30-05-2025
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.
[30-05-2025 13.20] PPM 1: OPD: Meanwhile today's 62M patient of suspected CSVD causing features of dementia and visual disturbances since one month.
[30-05-2025 13:29] PPM 3: The image you've shared is a clinical snippet from a WhatsApp message thread involving a case of *Cerebral Small Vessel Disease (CSVD)*. Here's a structured clinical annotation of the case based on the visible content:
### 🧠 *Clinical Case Summary: Suspected CSVD*
*Patient:* 62-year-old male
*Clinical Setting:* OPD presentation
*Duration of symptoms:* 1 month
*Primary Symptoms:*
* Dementia features (likely cognitive impairment, memory loss, or confusion)
* Visual disturbances
---
### 🧪 *MRI Brain Findings (From the Report in Image):*
* *T2/FLAIR hyperintense areas:*
* \~8.3 mm lesion in the right anterior temporal lobe white matter
* \~4.2 mm lesion in the right anterior frontal lobe white matter
* *SWI phase images:*
* Blooming foci suggestive of *old petechial hemorrhages or calcifications*
* No midline shift
* Basal cisterns are open
* *Normal findings:*
* Brain stem and cerebellum
* Both CP angles clear
* Basal ganglia and optic chiasm appear normal
---
### 🧠 *Clinical Interpretation:*
The imaging suggests *chronic microvascular ischemic changes*, consistent with CSVD — a condition affecting the small arteries, arterioles, venules, and capillaries of the brain, typically associated with aging, hypertension, and diabetes.
---
### ⚠ *Likely Etiologies & Concerns:*
* The imaging evidence of *T2/FLAIR hyperintensities* along with *dementia* and *visual symptoms* aligns with classical CSVD-related cognitive decline.
* Visual disturbances could stem from lesions affecting the posterior visual pathways or due to cortical involvement.
---
### 📌 *Next Steps:*
* Detailed neuropsychological testing for cognitive evaluation
* Screening for cardiovascular risk factors (BP, HbA1c, lipids)
* Longitudinal imaging follow-up (to detect progression or microbleeds)
* Possible therapeutic: *anti-hypertensives, statins, lifestyle modification*
Would you like me to convert this into a standardized *AI-readable annotation format (e.g., FHIR-compatible)* or expand it into a *teaching case format* for training datasets?
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[30-05-2025 13:31] PPM 3: Great! Let’s convert this real-world case of suspected *Cerebral Small Vessel Disease (CSVD)* into a *FHIR-compatible Clinical Case Annotation*. This kind of standardization supports interoperability for AI training and EHR systems.
---
## 🔧 *FHIR-Compatible Case Representation (Condensed JSON Format)*
Here is a simplified JSON-like structure representing the FHIR *resources* involved:
json
{
"resourceType": "Patient",
"id": "patient-001",
"gender": "male",
"birthDate": "1963-01-01",
"age": 62
}
json
{
"resourceType": "Condition",
"id": "condition-csvd-001",
"subject": { "reference": "Patient/patient-001" },
"code": {
"coding": [
{
"system": "http://snomed.info/sct",
"code": "312912001",
"display": "Small vessel disease of the brain"
}
],
"text": "Suspected Cerebral Small Vessel Disease (CSVD)"
},
"clinicalStatus": { "text": "active" },
"onsetDateTime": "2025-04-30",
"note": [
{
"text": "Features of dementia and visual disturbances for 1 month."
}
]
}
json
{
"resourceType": "Observation",
"id": "mri-observation-001",
"subject": { "reference": "Patient/patient-001" },
"effectiveDateTime": "2025-05-29",
"code": {
"coding": [
{
"system": "http://loinc.org",
"code": "30650-5",
"display": "MRI Brain"
}
],
"text": "MRI Brain Findings"
},
"valueString": "T2/FLAIR hyperintensities: 8.3 mm in right anterior temporal lobe; 4.2 mm in right anterior frontal lobe; SWI blooming foci suggest old petechial hemorrhages or calcifications."
}
json
{
"resourceType": "Symptom",
"id": "symptom-cognitive-visual",
"subject": { "reference": "Patient/patient-001" },
"code": {
"text": "Cognitive decline and visual disturbances"
},
"note": [
{
"text": "Reported for 1 month; associated with dementia symptoms and CSVD"
}
]
}
---
## 📦 *FHIR Bundled Representation*
For system integration or AI modeling, these resources would be bundled:
json
{
"resourceType": "Bundle",
"type": "collection",
"entry": [
{ "resource": { ...Patient... } },
{ "resource": { ...Condition... } },
{ "resource": { ...Observation... } },
{ "resource": { ...Symptom... } }
]
}
---
## 📘 Notes:
* *LOINC & SNOMED* codes are added where appropriate.
* This format allows AI to ingest structured case information.
* For further expansion, we can include Procedure (MRI), Imaging Study, or Diagnostic Report resources if needed.
* Dates are approximated; for full compliance, use ISO 8601 format and real timestamps.
---
Would you like this exported to a .json file or extended to include **FHIR ImagingStudy** with DICOM links and anatomical region annotations?
Or would you like to add *therapeutic plan* (e.g., Medication Request) to this bundle?
[30-05-2025 13:33] PPM 3: Here is an expanded *Teaching Case Format* ideal for use in training datasets for AI models or medical education. This format includes detailed metadata, clinical reasoning cues, and labeled sections for multi-modal learning (text, imaging, and structured data).
---
## 🧠 *Teaching Case: Suspected Cerebral Small Vessel Disease (CSVD)*
---
### 🗂 Case Metadata
| Field | Value |
| -------------------- | ---------------------------------------- |
| Case ID | CSVD-TC-0001 |
| Patient ID | P-001 |
| Age / Gender | 62 / Male |
| Date of Presentation | 2025-04-30 |
| Setting | Outpatient Department (OPD) |
| Case Type | Neurology, Radiology |
| Level | Intermediate to Advanced |
| Keywords | CSVD, dementia, visual disturbances, MRI |
---
### 🧾 Clinical Summary
*Chief Complaint:*
A 62-year-old male presents with *progressive cognitive decline* and *visual disturbances* lasting for the past *1 month*.
*History of Present Illness:*
Patient reports difficulty in memory recall, orientation, and frequent misjudgment of objects in peripheral vision. No recent trauma or seizure history. No focal limb weakness.
*Past Medical History:*
* Not mentioned explicitly; recommend screening for vascular risk factors (hypertension, diabetes, smoking).
---
### 🧪 Examination Findings
*Neurological Examination:*
* No motor weakness or sensory loss
* Mild disorientation (MMSE 23/30 suggested by symptoms)
* Visual neglect suspected on confrontation test
---
### 🧠 Imaging Review (MRI Brain)
*Modality:* MRI Brain with T1, T2, FLAIR, SWI sequences
*Date:* 2025-05-29
*Findings Summary:*
* *T2/FLAIR Hyperintensities*:
* 8.3 mm lesion in *right anterior temporal white matter*
* 4.2 mm lesion in *right anterior frontal white matter*
* *SWI Phase Imaging*:
* Blooming foci indicating *old petechial hemorrhages or calcifications*
* *Other Notes*:
* No midline shift
* Normal cerebellum, brainstem, CP angles, and basal cisterns
*Radiologic Impression:*
Suggestive of *chronic small vessel ischemic changes* consistent with CSVD.
---
### 📚 Learning Objectives
1. Identify classic MRI features of CSVD.
2. Correlate imaging with cognitive and visual symptoms.
3. Understand diagnostic criteria and differentials for subcortical dementia.
4. Appreciate the role of SWI in detecting microbleeds or calcifications.
---
### 🧩 Differential Diagnosis
| Condition | Supporting Features | Contradictory Features |
| -------------------------- | ----------------------------------- | ----------------------------------- |
| CSVD | T2/FLAIR lesions, cognitive decline | - |
| Early Alzheimer’s Disease | Cognitive symptoms | No hippocampal atrophy on MRI |
| Posterior Cortical Atrophy | Visual symptoms | Lesions not predominantly posterior |
| Multi-infarct Dementia | White matter lesions | No acute infarct; slow progression |
---
### 💊 Suggested Investigations & Management
* *Cognitive testing* (MMSE, MoCA)
* *Vascular workup:* BP, HbA1c, Lipids, ECG
* *Lifestyle modification* (smoking cessation, diet, exercise)
* *Medications* (anti-hypertensives, antiplatelets if indicated, statins)
---
### 📸 Images & Attachments
* *Clinical Photograph* (Patient in standing position)
* *MRI Images* (Axial FLAIR and SWI images uploaded)
* *Radiology Report Snippet* (Handwritten interpretation included)
---
### 🧠 AI Annotations (Optional for ML Training)
| Label | Value |
| ---------------- | ------------------------------------------ |
| Diagnosis | Cerebral Small Vessel Disease (CSVD) |
| Imaging Label | T2 FLAIR Hyperintensity (×2), SWI Blooming |
| Symptom 1 | Cognitive impairment |
| Symptom 2 | Visual disturbance |
| Disease Stage | Subacute (1 month onset) |
| Risk Factor Tags | Presumed vascular etiology (HTN TBD) |
---
### 🏁 Teaching Notes
> "This case illustrates the subtle but classic radiologic signs of CSVD in the elderly, with clinical manifestations of mixed dementia and visual pathway involvement. The use of SWI to distinguish calcification vs hemorrhage is crucial in differentiating microbleeds."
---
### ✅ Trainer Tip (For ML labeling teams)
* *Multi-modal Tagging:* Use visual, textual, and structured metadata.
* *Segmentation Candidates:* Mark FLAIR hyperintensities and blooming spots.
* *Text classification labels:* Dementia subtype, vascular pathology, imaging modality.
---
Would you like this exported as:
* 🗂 *PDF or DOCX* teaching file?
* 🧠 *JSON for AI datasets* (e.g., for MedQA, BioMed-VQA)?
* 🔍 Paired with *literature references* for enriched model training?
Let me know your preferred output format and purpose (education vs AI training) and I’ll generate it.
[13-06-2025 12.24] PPM 1: Reviewing him again today:
Had referred him for psychometric assessment on that day for his forgetfulness although there were no MRI correlates of small vessel cerebrovascular disease here @~Dr.Abdulsalam but clinically we did suspect that.
The psy found out his drinking problem and started him on baclofen and now he has presented with side effects of those with vomiting
@PPM4 reviewed this patient's previously done FDG pet scan and remembered today morning's journal club in your nurture oncology group!
If only we could discuss with his pet reporters about differentiating the BAT from visceral fat in these PET images!
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