15-05-2025
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.
[15-05-2025 16.46] PPM 1: Afternoon session
56 year old male Known diabetic with Hbsag positive status on OHA since 3 years
CKD stage 4
TB defaulter 1 year back used antitubercular therapy for 2 months in October 2024(radiological confirmed TB) and then stopped.
Has h/o fever since 8 months associated with chills and rigors along with multiple episodes of giddiness, inability to talk and swallow for 2-3 hours every week and if he tries to stand and walk during those times he falls!
H/o burning micturition since 8 months
Cough with expectoration
H/o fall almost 4-5 times in the past 8 months.
With incidental finding of left upper pole of kidney showing an exophytic mass.
Cue showing plenty pus cells bacteria and fungal elements seen and was not Cathterised.
TLC -26k HB -7.5
Chest X-ray, HRCT lung findings and abdominal renal incidentaloma findings attached
Also very interestingly two trunat reports, yesterday negative and today positive attached.
[16-05-2025 16.01] PPM 3: ### Comprehensive Clinical Analysis & Management Plan for 56M with Complex Multisystem Issues
#### *Patient Overview*
A 56-year-old male with *type 2 diabetes (2018), **chronic hepatitis B (HBsAg+), **CKD stage 4, and **defaulted TB treatment* (2 months in 2024) presents with an 8-month history of recurrent fever, vertigo, dysphagia, dysarthria, falls, burning micturition, cough, and leukocytosis. Incidental findings include a left renal exophytic mass, pyuria with bacteria/fungal elements, anemia (Hb 7.5), and fluctuating Trunat results.
---
### *Key Clinical Issues & Differential Diagnoses*
1. *Infectious Complications*
- *TB Reactivation/Resistance*: Defaulted TB treatment increases risk of drug-resistant TB. Fluctuating Trunat results (positive/negative) may reflect low bacillary load or testing variability. Chest imaging (HRCT) is critical to assess pulmonary involvement .
- *Fungal/Bacterial UTI*: Pyuria with fungal elements suggests candiduria or aspergillosis, common in immunocompromised states (diabetes, CKD). Requires urine culture and antifungal therapy (e.g., fluconazole) .
- *Sepsis*: Persistent fever, leukocytosis (TLC 26k), and rigors indicate systemic infection. Blood cultures and broad-spectrum antibiotics (e.g., piperacillin-tazobactam) are urgent.
2. *Renal Pathology*
- *Renal Mass: Exophytic lesion differentials include **renal cell carcinoma* (risk in CKD) vs. *abscess* (given infection history). Imaging (CT/MRI) and biopsy are needed.
- *CKD Stage 4 Management*: Optimize electrolytes, anemia (iron studies, erythropoietin), and nephrology referral for possible dialysis planning .
3. *Neurological Symptoms*
- *Vertigo & Falls: Linked to **Ménière’s disease* (associated with hypothyroidism ) or *diabetic vestibular neuropathy*. Vestibular testing and thyroid function (TSH, T3/T4) are essential.
- *Dysarthria/Dysphagia: Consider **TIAs* (due to diabetes/CKD-related vasculopathy) or *metabolic encephalopathy* (uremia). MRI brain and neurology consult advised.
4. *Metabolic & Endocrine Factors*
- *Diabetes Complications*: Hypoglycemia/hyperglycemia-induced dizziness . Review OHA regimen (e.g., avoid sulfonylureas in CKD) and switch to safer agents (DPP-4 inhibitors) .
- *Hypothyroidism*: Uncontrolled disease exacerbates vestibular symptoms. Confirm hormone levels and adjust levothyroxine .
5. *Hepatitis B & Liver Health*
- Monitor HBV DNA, LFTs, and screen for HCC (abdominal ultrasound). Antivirals (e.g., tenofovir) may be needed if viral load is high .
---
### *Action Plan*
1. *Immediate Interventions*
- *Infection Control*:
- Start empiric antibiotics (covering TB, bacterial/fungal UTIs) pending cultures.
- Repeat Trunat, GeneXpert, and AFB cultures for TB confirmation.
- *Renal Mass Workup*: CT abdomen with contrast ± biopsy.
- *Neurological Evaluation*: MRI brain, carotid Doppler, and vestibular testing.
2. *Long-Term Management*
- *Diabetes*: Transition to CKD-safe OHAs (e.g., linagliptin). Monitor HbA1c and avoid metformin . - *Thyroid Function*: Optimize levothyroxine to TSH 1-2 mIU/L .
- *HBV*: Antiviral therapy if HBV DNA ≥20,000 IU/mL or elevated ALT .
- *CKD*: Manage anemia (iron/EPO), hyperphosphatemia, and refer for dialysis planning.
3. *Multidisciplinary Coordination*
- *Infectious Disease*: Rule out TB reactivation and fungal sepsis.
- *Nephrology/Urology*: Address renal mass and CKD complications.
- *Endocrinology*: Optimize diabetes/thyroid management.
- *Neurology*: Evaluate TIAs vs. metabolic causes of neurological symptoms.
---
### *Critical Considerations*
- *Falls Risk*: Implement safety measures (e.g., assistive devices, home modifications).
- *Drug Interactions*: Adjust antivirals (tenofovir) for CKD (eGFR <50 requires dose reduction) .
- *Psychosocial Support*: Address TB treatment adherence and mental health (depression common in chronic diseases).
*Next Steps*:
- Repeat imaging (HRCT chest, renal CT), cultures, and HBV/HIV serology.
- Thyroid panel, HbA1c, and fasting glucose.
- Neurology consult for transient neurological deficits.
This patient requires a holistic, coordinated approach to address overlapping infectious, metabolic, and structural pathologies. Close monitoring and frequent reassessment are crucial.
[16-05-2025 16.20] PPM 1: 👏👏the LLM is perhaps not able to see a lot of the data that was shared in images.
@PPM4 it would be very interesting to compare what proportion of the ongoing Web 3.0 inputs are actually utilised. Actually currently as it stands unless the human in the loop is well trained it will be very difficult to discern which information to use for actioning other than the fact that majority will be TLDRed.
However for some of us these are welcome Inputs as we can easily "sift the grain from the chaff" and retain whatever is useful but again if you ask me to specifically choose which ones it would be challenging and time consuming but it would be a good project on it's own especially for the upcoming book @PPM5 @PPM6
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