69M Pedal Edema Abdominal Distension CCF CKD DM2 HTN Metabolic Syn WB PaJR

11-04-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

 [11-04-2025 08:01] PPM 1: Long distance patient reaching our OPD now. Please add the unit PGs who will be looking after him during his admission stay here

[11-04-2025 09:51] PPM 1: @~PPM3 @~PPM4 @~PPM5 are on duty today and will look after this patient henceforth till discharge.

[11-04-2025 12.22] PPM 1: OPD now:

69M from WB landed now to our hospital with anasarca (generalized edema) and a few leads to the root cause of his problem localisation (cardiac or liver).

[11-04-2025 12:42] PPM 1: @~PPM6 @~PPM5 

 

Please send:

chest X-ray pa view

Ecg

Hemogram 

LFT

Creatinine

Abdominal x-ray 

USG abdomen

Echocardiography

[11-04-2025 12:57] PPM 6: Ok sir

[11-04-2025 13.10[ PPM 1: History in the patient's voice and writing. Also needs an AI to deidentify the handwriting

[11-04-2025 12.38] PPM 1: Additional interesting findings in this patient @CR 👇

https://youtu.be/M8_HVkbixb0?feature=shared 

[11-04-2025 15.16] PPM 1: Afternoon session 69M bedside clinical imageology

[11-04-2025 16:49] PPM 1: @PPM 7 can we have his history in a proper event timelined sequence?

[11-04-2025 16:53] PPM 1: @~PPM 6 start him on tablet frusemide 40 mg at 8:00 AM and 20mg at 12:00 PM, Also add tablet telmisartan 20mg at 10:00AM

[11-04-2025 16:59] PPM 6: Ok sir

[11-04-2025 17:02] PPM 1: https://youtu.be/qGWAc7kN_do?feature=shared

[11-04-2025 17:03] PPM 1: Use this template for the history @PPM 7 👇

https://userdrivenhealthcare.blogspot.com/2024/08/template-for-pajr-user-driven-history.html?m=1

[11-04-2025 17:10] PPM 7: yes sir @~~PPM 8 and I will go and speak to the patient after they're done with their USG.

[11-04-2025 17:10] PPM 7: Okay sir!

[11-04-2025 20:09] PPM 1: Thanks

[12-04-2025 09:38] PPM 1: Are all investigation reports available now?

[12-04-2025 09:43] PPM 1: Among all the multiple causes and effects in this patient's anasarca, this is perhaps pivotal @PPM 2 @~~PPM 9 @~PPM 10 @PPM 11 and while it still doesn't explain his very low serum albumin which is enough on its own to cause his anasarca (is the hypoalbuminemia hepatic, glomerular or nutritional), we still need to look at the amount of albumin and protein he is excreting in 24 hours and should we start collecting today and will anyone be able to report it tomorrow or should we begin on Sunday morning @~PPM 6 @~PPM 3 @~PPM 12? Also please send a PT INR today to rule in the possibility of a liver synthetic failure

[12-04-2025 09:43] PA: Ok

[12-04-2025 09:57] PPM 5: Okay sir

[12-04-2025 10:09] PPM 1: Also, blood sugars

2 hours after breakfast

2 hours after lunch

2 hours after dinner

Every day

PT INR today

[12-04-2025 10:10] PPM 1: Please give them the jar to collect the 24-hour protein and creatinine

[12-04-2025 10:21] PPM 5: Okay sir

[12-04-2025 11.20] PPM 1: His current medications CILIX 10 Cilnidipine tablets.

TELISTA 40 Telmisartan tablets. CYRA -D Rabeprazole sodium and Domperidone capsules.

[12-04-2025 11:20] PPM 1: Please send him to urology for prostate evaluation

[12-04-2025 11:23] PPM 1: Have you started him on Tablet frusemide?

[12-04-2025 11:33] PPM 3: Yes sir

[12-04-2025 15:08] PPM 2: How's the JVP like and did you see any calcification of the pericardium?

Any past TB? What came first - right heart symptoms or left heart symptoms?

[12-04-2025 15:09] PPM 2: Looks like a predominantly right heart failure? JVP can clinch it.

[12-04-2025 15:12] PPM 1: No raised JVP. Any studies on sensitivity of JVP as a test?

[12-04-2025 15:12] PPM 1: No calcifications in pericardium. No past history of TB

[12-04-2025 15:13] PPM 2: That's good enough I guess. A study, in this context here will not really change management will it?

[12-04-2025 15:14] PPM 2: Are you planning on tapping the ascites sir?

[12-04-2025 16:35] PPM 1: Not much ascites even for diagnostic tap

[12-04-2025 16:36] PPM 1: It's just to support the hypothesis that if JVP is negative it's still very much heart failure as jvp is likely to have a poor sensitivity

[12-04-2025 16:36] PPM 1: We are supposed to collect his 24 hour protein and creatinine from 6:00 AM tomorrow. Please make sure they got the container from the biochemistry department

[12-04-2025 16:40] PPM 5: Okay sir

[12-04-2025 20:43] PPM 2: You said Anasarca was prominent?

[12-04-2025 20:44] PPM 2: I used to believe this until I moved here - Shoddy data logging can bend statistics anyway.

[12-04-2025 20:44] PPM 2: I have seen many JVPs, which my colleagues couldn't. How would you rate that?

[12-04-2025 20:44] PPM 2: Perhaps CVP measurement would be the best way forward

[12-04-2025 20:51] PPM 1: Good training!

[12-04-2025 20:51] PPM 1: It is. Mostly in scrotum and limbs. Ascites mild

[12-04-2025 23:20] PA: Daktar babu Jr, Dr, tho Asud delo na Pa Fular jono

[13-04-2025 07.06] PPM 6: 

[13-04-2025 07:42] PPM 1: Thanks. So the glomerular injury may turn out to be significant on 24 hour protein and creatinine monitoring. Hope they have received the jar and started collecting the sample from 6:00 AM from today?

[13-04-2025 07:43] PPM 1: @~PPM 6 please check if the patient is getting the frusemide because the patient's advocate believes he isn't getting it

[13-04-2025 07:43] PPM 6: Yes sir, they started collecting from 6 am sir

[13-04-2025 07:44] PPM 6: Ok sir

[13-04-2025 19:40] PPM 1: 👏👏

[13-04-2025 19:42] PPM 1: @~PA babu Khub bhalo haantchen kintu Patient ke video te chena jacche tai unar goponiyota bojai rakhar jonye video ta dekhe taratari delete kore dilam

[13-04-2025 19:51] PA: Tik Achay

[14-04-2025 16:10] PPM 1: 👆@~~PPM 9 what's the score here?

[14-04-2025 16.11] PPM 1: All part of his generalized edema

[14-04-2025 16:13] PPM 1: @~PPM 6 we have concluded that his anasarca is largely cardiac and hypoalbuminemia is nutritional. Very important case for @~PPM 13 thesis on hypoalbuminemia

[14-04-2025 16:13] PPM 1: @~PPM 6 please check if he's getting frusemide and telmisartan and asj them to share the images of all the current medications he is taking

[14-04-2025 16:28] PPM 6: He is getting sir

[14-04-2025 17:04] PPM 1: Let's get their discharges ready for tomorrow morning

[14-04-2025 17:30] PPM 14: May I suggest a urine culture?

[14-04-2025 18:21] PPM 6: Ok sir

[14-04-2025 18:22] PPM 13: Ok sir

[15-04-2025 20:03] PPM 1: Patient's EMR discharge summary shared in advance by @~PPM 6 for further edits if necessary:

Age/Gender: 69 Years/Male

Address:

Discharge Type: Relieved

Admission Date: 11/04/2025 11:24 AM

Diagnosis

HEART FAILURE WITH PRESERVED EJECTION FRACTION K/C/O DM SINCE 6-7 YEARS

K/C/O HTN SINCE 6-7 YEARS

Case History and Clinical Findings

C/O SWELLING OVER THE BOTH LEGS SINCE 4 MONTHS C/O GENERALIZED BODY SWELLINGS SINCE 4 MONTHS HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN HE DEVELOPED SWELLING OVER THE BOTH LOWER LIMBS BELOW KNEE, PITTING TYPE, GRADE 3+ C/O SHORTNESS OF BREATH GRADE I-II SINCE 4 MONTHS

H/O FEARFULLNESS SINCE CHILDHOOD

MET WITH ACCIDENT 5 YEARS BACK FROM THEN THE FEARFULLNESS INCREASED NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA, PND

NO H/O COUGH, H/O FREQUENT URINATION+, NO H/O BURNING MICTURITION PAST HISTORY:

K/C/O DM SINCE 6-7 YEARS ON TELMISARTAN

K/C/O HTN SINCE 6-7 YEARS ON HOMEOPATHY MEDICATION

N/K/C/O TB, CAD, CVA, ASTHMA, EPILEPSY AND THYROID DISORDERS

 H/O TOBACCO CHEWING SINCE 40 YEARS PERSONAL HISTORY:

DIET-MIXED

APPETITE- DECREASED BOWEL MOVEMENTS- NORMAL BLADDER- NORMAL

SLEEP- ADEQUATE

ADDICTIONS: TOBACCO CHEWING SINCE 40 YEARS FAMILY HISTORY : NOT SIGNIFICANT

GENERAL EXAMINATION:

PATIENT IS C/C/C

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA TEMP: AFEBRILE

BP:130/80MMHG PR:72BPM RR:18CPM GRBS :78MG/DL

SPO2: 99% AT RA SYSTEMIC EXAMINATION:

CVS:S1 S2 HEARD ,NO MURMURS RS:BAE +,NVBS HEARD PA:SOFT,NON TENDER

CNS: RIGHT LEFT

TONE - UL NORMAL NORMAL LL NORMAL NORMAL POWER UL 5/5 5/5

LL 5/5 5/5 REFLEXES BICEPS - +2 +2

TRICEPS +2 +2

SUPINATOR + 2 +2

KNEE +2 +2

ANKLE +2 +2

PLANTAR FLEXION FLEXION

 UROLOGY REFERRAL DONE ON 12/04/25 I/V/O DECREASED URINE FLOW ADVICED:

TAB TAMSULOSIN 0.4MG PO/HS X 1 MONTH CST

Investigation

HAEMOGLOBIN 9.6 gm/dl 13.0 - 17.0 Colorimetric LOX -PAPTOTAL COUNT 5,200 cells/cumm

4000 - 10000 Impedence NEUTROPHILS 84 % 40 - 80 Light Microscopy LYMPHOCYTES 10 % 20 -

40 Light Microscopy EOSINOPHILS 01 % 01 - 06 Light Microscopy MONOCYTES 05 % 02 - 10 Light

Microscopy BASOPHILS 00 % 0 - 2 Light Microscopy PCV 28.9 vol % 40 - 50 Calculation M C V 86.5 fl

83 - 101 Calculation M C H 28.7 pg 27 - 32 Calculation M C H C 33.2 % 31.5 - 34.5 Calculation RDW-

CV 15.7 % 11.6 - 14.0 Histogram RDW-SD 50.7 fl 39.0-46.0 Histogram RBC COUNT 3.34

millions/cumm 4.5 - 5.5 Impedence PLATELET COUNT 1.5 lakhs/cu.mm 1.5-4.1 Impedence SMEARRBC Normocytic normochromic Light Microscopy WBC Within normal limits with neutrophilia Light Microscopy PLATELETS Adequate in number and distribution Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic anemia with neutrophilia

COMPLETE URINE EXAMINATION (CUE) 12-04-2025 06:05:PM COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN ++++SUGAR trace BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 4-5EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil

Prothrombin Time 16 10-16secINR 1.11

SERUM CREATININE 11-04-2025 01:15:PM 1.2 mg/dl 1.3-0.8 mg/dl

LIVER FUNCTION TEST (LFT) 11-04-2025 01:15:PM Total Bilurubin 0.85 mg/dl 1-0 mg/dl Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl SGOT(AST) 37 IU/L 35-0 IU/LSGPT(ALT) 27 IU/L 45-0

IU/LALKALINE PHOSPHATASE 385 IU/L 128-56 IU/LTOTAL PROTEINS 5.5 gm/dl 8.3-6.4

gm/dl ALBUMIN 2.50 gm/dl 4.6-3.2 gm/dl A/G RATIO 0.83

24 HOURS URINEPROTEIN162.1 mg/day. <150 mg/day24 HOURS URINECREATININE0.7 g/day 1-

3 gm /day

RATIO 0.23URINE VOLUME 2,500 ml USG DONE ON 11/04/25

IMPRESSION:

RAISED ECHOGENICITY OF BILATERAL KIDNEYS

B/L PLEURAL EFFUSIONS WITH UNDERLYING LUNG COLLAPSE DIFFUSE GALL BLADDER EDEMA

MILD INTER BOWEL FLuiD+ REVIEW USG DONE ON 12/O4/25 IMPRESSION:

 BORDERLINE PROSTATOMEGALY

Treatment Given (Enter only Generic Name)

TAB FUROSEMIDE 40MG PO/OD AT 8 AM TAB FUROSEMIDE 20MG PO/OD AT 12 PM TAB TELMISARTAN 20MG PO/OD AT 10AM TAB TAMSULOSIN 0.4MG PO/HS

Advice at Discharge

TAB FUROSEMIDE 40MG PO/OD AT 8 AM TAB FUROSEMIDE 20MG PO/OD AT 12 PM TAB TELMISARTAN 20MG PO/OD AT 10AM TAB TAMSULOSIN 0.4MG PO/HS

Follow Up

REVIEW TO GM OPD AFTER 2 WEEKS/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: 15/04/25 Ward: SSW Unit: I

[15-04-2025 20:05] PPM 1: @~PPM6 Add to the diagnosis: Anasarca with multiple causative factors:

HfpEF

Hypoalbuminemia (multiple unexplained factors: Diet, liver function)

[18-04-2025 10.44] PA: Dakther babu Paa Obostha Akhon

[18-04-2025 11:03] PPM 1: 👍 Komche

[18-04-2025 22:02] PPM 9: I'll upload it on open AI and get back to you tomorrow morning Sir.

[19-04-2025 10.03] PA:

PPM 1: 👍

https://medicinedepartment.blogspot.com/2023/09/the-healthy-plate-diet-in-bengali-telegu.html?m=1

[26-04-2025 10.37] PA: Akhan pa fola ta anak komacha

[26-04-2025 10.57] PPM 1: Aekhon tahole Lasix oshudh ta sokale ekbar khelei habe

[18-05-2025 21.19] PA: Ei medicine ta 1 mash er chilo to ses hoye geche ,babar ekhono pa gulo ektu fule jachhe ...

[19-05-2025 12:09] PPM 1: Eta pa folar jonye noi. Prostate er jonye

[19-05-2025 12:09] PPM 1: 👆pa folar oshudh ekhane

[19-05-2025 12:10] PPM 1: Ajk tao onk ta kom mone hocche...

[19-05-2025 12:12] PA: Prostate gland ta kalk ektu fule chilo but ajk bolche..thik ache...

[19-05-2025 12:13] PPM 1: Prostate gland goto kal fulechilo ki bhabe anuman kora hoyeche?

[19-05-2025 12:14] PA: Ha baba to bollo fulechilo.. but ajk ektu komeche...

[19-05-2025 12.15] PA: https://youtu.be/IhOue1TQ0-w?si=a_daCZ6-8TyA7dDi

[19-05-2025 12:16] PPM 1: Heart failure ta pa fola chara unar sharirik energy, ghontai ghontai activities ebong saash koshto eguno share korle bojha jeto. Ekhane dekhte paren unar boyeshi arek joner heart failure shuddhu daily activities jeguno uni roj share koren 👇

https://pajrcasereporter.blogspot.com/2025/03/63m-metabolic-syn-dyspnea-2-years-wb.html?m=1

[23-05-2025 19.49] PA: 

[23-05-2025 20:03] PPM 1: Tamsulosin ta bondho korlen keno?

[23-05-2025 20:05] PA: Ota almas khate bolecilen tahole ota ar kotodin khabe

[23-05-2025 20:07] PA: Ota akmas ar chilo

[23-05-2025 20:15] PPM 1: Ota pechchap ta shoru hoye jate na beroi tai jonye dewa. Aemni te pechchap korte kono asubidhe na hole newar dorkar nei

[23-05-2025 20:16] PPM 1: Baki mon kharap thaka ta depression er jonye.

[23-05-2025 20:25] PA: Depression er ki kono osudh ache janaben

[23-05-2025 20:28] PPM 1: Okhane local psychiatrist ke dekhate habe

[23-05-2025 21:16] PA: Dakther babu Nomoskar Neban Akta kono Osud dela

Kub Valo hotho

[24-05-2025 07:09] PPM 1: Kisher oshudh? Depression er? Ota ekmatro local psychiatrist ke dekhiye nite hoi

[24-05-2025 07:16] PA: But babar to serokom kisu nei , IPL o dekhche ,walk , bajare jaoya sob e cholche... Ektu pa ta majhe  majhe dekhe fuleche mone hoy.. abar kisukhon por thik lage....

[24-05-2025 08:06] PPM 1: 👆 ekhane lekha ache: kono kichu tei agroho nei, mone kono anondo nei, sob kichu tei bhoi bhoi bhab! @PA

[24-05-2025 08:07] PPM 1: Jodi goto kaaler ghontai ghontai unar sara deener activities ta share korte parten tahole bhalo bojha jeto

[24-05-2025 08:07] PA: Ok...ajk sob ta kore rate dicchi..

[24-05-2025 08:08] PA: Ota to baba mar moddhe cholte thake🙃

[24-05-2025 08:10] PPM 1: Hain aei jonyei amader ekjon neutral observer er daily hourly Inputs dorkar about his activities

[24-05-2025 08:11] PA: Okay..

[24-05-2025 22.57] PA: 

[25-05-2025 09.05] PPM 1: 10:00 AM er por guno ektu ghontai ghontai janaben

Jemon:

10AM to 11:00 AM

11:00 AM to 12:00 PM etc

[25-05-2025 23.32] PA: 

[26-05-2025 06:56] PPM 1: 12:30PM to 2:00 PM?

[26-05-2025 06:56] PPM 1: Hain tamsulosin ta continue korte paren jaate pecchap er dhara ta shothik thake

[26-05-2025 11:53] PA: San kore bose thake

[26-05-2025 11:54] PPM 1: TV'r saamne?

[26-05-2025 11:55] PA: Na chup chap

[26-05-2025 12:20] PPM 1: Aei muhurte ki shei bhabei boshe achen aajke?

Kone jaigai boshechen? Oi ghore ki uni eka?

[26-05-2025 14:03] PA: Na ajke uni sala r bari ta barate asache

[29-05-2025 22.50] PA: 

[29-05-2025 22:53] PA: Upokar oshud ta na paye nicher ta nilam thik aache to

[29-05-2025 22:53] PA: Uporar

[30-05-2025 09:37] PPM 1: Uporer oshudh ta ki sheta dekha jacchena

[30-05-2025 09:47] PA: Ota tamsulosin

[30-05-2025 10:14] PPM 1: Nicher ta ki tamsulosin noi?

[30-05-2025 10:17] PA: Yes otao tamsulosin

[30-05-2025 11:11] PPM 1: Ebar dekhun dutor dose ta aeki kina. 0.4 mg

[30-05-2025 11:40] PA: Yes dutor dose aeki

[07-06-2025 01:03] PA: Babar pa ta kisu din dhore ektu fulche...

[07-06-2025 07:01] PPM 1: Chobi share korun

[07-06-2025 11:10] PA: Dakther Babu Nomoskar  Osud khachay thao Fula ta kano Komchay Na

[07-06-2025 12:01] PPM 1: Folar jonye ki oshudh khacchen taar chobi pathan

[07-06-2025 12:38] PPM 1: 👆 uporer duto oshudh hi to aeki oshudh.

Kono tai pa fola to komar kotha noi!

[07-06-2025 12:46] PA: Eta to 1 mas cholechilo... But babar to pa ta r prostate ta ektu fulechilo jonno abar eta khte bolechilen.. but ekhon pa ta aro fulche.....

[07-06-2025 12:49] PA: Sir message a thikthak conversation ta hocche na .... Apni ektu time pele call ba vc korle khub valo hoy....

[07-06-2025 12:51] PPM 1: Pa folar jonye tablet lasix ta abar shuru kora jete pare 40 mg in the morning 8:00 AM

And 20 mg in the afternoon 1:00PM

[07-06-2025 12:51] PA: Okay..

[07-06-2025 12:51] PA: R prostate er ta ki cholbe...?

[07-06-2025 12:52] PA: Kalk bollo ektu fuleche ?

[07-06-2025 12:57] PPM 1: Ota dutoi khacchen naki ekta?

[07-06-2025 13:00] PA: Rate ekta kore...