effects: Research suggests that EPO may have neuroprotective properties, potentially benefiting patients with neurological diseases like Alzheimer's, Parkinson's, and schizophrenia.
- Potential Renal Benefits: Some studies indicate that EPO may retard CKD progression by mitigating tissue hypoxia and renal tissue injury.¹ ² ³
Comparison to Placebo:
While specific study results aren't provided here, the benefits of EPO over placebo can be inferred from its widespread use and research. EPO has revolutionized CKD anemia treatment, and its effectiveness is well-established. Newer agents like vadadustat, which stimulate endogenous EPO production, are being studied for their potential benefits.⁴
Key Considerations:
- Hemoglobin Oscillations: EPO treatment can lead to hemoglobin fluctuations, which may impact treatment efficacy and safety.
- Circulating EPO Levels: Research suggests that lower, more stable EPO levels might be beneficial, as seen with novel agents like vadadustat.⁵
Overall, erythropoietin has demonstrated substantial benefits in managing anemia secondary to CKD, going beyond marginal effects. Its impact on hemoglobin levels, quality of life, and potential neuroprotective and renal benefits make it a valuable treatment option.
[17/04, 23:16] Medical Student CBBLE: it could be due to GI loss also but bleeding stopped before admission, patient hb should have stayed constant or increased. but rather it decreased which lead to other causes sir
[18/04, 06:34]cm: Other than the key considerations which are interesting, there is no data here.
A better prompt would be @Meta AI please share a single valid RCT with searchable and verifiable reference, that compares the efficacy of erythropoietin with placebo and express the values in a PICO format taking care to share only absolute numbers and not relative percentages
[18/04, 06:34] Meta AI: Here's a valid RCT comparing erythropoietin with placebo, expressed in PICO format with absolute numbers:
PICO Format:
- *P*opulation: Patients with chemotherapy-induced anemia (n = 344)
- *I*ntervention: Erythropoietin (40,000 IU/week) (n = 171)
- *C*ontrol: Placebo (n = 173)
- *O*utcome: Hematocrit response (increase ≥6% from baseline)
Results:
-Hematocrit response:
- Erythropoietin: 61/171 (35.7%)
- Placebo: 12/173 (6.9%)
Reference:
- Wright JR, et al. "Erythropoietin for the Treatment of Chemotherapy-Induced Anemia: A Randomized, Double-Blind, Placebo-Controlled Trial." Journal of Clinical Oncology, vol. 25, no. 19, 2007, pp. 2707-2714. doi: 10.1200/JCO.2006.09.5930.
This study is searchable and verifiable through PubMed or the Journal of Clinical Oncology website.
[18/04, 06:35]cm: @Meta AI again please don't share percentages but share absolute numbers.
Also share the erythropoietin trial in CKD patients
[18/04, 06:35] Meta AI: Here are the results in absolute numbers for both trials:
Chemotherapy-induced anemia trial:
- *P*opulation: Patients with chemotherapy-induced anemia (n = 344)
- *I*ntervention: Erythropoietin (40,000 IU/week) (n = 171)
- *C*ontrol: Placebo (n = 173)
- *O*utcome: Hematocrit response (increase ≥6% from baseline)
- Results:
- Erythropoietin: 61 patients achieved hematocrit response
- Placebo: 12 patients achieved hematocrit response
- Reference: Wright JR, et al. "Erythropoietin for the Treatment of Chemotherapy-Induced Anemia: A Randomized, Double-Blind, Placebo-Controlled Trial." Journal of Clinical Oncology, vol. 25, no. 19, 2007, pp. 2707-2714. doi: 10.1200/JCO.2006.09.5930.
CKD trial:
- *P*opulation: Patients with chronic kidney disease (CKD) and anemia (n = 139)
- *I*ntervention: Erythropoietin (50-150 IU/kg, 3 times/week) (n = 69)
- *C*ontrol: Placebo (n = 70)
- *O*utcome: Patients requiring ≥1 unit of blood transfusion
- Results:
- Erythropoietin: 18 patients required ≥1 unit of blood transfusion
- Placebo: 47 patients required ≥1 unit of blood transfusion
- Reference: Eschbach JW, et al. "Recombinant human erythropoietin in anemic patients with end-stage renal disease. Results of a phase III multicenter clinical trial." Annals of Internal Medicine, vol. 111, no. 12, 1989, pp. 992-1000. doi: 10.7326/0003-4819-111-12-992.
[18/04, 06:38]cm: @Meta AI what was the duration of follow up for which the outcomes were assessed? When you say more than 1 transfusion how many exact transfusions in the Placebo group and how many in the erythropoietin group? Also please tell us the exact hemoglobin rise in each group instead of telling more than 6 %
[18/04, 06:38] Meta AI: The trial details you're asking about are based on a study by Eschbach JW et al., published in Annals of Internal Medicine in 1989. Here's the information you requested:
- Duration of follow-up: The study duration was 52 weeks (12 months), divided into a 2-month baseline period and a 10-month treatment phase.
- Number of transfusions:
- Placebo group: 146 units of blood transfused in the placebo group, with 47 patients requiring transfusions. The exact number of transfusions per patient isn't specified, but we know 47 out of 70 patients required at least one transfusion.
- Erythropoietin group: 23 units of blood transfused in the erythropoietin group, with 18 patients requiring transfusions.
- Hemoglobin rise:
- The mean hemoglobin level in the erythropoietin group rose from approximately 6.5 g/dL to around 10.5 g/dL.
- In the placebo group, the mean hemoglobin level remained relatively stable, around 6.5 g/dL to 7 g/dL.
Keep in mind that these results are based on patients with chronic kidney disease (CKD) and anemia, and the specifics might vary depending on the study context.¹
[18/04, 06:40]cm: @Meta AI how were the study participants blinded to the placebo vs the intervention in this particular study or was it an open label design?
[18/04, 06:40] Meta AI: The study by Eschbach JW et al., published in Annals of Internal Medicine in 1989, was a randomized, double-blind, placebo-controlled trial.
To maintain blinding, the study used a placebo that was indistinguishable from the active erythropoietin. The erythropoietin and placebo were supplied in identical vials, and the dosing regimen was designed to maintain the blind.The double-blind design aimed to minimize bias and ensure that both the patients and the investigators were unaware of the treatment assignments.
Let's give 80 mg today and repeat the chest X-ray tomorrow?
[18-04-2025 08:46] PPM 3: one dose 40mg was given sir
[18-04-2025 08:48] PPM 1: Yes that's low dose
[18-04-2025 08:49] PPM 1: I'm more convinced about the diagnosis being pulmonary edema although it can only be confirmed after complete disappearance of the shadows.
[19-04-2025 09:19] PPM 1: Yesterday's?
[19-04-2025 10:48] PPM 1: @~PPM 5 can someone share the deidentified discharge summary for this patient or give me the IP number so that I can ask the clerk to email it to me in word.
Also @~PPM 3 did you prescribe any injection for the patient?
[19-04-2025 11:08] ppm 13: Thanks for sharing the chest X-rays (PA and lateral views). Here are a few general observations based on the images:
1. Lung fields: Appear clear without obvious consolidation, cavitation, or mass lesion.
2. Cardiac silhouette: Within normal limits in the PA view, though lateral view assessment is limited due to image quality.
3. Costophrenic angles: Appear sharp; no blunting to suggest pleural effusion.
4. Diaphragm: Normal contour and position.
5. Bones: No obvious fractures or lytic lesions.
If this is for the patient with chronic diarrhea (as the chat title suggests), it would be helpful to correlate these findings with systemic symptoms — for instance, looking for signs of tuberculosis, malignancy, or other chronic infections/systemic illnesses.
Would you like a more focused interpretation in context of the clinical case or lab findings?
[19-04-2025 11:17] ppm 1: Let that be decided by his local doctor (nephro)
Can you share the images of which antihypertensives he's currently on and write a prescription for a strip of ten each and he'll need to monitor his BP once weekly for 10 times once he reaches home. I'm assuming no one monitored his BP during his stay here but by chance if they have can you share the chart here?
[19-04-2025 11:17] PPM 1: 👏
[19-04-2025 11.34] PPM 13: Dramatic outcome 👏
[19-04-2025 19.40] PPM 1:
His EMR summary:
Age/Gender: 50 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 05/04/2025 05:33 PM
Diagnosis
CKD WITH PULMONARY EDENA (RESOLVING) ANEMIA OF CHRONIC DISEASE
K/C/O HTN SINCE 9 MONTHS K/C/O CKD SINCE 9 MONTHS
Case History and Clinical Findings
CHIEF COMPLAINTS-
C/O GREASY STOOLS SINCE 4-5 MONTHS C/O PAIN IN EPIGASTRIUM SINCE 1 MONTH C/O COUGH SINCE 2 MONTHS
HOPI-
PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK THEN HE DEVELOPED GREASY STOOLS 2 EPISODES/DAY ON AND OFF
H/O RED COLOURED STOOLS 8-9 MONTHS BACK FOLLOWED BY DARK COLOURED STOOLS [TARRY STOOLS] 10-11 DAYS AFTER RED COLOURED STOOLS WHICH SUBSIDED 4 MONTHS BACK WITH MEDICATION .
C/O EPIGASTRIC PAIN INSIDIOUS ONSET ON AND OFF NO Aggravating AND RELIEVING FACTORS
H/O COUGH SINCE 4 MONTHS INSIDIOUS ONSET A/W FEELING OF Something STUCK IN THROAT
H/O FROTHING OF URINE + SINCE 8-9 MONTHS
H/O INCREASED FREQUENCY OF URINATION DURING NIGHT [4 TIMES/NIGHT] AFTER MEDICATION
NO H/O BURNING MICTURITION PAST HISTORY-
K/C/O CKD SINCE 8-9 MONTHS K/C/O HIATUS HERNIA TYPE II
H/O ULCER PRESENT OVER RIGHT LEG AND RIGHT GROIN 9 MONTHS BACK [HEALED NOW] K/C/O HTN SINCE 9 MONTHS ON TAB CILNIDIPINE 20MG PO/OD NON COMPLIANCE TO TREATMENT
N/K/C/O DM,EPILEPSY,CVA,CAD,TB ,ASTHMA PERSONAL HISTORY:
APPETITE -NORMAL BOWELS- GREASY STOOLS+
BLADDER-FROTHING OF URINE+ SLEEP- ADEQUATE
NO ALLERGIES
ADDICTIONS -CHRONIC Alcoholic STOPPED 8 YRS BACK TOBACCO OCCASIONAL STOPPED NOW
FAMILY HISTORY- NOT SIGNIFICANT GENERAL EXAMINATION:
PATIENT IS C/C/C PALLOR-YES ,MODERATE
NO ICTERUS,CYANOSIS,CLUBBING,LYMPADENOPATHY,MALNUTRITION,DEHYDRATION TEMPERATURE - 98.4 DEGREE F
BP - 140/90 MMHG PR - 82 BPM
RR - 16CPM
SPO2 - 99 % AT RA GRBS: 111
CVS - S1 S2 HEARD, NO MURMURS RS - BAE PRESENT, NVBS HEARD
PER ABDOMEN -SOFT,NO TENDERNESS .
SOFT, NO HEPATOMEGALY, NO SPLENOMEGALY CNS - PT WAS C/C/C
TONE RIGHT LEFT UL N N
LL N N
POWER RIGHT LEFT UL 5/5 5/5
LL 5/5 5/5
BULK RIGHT LEFT UL N N
LL N N
REFLEXES B +2 +2
T+2 +2
S+1 +1
K +2 +2
A+1 +1 PLANTAR F F
GLASGOW SCALE -E4V5M6
PULMONOLOGY REFERRAL WAS DONE I/V/O CHEST X RAY CHANGES I.E., HOMOGENOUS OPACITY IN LEFT MIDDLE LOBE AND TRANSBRONCHIAL BIOPSY
IMPRESSION-LEFT LOWER LOBE COMMUNITY ACQUIRED PNEUMONIA (E.COLI) ADVICE-INJ.AUGMENTIN 1.2GM IV/BD
INJ.LEVOFLOXACIN 500MG IV/OD INJ.PAN 40MG IV/OD/BBF SYP.ASCORIL 10ML PO/TID
GENERAL SURGERY REFERRAL WAS DONE I/V/O CERVICAL AND AXILLARY LYMPHADENOPATHY
ADVICE -USG GUIDED FNAC UPGI ENDOSCOPY
STOOL FOR OCCULT BLOOD
PATIENT DENIED FOR FNAC FOR WHICH DENIAL CONSENT WAS TAKEN.
Investigation
24 HOURS URINEPROTEIN270 mg/day. <150 mg/day24 HOURS URINECREATININE0.9 g/day 1-3 gm /dayRATIO 0.30URINE VOLUME 1,500 ml
HEMOGRAM 6/4/25
HAEMOGLOBIN 5.9 gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 12,200 cells/cumm
4000 - 10000 ImpedenceNEUTROPHILS 82 % 40 - 80 Light MicroscopyLYMPHOCYTES 10 % 20 -
40 Light MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 07 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 18.6 vol % 40 - 50 CalculationM C V 81.6 fl
83 - 101 CalculationM C H 25.9 pg 27 - 32 CalculationM C H C 31.7 % 31.5 - 34.5 CalculationRDW-
CV 16.1 % 11.6 - 14.0 HistogramRDW-SD 48.5 fl 39.0-46.0 HistogramRBC COUNT 2.28
millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 2.0 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC counts increased on smear withabsolute neutophiliaLight MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light Microscopy
LIVER FUNCTION TEST (LFT) 06-04-2025 08:59:AMTotal Bilurubin 0.44 mg/dl 1-0 mg/dlDirect Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 21 IU/L 35-0 IU/LSGPT(ALT) 20 IU/L 45-0
IU/LALKALINE PHOSPHATASE 278 IU/L 280-53 IU/LTOTAL PROTEINS 6.5 gm/dl 8.3-6.4
gm/dlALBUMIN 2.42 gm/dl 5.2-3.5 gm/dlA/G RATIO 0.59
COMPLETE URINE EXAMINATION (CUE) 06-04-2025 08:59:AMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR +BILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-6EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilSERUM CREATININE 06-04-2025 08:59:AM 5.2 mg/dl 1.3-0.9 mg/dl
HBsAg-RAPID 08-04-2025 07:05:PM NegativeAnti HCV Antibodies - RAPID 08-04-2025 07:05:PM
Non Reactive
BLOOD UREA 08-04-2025 07:05:PM 95 mg/dl 42-12 mg/dlSERUM ELECTROLYTES (Na, K, C l) 08- 04-2025 07:05:PMSODIUM 135 mmol/L 145-136 mmol/LPOTASSIUM 4.6 mmol/L 5.1-3.5
mmol/LCHLORIDE 102 mmol/L 98-107 mmol/L
SERUM CREATININE 08-04-2025 07:05:PM 5.4 mg/dl 1.3-0.9 mg/dl HEMOGRAM 14/4/25
HAEMOGLOBIN 6.6 gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 8,200 cells/cumm
4000 - 10000 ImpedenceNEUTROPHILS 69 % 40 - 80 Light MicroscopyLYMPHOCYTES 21 % 20 -
40 Light MicroscopyEOSINOPHILS 02 % 01 - 06 Light MicroscopyMONOCYTES 08 % 02 - 10 Light
MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 21.0 vol % 40 - 50 CalculationM C V 81.7 fl
83 - 101 CalculationM C H 25.7 pg 27 - 32 CalculationM C H C 31.4 % 31.5 - 34.5 CalculationRDW-
CV 17.3 % 11.6 - 14.0 HistogramRDW-SD 52.4 fl 39.0-46.0 HistogramRBC COUNT 2.57
millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 2.20 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adequate in number and distribution Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemia
BLOOD UREA 14-04-2025 12:15:AM 84 mg/dl 42-12 mg/dl
SERUM CREATININE 14-04-2025 12:15:AM 5.1 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na, K, C l) 14-04-2025 12:15:AMSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5
mmol/LCHLORIDE 106 mmol/L 98-107 mmol/L ON 7/4/25
TRUNAAT -NEGATIVE
USG ABDOMEN AND PELVIS ON 9/4/25 B/L GRADE I RPD CHANGES
USG NECK ON 14/4/25
IMPRESSION-B/L CERVICAL LYMPHADENOPATHY FEW WITH HILUM AND FEW WITHOUT HILUM
SPUTUM FOR C/S
REPORT-E.COLI ISLOATED HTCT CHEST :
CONSOLIDATION IN APICAL SEGMENT OF LEFT LUNG UPPER LOBE
SEGMENTAL ATELECTASIS WITH BRONCHIECTASIS IN RIGHT LUNG MIDDLE LOBE MILD FIBROSIS IN APICAL SEGMENT OF RIGHT LUNG UPPER LOBE
2D ECHO DONE ON 12/4/25 IMPRESSION
TRIVIAL TR NO PAH, TRIVIAL AR, NO MR / PR NO RWMA, NO AS/MS, SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION, NORMAL DIASTOLIC DYSFUNCTION NO PE, LV CLOT
Treatment Given (Enter only Generic Name)
T.CINOD 10MG PO/HS
T.TAMSULOSIN HCL PO/OD T.PCM 650MG PO/TID T.NODOSIS PO/BD
T.LASIX 40MG PO/OD
Advice at Discharge
T.CINOD 10MG PO/HS TO CONTINUE (0-0-1) T.NODOSIS PO/BDTO CONTINUE
Follow Up
REVIEW TO GM OPD AFTER 1 WEEK/SOS
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:19/4/25 Ward:MMW Unit:V
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