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.
**CASE REPORT: 69M WITH MULTIMORBIDITY AND ACUTE-ON-CHRONIC ORTHOPEDIC INJURY**
**INTRODUCTION**
This case involves a 69-year-old male with a complex medical background, including Congestive Cardiac Failure (CCF), Chronic Kidney Disease (CKD Stage 3/4), Type 2 Diabetes Mellitus (DM2), and Hypertension. The patient has a documented history of metabolic syndrome and chronic liver pathology. The clinical focus shifted recently following a fall, necessitating an evaluation of surgical fitness in the context of significant systemic frailty.
**METHODS**
Data was synthesized from longitudinal Remote Patient Monitoring (RPM) logs, historical clinical notes (dated 2019 and 2026), and recent diagnostic imaging. Radiographic analysis of the pelvis and hips was performed to assess acute injury, while historical lab values (Hb: 7, Creatinine: 3.63, Urea: 102) were reviewed to establish a physiological baseline.
**RESULTS**
🔹 **Primary Finding**: Imaging confirms a comminuted and significantly displaced fracture of the left femoral neck (Garden Type IV, Pauwels Type III).
🔹 **Cardiac Status**: Known systolic dysfunction, moderate Mitral Regurgitation (MR), enlarged atria, and pulmonary hypertension.
🔹 **Renal/Metabolic**: Baseline creatinine of 3.63 mg/dL suggests advanced CKD; Hb of 7 g/dL indicates significant chronic anemia.
🔹 **Historical Context**: A previous right trochanteric fracture (2019) was managed with internal fixation, indicating a pattern of bone fragility or recurrent falls.
**DISCUSSION**
The patient presents a high-stakes surgical challenge. The Garden Type IV fracture is inherently unstable and carries a high risk of avascular necrosis. However, the "cardio-renal-metabolic" triad (CCF, CKD, DM2) significantly elevates the Perioperative Mortality Risk. The presence of pulmonary hypertension and moderate pleural effusion further complicates anesthetic clearance. Management must balance the urgency of restoring mobility to prevent secondary complications (e.g., VTE, hypostatic pneumonia) against the high probability of perioperative decompensation.
**SOCRATIC QUESTIONS**
1. **What is the most critical physiological barrier to immediate surgical intervention?**
Given the Hb of 7 and Creatinine of 3.63, is the primary risk anesthetic-related cardiac arrest or acute-on-chronic renal failure post-contrast/stress?
2. **How does the historical right femur fracture influence the current surgical plan?**
Does the previous successful fixation suggest a resilient recovery profile, or does it highlight a progressive frailty syndrome that favors non-operative or palliative approaches?
3. **In the presence of moderate MR and Pulmonary HTN, what is the optimal fluid management strategy?**
How can we maintain adequate renal perfusion for the CKD without triggering an acute exacerbation of the CCF/Pleural effusion?
📋 **Case Title**: 69M Pedal edema abdominal distension CCF CKD DM2 Htn metabolic syn WB PaJR
[11-04-2025 09:51] PPM 1: @~PPM3 @~PPM4 @~PPM5 are on duty today and will look after this patient henceforth till discharge.
[23-05-2025 19.49] PA: 
[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 👇
[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 3.34millions/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 8.3-6.4gm/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: 👍
[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 👇
[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: 
[08-08-2025 10.54] PA: Doctor babu akhan pa fola r obostha arokom tahole ki ager oshodgulo aki vabe khabe
[3.12 pm, 30/03/2026] PPM 1: Reviewed the patient now after one yearhttps://youtube.com/shorts/pVdB-lDwnXY?si=MNsADFWimWXr12yW
[3.23 pm, 30/03/2026] PPM 1: Right sided pleural effusion detected two weeks back when he was hospitalized in Kolkata for shortness of breath. He recovered on diuretics and after coming home 10 days back he fell on his right side and broke his neck of femur.
https://youtu.be/rZvhVh0fp6I?si=jxtVD8xMOIKrLVod
[31/03, 08:06]hu2: Pleural fluid protein to serum protein appears to be 0.6
[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...
[08-07-2025 15.59] PA:
[08-07-2025 21:27] PA: Dakther Babu patient Ar paa Fula ta Komchay na Aktuk Dakhen Sudhu mon kharab koray ke kora jay Janaben
[08-07-2025 21:29] PPM 1: Regular ghontai ghontai janale aro bhalo bola jeto
Aekhon bortomane ki oshudh khacchen ektu chobi share korun ebong timing tao janaben
[09-07-2025 10.30] PA:
[09-07-2025 10:33] PPM 1: 👆@Researcher can you read what's written in point 3?
[09-07-2025 10:39] PA: Lasix half khai dupur 1 tai
[09-07-2025 10:48] PPM 1: Sokale one and a half kore dewa jete pare, Dupure one
[09-07-2025 11:07] Researcher: 1. Morning 8 an
2. Morning 10 am
3. Morning 8 am another one
4. Night at 10 pm
[09-07-2025 11:27] PPM 1: According to @PA it appears that point 3 is "Lasix half khai dupur 1 tai"
[09-07-2025 11:28] PA: Right
[17-07-2025 00:17] PA: Lasix 1.5 ta kore khaoar pore payer chobi ta pathalam. @Rakesh Biswas Sir dr. babu dekhun
[17-07-2025 07:19] PPM 1: Sokale 1.5 ebong ebong dupure 1 tai to?
[17-07-2025 16:04] PA: Yes
[17-07-2025 16:08] PPM 1: Sokaler ta 2 ebong dupurer ta 1.5 kora jete pare
[17-07-2025 16:09] PA: Ok
[26-07-2025 12.38] PA: Doctor babu pa er chobi ta pathalam akhan ki toba ager oshudh gulo akai vabe khete hobe
[26-07-2025 12:44] PPM 1: Aager oshudh bortomane ki khacchen chobi ebong time somet janaben
[26-07-2025 16:16] PA: 1, Morning 8 Lasix 2ta
2, Morning 10 Telma 20
3, dupur 1 ta Lasix1 .5
4.Night at 10 Tamsulosin 1 ta
[26-07-2025 16:19] PA: Bortomane sorir ta weak lage
[08-08-2025 14:19] PPM 1: Hain
Ekbar aager oshudh guno bortomane ki bhabe cholche chobi soho share kore janaben
[08-08-2025 16:29] PA: Evabei khacche
[08-08-2025 16:30] PA: 1, Morning 8 Lasix 2ta
2. Morning 10 Telma 20
3. dupur 1 ta Lasix1 .5
4. Night at 10 Tamsulosin 1 ta
[8.17 pm, 23/03/2026] PPM 1: Today's update
The patient has had a recent fracture neck of femur and may want to travel all the way to this hospital in Telangana for open reduction and internal fixation where his PaJR group had been created earlier last year 7/4/25
[8:19 pm, 23/03/2026] PPM 1: @PaJR Health can you share this patient's case report in an IMRAD format adding the Socratic questions below?
[9:08 pm, 27/03/2026] PA: Doctor babu amra kalk train a utbo. Vijayawad neme hospital a dhukbo Sunday 4am, apni ekta junior doctor k bole rakhben r ekta junior doctor er number dile valo hoy..
[9:10 pm, 27/03/2026] PA: Amar baba k kon ward admit korbo ?
[9:12 pm, 27/03/2026] PA: Special room ta pete gele ki korbo ??
[9:14 pm, 27/03/2026] PPM 1: @PPM3 any idea who's on duty on Saturday night tomorrow?
[11:55 am, 28/03/2026] PPM 4: Using 'team member' and 'ekjon' might be more appropriate @PPM1
[11:58 am, 28/03/2026] PPM 1: The hospital ambulance is supposed to pick him up today from Hyderabad and drop him here at 4:00 AM tomorrow
The team members today on duty are @PPM5 @PPM6 @PPM7 and tomorrow are @PPM8 @PPM9 @~PPM10
[12:01 pm, 28/03/2026] PPM 1: Not sure what the message was from @PPM3 as it got deleted before I could see
[12:02 pm, 28/03/2026] PPM 4: My comment was based on the PA's comment
[12:02 pm, 28/03/2026] PPM 3: I just messaging who was on duty turns out that was not the case, so I deleted it
[12:07 pm, 28/03/2026] PPM 1: @PPM3 is PG
[1:04 pm, 28/03/2026] PPM 4: @PPM3 is PGI understand.
My only point is we are all juniors in our learning journeys. A semantic disagreement with the 'junior' terminology which is commonly thrown around in the Indian health system.
[1:11 pm, 28/03/2026] PPM 1: Okay so I am guessing @PPM3 said something like "the junior" on duty is...etc
I agree. Wish we could get past these hierarchies in a team based learning ecosystem
[1:14 pm, 28/03/2026] PPM 4: I didn't see what PPM3 typed. I just saw what the patient advocate typed last night. And I understand it's a very common terminology used in the Indian healthcare system, but as seniors, we have the responsibility to correct the terminologies as much as possible.
[1:15 pm, 28/03/2026] PPM 1: 👆oh got it!
This is the text you were responding to.
Agree absolutely
[1:16 pm, 28/03/2026] PPM 4: Yes
[1:16 pm, 28/03/2026] PPM 1: It's very difficult to train patient relatives.
[1:18 pm, 28/03/2026] PPM 1: Sunday 4am, apni ekta junior doctor k bole rakhben r ekta junior doctor er number dile valo hoy..
Sunday 4:00 Senior doctor @PPM6 @PPM5 hospital a thakben ebong unader ekhane bola roilo
[1:20 pm, 28/03/2026] PPM 4: Absolutely sir. Totally agree. That's why I try to impress upon them that our team members are not seniors or juniors. There is one team leader ofcourse but the hierarchy is circular
[7:16 pm, 29/03/2026] PPM 1: Any idea if this patient reached today at 4:30 AM? @PPM5 @PPM6
[7:17 pm, 29/03/2026] PA: Sir amader train late ache...amar hyto 1 tay vijaywada te pouchabo..
[7:23 pm, 29/03/2026] PPM 6: They didn't sir
[7:50 pm, 29/03/2026] PPM 1: 24 hours late?
[7:50 pm, 29/03/2026] PPM 1: Who's on duty today?
[7:51 pm, 29/03/2026] PA: 4 hours sir
[8:14 pm, 29/03/2026] PPM 1: 👆Unar to aajke 4:00AM hospital a dhokar kotha chilo apni upore aage janiyechilen?
[8:15 pm, 29/03/2026] PA: Sir train late chilo.. 5am a pouche jabo...
[8:17 pm, 29/03/2026] PPM 1: Hain ami just aetai bolchilam je aajke 4:00 AM jodi ashar kotha hoye thake kintu kalke 4:00AM pahunchote hoi tahole 24 hours late hi hoito dhora jete pare
[8:19 pm, 29/03/2026] PA: Na na sir 4hours er moto late ache.. vijaywada te 1 tay pouche jabo..pore ambulance a 4 hours er moto lagbe..kalk sokale 5 tay pouche jabo...
[8:24 pm, 29/03/2026] PPM 1: 👆apni ekhane likhechen aajke 4:00AM dhuke jawar kotha
[8:25 pm, 29/03/2026] PA: Sorry Sir dekhi nai eta... Monday asbo...
[8:42 pm, 29/03/2026] PPM 1: @PPM11 this patient may arrive early morning today
[8:47 pm, 29/03/2026] PA: Sir baba k ki imargency te Admit korabo ?
[8:51 pm, 29/03/2026] PPM 1: Hain Casualty theke ward a transfer kore dewa habe
[8:51 pm, 29/03/2026] PA: Okay sir..
[9:27 pm, 29/03/2026] PPM 11: ok sir
[5:12 am, 30/03/2026] PA: Doctor babu amar pouche gechi..baba k general ward a admit korlam..
[7:22 am, 30/03/2026] PPM 1: Aajke OPD te dekha habe 10:00 AM
[7:23 am, 30/03/2026] PPM 1: Send him to Orthopedic OPD and Medicine OPD for further planning in the morning today
[8:37 am, 30/03/2026] PA: Dakther Babu Madechen word A Vorthi Achay Aponi Aktuk Dakben patient Ar Obosta
[8:41 am, 30/03/2026] PPM 1: Spoke to Prof in the bus
He'll evaluate in Orthopedics OPD and I shall evaluate him in Medicine OPD. Send him to Orthopedic OPD first.
@Meta AI translate the above to Bengali
[8:41 am, 30/03/2026] Meta AI: ঠিক আছে স্যার 😐 বাসে প্রফেসর অনিলের সাথে কথা বলেছি তিনি অর্থোপেডিকস OPD-তে মূল্যায়ন করবেন এবং আমি মেডিসিন OPD-তে তাঁর মূল্যায়ন করব। তাকে প্রথমে অর্থোপেডিক OPD-তে পাঠান।
[12:35 pm, 30/03/2026] PA: Doctor babu baba k dekhte ascho tokhon baba potty korchilo to orthopedic er test gulo suru hoy nai...
If we compare his nutritional status in the current group DP from one year back and the current nutritional image here now, he appears to be severely malnourished
[3:17 pm, 30/03/2026] PPM 1: Raised JVP but what is captured here by tge camera is perhaps the accessory muscles of respiration
[3:18 pm, 30/03/2026] PPM 1: The apex beat is RV dominant with parasternal heave
[3.23 pm, 30/03/2026] PPM 1: Right sided pleural effusion detected two weeks back when he was hospitalized in Kolkata for shortness of breath. He recovered on diuretics and after coming home 10 days back he fell on his right side and broke his neck of femur.
Looking at his left abdomen he also appears to be suspicious for a left diaphragmatic palsy and @PPM12 is currently doing an ultrasound for the diaphragm and also repeating his pleural tap
https://youtu.be/o0FjrVG63pM?si=V6p0aKVkutg40ah_https://youtu.be/rZvhVh0fp6I?si=jxtVD8xMOIKrLVod
[9:04 pm, 30/03/2026] PPM 1: [30/03, 16:20]hu2: The EF appears to have reduced in comparison to the previous echo archived in the case report although slightly and there's the large pleural effusion still visible behind the heart, which you would need to tap now under ultrasound guidance and send for TLC, DLC of pleural fluid with protein, LDH along with serum protein and LDH at the same time
Also check the diaphragmatic movement on ultrasound
[30/03, 16:25]hu1: yes
[30/03, 20:40]hu1: we have removed approximately 700ml
[30/03, 20:55]hu2:
Looks like hemorrhagic effusion
Please also send the hb and PCV of the pleural fluid and blood to rule out hemothorax. If pcv of pleural fluid is more than 50 then it's hemothorax and he'll need an ICT.
Also send the pleural fluid and serum protein and LDH along with TLC and DLC of the pleural fluid.
Let's plan for an HRCT now or tomorrow.
Also share the ultrasound video for diaphragmatic movement whenever possible.
[9:19 pm, 30/03/2026] PPM 1: [30/03, 20:59]hu1: will pcv and hb of pleural fluid be done in our lab?
[30/03, 21:00]hu2: Yes why not?
Otherwise how will we differentiate between hemothorax and hemorrhagic effusion
[30/03, 21:12]hu1: I talked to pathology pgs, they said pcv and hb of pleural fluid will not be done
[30/03, 21:13]hu2: Ask them why not
[30/03, 21:16]hu2: Tell them it's important to decide if he will need ICD placement or not
[30/03, 21:46]hu1: cell count
predominantly neutrophils
total count -1050 cells
dc- 100% neutrophils
[30/03, 22:09]hu2: What about RBCs?
Did they correct for the number of RBCs and reduce the WBCs accordingly?
[30/03, 21:51]hu1: Should we administer foleys for the pt
[30/03, 22:00]hu2: Why?
Isn't he passing urine through bed bottle?
[30/03, 22:05]hu1: It is getting difficult for him
[30/03, 22:09]hu2: Why?
[30/03, 22:10]hu2: Has he obtained a urine bottle for passing urine?
No foleys necessary. If at all, condom catheter can be administered
[30/03, 22:13]hu1: 10-15rbcs / hpf sir on wetmount
[31/03, 08:00]hu2: The pleural fluid serum LDH ratio appears to be 0.77 which is suggestive of exudate
Let's also look at the serum protein
Let's get his HRCT chest and diaphragmatic movement ultrasound today.
Latest X ray sir after tap
[31/03, 08:06]hu2: Pleural fluid protein to serum protein appears to be 0.6
[31/03, 08:08]hu2: Serum albumin is very low. Is that malnutrition, liver disease, losing proteins through urine (let's do a 24 hour urine for protein and creatinine) or a negative acute phase reactant?
Today's plan @PPM13, @PPM8@PPM14
HRCT chest
Share the deidentified images here and depending on the findings:
Pulmonology opinion for fibre optic bronchoscopy if necessary
Diaphragmatic movement assessment ultrasound or even fluoroscopy. Please discuss this with the radiologists.
Orthopedic evaluation also to consider the possibility of a pathological fracture
[12:03 pm, 31/03/2026] PPM 1: The fact that he has been having rapid refilling of his pleural effusion may also point toward something sinister that we expect to unearth with the HRCT lung today
[2:36 pm, 31/03/2026] PPM 1: Thanks.
Nothing remarkable.
Lets get the chest opinion for possible tube placement
@PaJR Health what are the criteria for intercostal tube placement including pleural fluid pH and recurrent filling up and which one does this patient fit into?
[2:37 pm, 31/03/2026] PaJR Health: Got it. Here are the general criteria for chest tube placement for a pleural effusion, followed by how this patient fits.
*GENERAL CRITERIA FOR INTERCOSTAL DRAINAGE*
1. *Large, Symptomatic Effusion:* Any large effusion causing significant dyspnea or respiratory distress.
2. *Complicated Parapneumonic Effusion/Empyema:*
* *Pleural Fluid pH < 7.20:* This is a strong indicator for drainage.
* *Pleural Fluid Glucose < 60 mg/dL.*
* *Positive Gram Stain or Culture:* Indicates infection.
* *Loculated Effusion:* Suggests organization and requires drainage.
3. *Malignant Effusion:* For symptomatic relief, especially if recurrent.
4. *Hemothorax:* To drain blood and prevent fibrothorax.
5. *Post-Operative or Traumatic Effusions.*
*THIS PATIENT'S SITUATION*
Based on the records, this patient meets the following criteria for chest tube placement:
* *Recurrent, Rapid Filling:* The primary driver here. The log from 12:03 PM today explicitly notes "rapid refilling" after the last thoracentesis. This alone is a strong indication for a more definitive drainage solution like an indwelling catheter to manage symptoms and prevent respiratory compromise from re-accumulation.
* *Massive, Symptomatic Effusion:* The latest chest X-ray and HRCT confirm a massive left-sided effusion with a significant mediastinal shift. This is a life-threatening condition causing severe compression of the lung and heart, demanding immediate and effective drainage.
* *Exudative Nature:* The pleural fluid analysis confirms an exudate (Protein 3.4 g/dL, LDH ratio 0.77), which is more likely to be associated with underlying pathology that benefits from drainage.
We don't have a pleural fluid pH value in the current labs, but given the rapid re-accumulation and the sheer size causing hemodynamic compromise, the indication is already clear.
Today's update
Continuation of the above case report available in the below link. 👇
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