PaJR Case Reports: 44F Lateral Epicondylolagia, Diabetes 3 yrs Corneal Dystrophy Partial Keratoplasty NUD CCF WB PaJR

CONTINUATION OF THE CASE REPORT OF THE PATIENT 44F DIABETES, NUD, CCF FROM WEST BENGAL, FROM THE PREVIOUS CASE REPORT LINK BELOW 👇

https://pajrcasereporter.blogspot.com/2024/12/44f-diabetes-nud-ccf-wb-pajr.html

[16-06-2025] PPM 1: 1) Yes it would be important to highlight our engagement with the patient directly and highlight her inputs if not get her as co-author considering her privacy issues perhaps although I had invited her to be the author and shown her the first draft and she expressed fear that after we publish this finally we may all stop provide our regular PaJR service to her which was currently benefit her daily. I reassured her we will continue this unconditional service for all our patients life long.

Following are the pm transcripts of my conversation with her

[09/06, 17:34] Patient Advocate Diabetes 44F WB:
Sir, I have nothing much to say. You all have observed my day-to-day reports so well, and the way you've explained everything using AI tools and the cable system is wonderful… I really have nothing more to say. I’m extremely happy thinking that currently, my BP medicine is stopped (though in the past, it was stopped 3 times for around 3 months). And the dose of my diabetes medicine has also reduced. My lifestyle has changed a bit, and I’m truly happy. Yes, it’s true that I still have many problems and may continue to have them, but at least I’m not bedridden.

Even though it's just a little, I can now do my own work, I’ve gained confidence, and I’ve gotten back a much better life. I’m really grateful to you and your team members, and also to my daughter.

[09/06, 17:34] Patient Advocate Diabetes 44F WB:
But what will happen if this report gets published in a journal?

[09/06, 17:38] Patient Advocate Diabetes 44F WB:
For people like me who are suffering, and for the way you are using proper technical tools and evidence-based treatment — will this open up new avenues? I mean, will it lead to developments in the field of medical treatment for students?

[09/06, 17:42] Patient Advocate Diabetes 44F WB:
I have one question… After this report gets published in a journal, will you no longer see me if I face any problems? Will my treatment stop here? But I’m not completely cured yet. Even now, if I eat a bit too much or eat late, I get stomach pain, my sugar level rises — then what will happen?

[09/06, 17:46] Patient Advocate Diabetes 44F WB:
One thing I’ve noticed — people only think about changing themselves when they’re pushed too hard, or they don’t follow the guidance you give, like updating daily activities with photos. I don’t understand why.

[09/06, 19:39] cm:
No, no — we will take care of you lifelong, and also continue supporting all the others who are joining our PaJR group daily.

We want to publish your and everyone else’s case reports so that the rest of the world gets to know about this, and we can find answers to the many questions about your and others' conditions that are still unanswered. In a way, these case reports are already being shared through blogs, but if they get published in a journal, this movement can spread further in the scientific community, so that others like us can use this method to support many more patients.

[09/06, 20:52] Patient Advocate Diabetes 44F WB:
Okay, I feel a little more at ease now.

Truly golden inputs @PPM8 and @PPM9. Never have we seen such a rich perspective from the patient about the use of PaJR and AI by them.

[20/06, 06:49] PPM 8: Good morning sir, PPM9 and I spoke to the patient yesterday, and these were the answers we got from her:

[20/06, 06:50] PPM 8: The statement "Patient's weight decreased" could be elaborate upon -
1. Was the weight loss intentional?
from December to June she has followed recommended diet and muscle strengthening exercises which makes her believe what made her lose her weight
2. Was it clinically significant?
She has lost more than 8kgs in 6 months (clinically significant(?))
3. Were there any active efforts to lose the weight?
Yes, she changed and tried to adhere to the recommended diet plan and performed strength training exercises
Regarding alopecia-
She faced increased hair loss from December to April which she thinks could be due to the frequent antibiotics she was consuming during that time
What interventions through PaJR made a measurable impact?
1. She is able to be in constant contact with Doctors
2. She feels that she is being monitored very closely which helps her adhere to a good lifestyle
3. It gives her mental strength and a sense of hope that she is not alone and that she will be able to overcome her health problems.
4. She is able to pinpoint what food intake is affecting her blood glucose levels which she learnt to do because of the group.
5. Sharing her hourly activity made her understand how her blood sugar levels were thought out the day and she could correlate her energy levels
6. The group provides her with accountability especially which regard to food intake.
7. She feels seen and heard
8. It gives her motivation to make innovative healthy food for herself.
9. She's able to ask and update about her symptoms in the group everyday which she wouldn't have been able to if not because of the group
10. Her being a member of other patients group also helps her feel less alone
11. She has been more conscious about outside food and is able to identify what is good for her to consume.
12. She is deeply grateful that she is able to get better without much medication and without getting expensive tests which was the case before which would not result in any improvement.
Were there any areas where the platform did not aid in relief?
At some very few instances she did not get satisfying answers or solutions to her problems
eg- why is she having recurring eye problems?
why is she not able to straighten her arm even though she did what she was told to.
Use of AI by the patient
She uses AI once every 2-3 days when she tries out a new food recipe and doesn't know the amount of calories, protein and fat content in it.
What keeps her so motivated to update everything in the group?
She feels accountable and empowered when she does, it's completely because of her internal interest as she understands how much the group helps her on a daily basis.

[21-06-2025 22:03] PA: Feeling dizziness, neck and arm pain, can't fold hand, sweating, breathing shortness from this evening.

[21-06-2025 22:03] PA: BP monitor is not working properly that's why she measured in medical shop. BP was 125 by 85 and heart rate 122. From last 3 months patient did not take any BP medicine.

[21-06-2025 22.28] PA: BP 93/56, P 96

[21-06-2025 23:52] PA: 124/85 BP -at the time of 9 pm.when she feels uneasiness nd too much weakness with sweating nd breathing shortness ,nd neck pain.it continues almost half n hour .after that she lays down on the bed.

[21-06-2025 23:58] PA: After 1.5 hours she repeatedly checked her BP nd it was 93/56 nd heart rate was 96 . That time she feels better than before.

[22-06-2025 06:34] PPM 1: Sounds like anxiety symptoms

[22-06-2025 06:51]PA: Fasting blood sugar levels is 120

[22-06-2025 07:25] PA: Morning tea and soaked chana

[22-06-2025 10:37] PPM 1: 👍

[22-06-2025 10:43] PA: The image shows a cup of tea and a bowl of chickpeas on a metal tray. The cup is filled with a reddish-brown liquid, likely tea, and has a handle on the left side. The bowl contains several chickpeas, some of which have sprouted. The tray is placed on a pink cloth with a floral pattern.

Key Elements:

- Cup of tea

- Bowl of chickpeas

- Metal tray

- Pink cloth with floral pattern

Relevant Details:

- The tea appears to be brewed from the chickpeas or another ingredient.

- The chickpeas are sprouted, indicating they have been soaked in water.

- The metal tray and cup suggest a traditional or cultural setting.

Conclusion:

The image depicts a simple yet meaningful scene, possibly related to a traditional practice or cultural ritual involving tea and chickpeas.

[22-06-2025 10:43] PA: Pl measure protein, fat and carb

[22-06-2025 10:43] PA: To provide an accurate measurement of protein, fat, and carbohydrates in the chickpeas and tea, I'll need to make some assumptions based on average values for these ingredients.

Chickpeas (100g serving):

- Protein: 19g

- Fat: 6g

- Carbohydrates: 61g

Tea (1 cup, brewed):

- Protein: negligible

- Fat: negligible

- Carbohydrates: 0-2g (depending on sweetener or cream added)

Total (approximate):

- Protein: 19g (from chickpeas)

- Fat: 6g (from chickpeas)

- Carbohydrates: 61-63g (from chickpeas and tea)

Please note that these values are approximate and may vary depending on specific ingredients, portion sizes, and preparation methods.

[22-06-2025 10:43]PA: The image shows a plate of food with a salad and what appears to be a type of flatbread or pancake. The flatbread is light brown and has holes in it, with some orange and green toppings. The salad consists of diced tomatoes, cucumbers, and lettuce.

To estimate the nutritional content of this meal, we can make some assumptions based on average values for these ingredients.

Flatbread (100g serving):

- Protein: 10-15g

- Fat: 2-3g

- Carbohydrates: 40-50g

Salad (100g serving):

- Protein: 2-3g

- Fat: 0-1g

- Carbohydrates: 5-7g

Total (approximate):

- Protein: 12-18g

- Fat: 2-4g

- Carbohydrates: 45-57g

Please note that these values are approximate and may vary depending on specific ingredients, portion sizes, and preparation methods.

[22-06-2025 10:43] PA: There r rice atta, chattu, besan little amount of grated carrots,salt nd little bit oil. Salad -tomato , cucumber nd little amount of salt

[22-06-2025 10:43] PA: With the ingredients you provided, here's an updated estimate of the nutritional content:

Flatbread (made with rice atta, chattu, besan, grated carrots, salt, and little oil):

- Protein: 10-12g (from besan, chattu, and rice atta)

- Fat: 2-3g (from oil and besan)

- Carbohydrates: 40-50g (from rice atta, chattu, and besan)

Salad (tomato, cucumber, and little salt):

- Protein: 1-2g (from tomato and cucumber)

- Fat: negligible

- Carbohydrates: 5-7g (from tomato and cucumber)

Total (approximate):

- Protein: 11-14g

- Fat: 2-3g

- Carbohydrates: 45-57g

Please note that these values are still approximate and may vary depending on specific ingredient quantities and preparation methods.

[22-06-2025 14:38] PPM 5: Brilliant! Very nice use of AI to know what calories the patient is planning to take in.

[22-06-2025 14:40] PA: The image shows a traditional Indian thali, which is a balanced meal consisting of various dishes. Here's a breakdown of the nutritional value of each component:

1. White Rice: Carbohydrates, fiber, and some B vitamins.

2. Yellow Dal (Lentil Soup): Protein, fiber, vitamins, and minerals like iron, potassium, and zinc.

3. Red Chutney or Pickle: Antioxidants, vitamins, and minerals from the ingredients used (e.g., tomatoes, chilies, garlic).

4. Vegetable Dish: Vitamins A and C, potassium, and fiber from the green beans, carrots, and other vegetables.

5. Dark Brown or Black Dish: Possibly a leafy green vegetable or legume-based dish, providing vitamins A and K, iron, and fiber.

This meal offers a good mix of:

- Carbohydrates (rice, dal)

- Protein (dal, possibly from the dark brown dish)

- Fiber (dal, vegetables, whole grains)

- Vitamins (A, C, K, B vitamins)

- Minerals (iron, potassium, zinc)

Keep in mind that the exact nutritional value depends on specific ingredients, portion sizes, and cooking methods.

[22-06-2025 14:40] PA: The image shows a traditional Indian thali with various dishes. Here's an approximate measurement breakdown:

1. White Rice: 1/2 cup to 3/4 cup (100-150g)

2. Yellow Dal (Lentil Soup): 1/2 cup to 3/4 cup (100-150g)

3. Red Chutney or Pickle: 1-2 tablespoons (15-30g)

4. Vegetable Dish: 1/2 cup to 3/4 cup (100-150g)

5. Dark Brown or Black Dish: 1/4 cup to 1/2 cup (50-100g)

Note: Measurements are approximate and may vary based on individual serving sizes and preferences.

[22-06-2025 14:44] PPM 5: Do capture any emotional ups and downs if possible. Was there anything that may have caused the anxiety?

Do note that in case of any fast change in symptoms or if you feel worried, always consult local doctor immediately.

[22-06-2025 17:03] PA: Tiffin plate....some fruits, boiled chana and (aparita) blue tea

[22-06-2025 18:09] PA: How much is this plate related with my blood sugar

[22-06-2025 18:09] PA: The plate contains Chola (chickpeas), Kala Jamun (black jamun), Guava, and Blue Tea. Let's analyze how each food item might affect your blood sugar levels:

1. Chola (Chickpeas):

- Chickpeas have a low glycemic index (GI), which means they may help regulate blood sugar levels.

- The fiber and protein content in chickpeas can slow down the digestion and absorption of carbohydrates, potentially reducing the impact on blood sugar.

2. Kala Jamun (Black Jamun):

- Kala jamun has a moderate GI, which might cause a slight increase in blood sugar levels.

- However, the fiber and antioxidant content in kala jamun may help mitigate this effect.

3. Guava:

- Guava has a low GI, which suggests it may not cause a significant spike in blood sugar levels.

- The fiber and antioxidant content in guava can also help regulate blood sugar levels.

4. Blue Tea:

- Blue tea is unlikely to affect blood sugar levels significantly, as it contains negligible amounts of carbohydrates.

Overall, the plate's food items might have a moderate impact on blood sugar levels, primarily due to the Kala Jamun. However, the fiber and antioxidant content in these foods can help regulate blood sugar levels.

If you have diabetes or concerns about blood sugar, consider the following:

- Portion control: Monitor the serving sizes of each food item to manage carbohydrate intake.

- Balanced meal: Ensure that your meal is balanced with protein, healthy fats, and complex carbohydrates to regulate blood sugar levels.

- Monitoring: Keep track of your blood sugar levels and adjust your diet accordingly.

Consult a healthcare professional or registered dietitian for personalized advice on managing blood sugar levels through diet.

[22-06-2025 18:12] PPM 1: Any blood sugar medicine was taken before and after this? Please mention or share a picture of that medicine

[22-06-2025 18:20] PA: Yes, sir, after breakfast and lunch she took metformin 500 in half tab

[22-06-2025 18:30] PA: After tiffin she takes metformin 500 and 2hours later sugar level is 119

[22-06-2025 18:35] PA: Is there any relation to the food quantity and blood sugar level ups and downs.

[22-06-2025 18:37] PA: Please correct those plates and quantity if necessary.

[22-06-2025 19:03] PPM 1: Food appears fine.

Can we have an account of the patient's hourly activities since morning including before and after meals?

[22-06-2025 19:27] PA: Yes sir

[22-06-2025 20:10] PA: At morning 6 o clock wake up and freshen up. Then 7.15am checked fasting blood sugar, then after cleaning the bed she takes a cup of tea with soaked chola at 7.45am. After bathing she does puja, meditation and then prepare breakfast at 8.40 am. After having breakfast she takes metformin 500 half tab and then goes to drop her daughter for tution by toto. Returns back by 9.15am and feels very tired, She needs to take rest. Then 10.30 am checked her sugar level. 11.15am opens her tailoring shop. 12.15pm she has her lunch and takes metformin 500 half tab. 1.30pm goes outside for some necessary work within 30 minutes and she returns back. 2.30 pm_did some stitching 30 mints for ordered work and applied a reflex point for reducing sugar level.

[22-06-2025 20:20] PA: 4 pm goes outside for 15 minutes, then takes snacks with above mentioned plate.5.30pm watering plants, chatting with school friends and daughter for 30 minutes. 6.pm checked blood sugar.

[22-06-2025 20:23]PA: After that she prepares and completes dinner by 7.45pm, then takes metformin 500 half tab.

[22-06-2025 20:46] PPM 1: 120 fasting?

[22-06-2025 20:46] PPM 1: 132 Post breakfast?

[22-06-2025 20:47] PPM 1: 211 post lunch?

[22-06-2025 20:49] PPM 1: 👆11:15AM to 2:30PM activities in detail are important to factor in to explain the single high 2 hours after lunch

[22-06-2025 20:59] PPM 5: Anything that explains the BP fluctuation, sweating and neck/hand pain yesterday?

[22-06-2025 21:31] PPM 1: For that we'll need to know her activities and thoughts hourly before the events yesterday

[22-06-2025 21:36] PA: She completed her dinner at 7.45pm, then took metformin 500 half tab

[22-06-2025 22:09] PA: Everything was normal yesterday afternoon, but she had severe neck and hand pain. She was sweating a lot and felt uneasy whole evening, even used an iced pack 2 times. At night instead of checking her BP at home she checked at medical shop for cross check. Her heart was pounding heavily. After returning home, she laid down quietly for an hour. Then she felt better. Today she feels better, the pain of her hand has reduced, but still has some discomfort when folding it.

[22-06-2025 22:12] PA: 2 hours later sugar level is 181

[22-06-2025 22:23] PA: She was feeling bit worried about her work. Sometimes her body feels very weak, does not permit any hard work. Sometimes feels very lonely and doesn't feel to talk to anyone.

[22-06-2025 22:31] PA: For few days now, she has been suddenly feeling uneasy from time to time, whenever she does more work, cook over gas oven or get into an argument or heated discussion. She starts sweating.

[22-06-2025 22:39] PA: On the other hand the patient feels that she may need to reduce the amount or quantity of food because after having two meals like lunch and dinner, feeling very uneasy, abdomen pain and shortness of breath.

[22-06-2025 22:50] PA: Can this happen due to change in rice? This has happened twice before, her sugar level would rise a lot, shortness of breath, dryness of mouth, weakness etc and used to have abdomen pain after meals but after changing the rice it got better. Could something similar be happening again? The last 2 times, her sugar level increased, but only after eating rice.

[23-06-2025 06:52] PPM 1: What was the exact change in rice? Was it in terms of quality or quantity?

[23-06-2025 06:53] PA: Quality

[23-06-2025 06:54] PPM 1: What are the different quality of rice she consumes?

[23-06-2025 06:54] PPM 1: Does the severe neck and head pain happen once a month or once a week?

[23-06-2025 06:55] PA: After cooking it was hard.

[23-06-2025 06:56] PPM 1: Alright so the quality depends on the cooking and not any particular variety of rice she consumes?

[23-06-2025 06:57] PA: Yes.

[23-06-2025 07:03] PPM 1: 👆@PPM5 the sequence of events in this patient have been very well described. We know that certain events in the past can be associated as a cascade to explain causality for certain events in the present and future.

Her present events of anxiety appears to have been triggered by her body pains

[23-06-2025 07:24] PA: Eating cooked hard rice causes abdomen pain, burning sensation , even small amounts make the stomach feel full.

[23-06-2025 07:25] PA: This has been happening since 2-3days

[23-06-2025 07:54] PPM 1: Is that due to rice being undercooked or is it a particular variety of rice that remains undercooked?

[23-06-2025 08:07] PPM 5: https://glycemic-index.net/glycemic-index-of-rice/

Glycemic index varies significantly with the type of rice. Also the way it cooked matters. Details in the article linked above.

[23-06-2025 08:43] PA: No, this kind of pain in the hand and neck, breathing shortness has occurred for a long time. According to previous history whenever blood pressure would rise, there used to be pain in the hand (pain down to the palm and tingling sensation) and neck with sweating as well. Last time when the patient was admitted in nursing home she was given iv saline (about 60 bottles). Hand pain has increased a few days later. For the last 2-3months BP medicine has been stopped and It is possible that the blood pressure increased slightly, the pulse rate is usually high, from 2018 she took Inderal 10, but stopped since few months. She also has history of decreased O2 level in the last addmission of nursing home. It was 70-72. While doing muscle strengthening exercises she realised that her right hand is weak. She had also fallen several times might be after effects. One more thing is that in her family history her paternal sides had rheumatoid arthritis.

[23-06-2025 08:46] PPM 1: The patient's blood pressure rise event appears likely secondary to pain and is very common.

Blood pressure per se doesn't cause any symptoms and is hence known as a silent killer. In this patient it appears to be the opposite.

Her blood pressures rise is due to pain and anxiety, the anxiety hormone adrenaline causes rise in blood pressure.

[23-06-2025 08:47] PPM 1: 👆@PPM5 another important consideration in formulating a closer diagnosis with lesser uncertainty is the duration of the disease

[23-06-2025 08:47] PA: The patient believes that no matter what the reason is now, with your guidance she will be able to recover quickly.

[23-06-2025 08:50] PPM 1: We believe so too.

[25-06-2025 09:34] PA: For breakfast 1 roti, mixed veg curry and pickle

[25-06-2025 12:02] PPM 5: Just a random suggestion do try if you think useful -

I've seen someone close whose pains in the arms reduced dramatically when they reduced vatta inducing food (per ayurveda). In this case, the daily dose of chole (chickpeas) may be causing vatta which causes the pain.

Can you try not having vatta inducing foods like chole, potato, peas, eggplant (brinjal) for one/two weeks to see if pains go down.

[25-06-2025 12:26] PA: Thank you sir.

[25-06-2025 12:48] PA: Sir, for the last few days the patient has been wondering the cause of too much pain in the arms, but also (fingers, shoulder joint, chest bone, jaw). She also feels she is consuming chola, nuts, masoor daal more these days. Please suggest that what can be eaten on an empty stomach with tea in the morning or snack time? The patient is diabetic and eats very little amount of rice and 1 roti. How can she get the required protein.

[25-06-2025 12:55] PA: As per ayurveda she doesn't take brinjal, ladies finger, taro type any veggies.

[25-06-2025 13:05] PPM 5: Would roti or palak paratha, or sevaiya upma, or oats, or moong dal chila be possible in the morning?

Do try and have tindli, ridge gourd, dudhi (squash), red pumpkin during meals.

[25-06-2025 14:29] PA: In empty stomach with tea or tiffin which one is better?

[25-06-2025 15:23] PPM 5: The first list - roti, paratha..

[25-06-2025 16.59] PPM 5: Glycemic index for each of these (via ChatGPT)

Here's a breakdown of the glycemic index (GI) values of the foods you mentioned. The glycemic index is a measure (0–100) of how quickly a food raises blood sugar. Lower values are better for diabetic and metabolic control:

---

🌾 Grain-based / Main Foods

Food Item Approx. GI Comments

Roti (Whole Wheat) 55–70 Medium GI; depends on how finely the flour is ground and what it's eaten with.

Palak Paratha 50–60 Slightly lower GI due to spinach (fiber); still medium GI.

Sevaiya Upma 60–70 Medium to high GI depending on vermicelli type (maida vs. wheat).

Oats (Rolled) 55 Medium GI; high fiber helps reduce sugar spikes. Instant oats have higher GI.

Moong Dal Chilla 30–40 Low GI; high in protein and fiber, very good for sugar control.

---

🥦 Vegetables during meals (Non-starchy → Generally Low GI)

Vegetable Approx. GI Comments

Tindli (Ivy Gourd) 15–20 Low GI; may help regulate blood sugar.

Ridge Gourd ~20 Very low GI, water-rich, great for diabetic diet.

Dudhi (Bottle Gourd) ~15–20 Low GI, high water and fiber content.

Red Pumpkin 60–75 High GI but low glycemic load if portion is small (high water content). Use sparingly.

---

✅ Takeaways for Diabetic-Friendly Meals

Best choices: Moong dal chilla, oats, tindli, ridge gourd, dudhi.

Caution: Roti and sevaiya upma are okay if portion controlled and paired with protein/fiber (dal, sabzi).

Limit: Red pumpkin (in small portions only).

[26-06-2025 06:27] PA: Morning Tea

[26-06-2025 07:03] PPM 5: Moong chilla etc anything in cooked form is good but unfortunately sprouted moong is not good for vatta dosha.

https://timesofindia.indiatimes.com/life-style/food-news/ayurvedic-perspective-on-sprouts-and-gut-health/articleshow/112236064.cms

[26-06-2025 07:04] PPM 5: Some dos and don'ts

https://m.netmeds.com/health-library/post/vata-diet-all-you-need-to-know-about-this-dosha-and-a-regime-to-pacify-the-imbalance

[27-06-2025 07.09] PA: Morning black tea with puffed rice.

[27-06-2025 08.28] PA: Breakfast roti with curry.

[27-06-2025 10:48] PPM 5: Nice!

Is that potato or pumpkin.. if potato try to avoid potato as it builds vatta.

[27-06-2025 12:13] PA: Thank you sir

[27-06-2025 12:52] PA: Homemade rath Yatra special dish made by patient.

[28-06-2025 09:04] PA: The patient can't understand what's happening. From last few days even today morning she felt very weak, even her vision turns dark. After doing little work. Even after a full meal like lunch and dinner she feels very weak and breathlessness. All the works which she has to do forcefully..if she closes her eye feels good.

[28-06-2025 09:20] PPM 5: Is this because of low BP @PPM1 Sir?

Would salt and lemon mixed with water (no sugar) help?

[28-06-2025 09:21] PA: Just now she had salt and lemon water.

[28-06-2025 09:27] PPM 1: Her recorded BP as shared and archived appears to be normal

Again the only way to get to the bottom of these symptoms is to analyse the events preceding and following them

[28-06-2025 10:11] PPM 5: Could this also be because of haemoglobin deficiency or thyroid imbalance?

[28-06-2025 10:14] PPM 1: From what I recall from memory if not her archived case report (@CR would it be possible to fish out her hemogram and thyroid function tests from there), she had a normal Hb and thyroid function test.

[28-06-2025 11.48] CR: 👆test reports of 28/12/24

[28-06-2025 12:04] PPM 5: TSH?

[28-06-2025 12:05] CR: Couldn't find. @PA do you have any Thyroid reports?

[28-06-2025 12:15] PA: Dated on 19/10/24

[28-06-2025 12:30] PA: Constant vomiting tendency

[28-06-2025 12:30] PA: No taste to eat anything. Slight pain in abdomen

[28-06-2025 12:30] PA: Whichever I am doing and eating have to do forcefully.

[28-06-2025 12:49] PPM 1: Please start the patient's hourly activities description from waking up yesterday till now specifically mentioning which hours the patient started feeling the symptoms and at which hours they continued

[28-06-2025 13:26] PA: Yesterday she ate prasad khichuri, that could be the reason for vomiting tendency.

[28-06-2025 13:37] PA: This morning she ate 4 Kheera slices, black plum and chole and potato mix

[28-06-2025 14:30] PPM 1: 👆 yesterday's?

[28-06-2025 14:58] PA: No. today snack time

[28-06-2025 15:01] PA: Woke up at 6.am

[28-06-2025 15:06] PA: Then freshen up and clean the room and bed feels very weak and vison turns dark. After that she checks her BP. Then lied down on the bed for some time.

[28-06-2025 15:16] PA: After that she gave lunch box to her daughter and had small quantity of rice and gram mixed chila. (At that time she felt very uneasy, and had little piece of chilla)

[28-06-2025 15:20] PA: After half an hour then she takes a glass of water with salt and lemon.

[28-06-2025 15:25] PA: Then she took bath and after that had severe nausea and vomiting. Then she had some relief.

[28-06-2025 15:26] PA: It continues for about 2-3hours.

[28-06-2025 15:31] PA: 11.15 am she had lunch but couldn't eat much. After that she takes metformin 500 half tab and relaxed for some time.

[28-06-2025 15:34] PA: Then she goes to her tailoring shop which is situated in front of the house.

[28-06-2025 15:36] PA: She has no taste

[28-06-2025 15:38] PA: Weakness is continuously there since morning.

[28-06-2025 16:04] PA: She takes some fruits and 2 spoon daal then takes metformin

[28-06-2025 16:07] PPM 1: Today's I guess?

[28-06-2025 16:07] PPM 1: 👆@PPM5

[28-06-2025 16:41] PPM 5: Hmm potato and channa - both bad for vaata but doesn't explain vomiting. Maybe something in the food from outside.

[28-06-2025 16:42] PPM 5: Should a latest blood test be done for TSH, Haemoglobin and any other indicators? Oct 2024 is too early. Hormonal changes may swing TSH quite a bit, no? @PPM1 Sir

[28-06-2025 16:48] PPM 1: Clinically she appeared euthyroid with a normal hemoglobin during her recent visit here. @PA when was her last visit here?

[28-06-2025 18:23] PA: She visited the last week of March this year. Mostly they reached 25th of March

[28-06-2025 18:25] PA: What is euthyroid? Can you tell me pl

[28-06-2025 18:43] PA: I think it may be right.If u noticed that in yesterday's lunch plate there were small pieces of paneer 2-3pic in veggies and all were homemade but after eating there were no complications. I think the dinner plate didn't suit.

[28-06-2025 18:45] PPM 5: @Meta AI what is euthyroid?

[28-06-2025 18:45] Meta AI: Euthyroid refers to a state of normal thyroid function. When your thyroid gland is working properly, producing the right amount of thyroid hormones, you're considered euthyroid. This balance is crucial for metabolism, energy, and overall health. If you've had thyroid issues or are experiencing symptoms, getting to a euthyroid state is usually the goal of treatment!

[28-06-2025 18:46] PPM 5: @Meta AI What are abnormal readings for thyroid? What parameter should be tested? What hormonal changes could be affecting thyroid?

[28-06-2025 18:46] Meta AI: Let's break it down:

Abnormal Readings:

1. TSH (Thyroid-Stimulating Hormone):

- High TSH (above 4.5-5 μU/mL): May indicate hypothyroidism (underactive thyroid).

- Low TSH (below 0.4-0.5 μU/mL): May indicate hyperthyroidism (overactive thyroid).

2. Free T4 (FT4):

- Low FT4 (below 0.8-1.2 ng/dL): May indicate hypothyroidism.

- High FT4 (above 1.7-1.8 ng/dL): May indicate hyperthyroidism.

3. Free T3 (FT3):

- Low FT3 (below 2.3-4.2 pg/mL): May indicate hypothyroidism.

- High FT3 (above 4.2-6.8 pg/mL): May indicate hyperthyroidism.

Parameters to Test:

1. TSH

2. Free T4 (FT4)

3. Free T3 (FT3)

4. Thyroid Antibodies (e.g., TPOAb, TgAb) to check for autoimmune thyroiditis

Hormonal Changes Affecting Thyroid:

1. Thyroid Hormones (T3 and T4): Imbalances can cause hypothyroidism or hyperthyroidism.

2. Thyroid-Stimulating Hormone (TSH): Produced by the pituitary gland, TSH regulates thyroid hormone production.

3. Thyrotropin-Releasing Hormone (TRH): Produced by the hypothalamus, TRH stimulates the pituitary gland to release TSH.

Other factors that can affect thyroid function include:

1. Iodine deficiency or excess

2. Certain medications (e.g., lithium, amiodarone)

3. Autoimmune disorders (e.g., Hashimoto's thyroiditis, Graves' disease)

4. Pregnancy or postpartum changes

5. Pituitary or hypothalamic dysfunction

Keep in mind that test results should be interpreted by a healthcare professional, considering individual factors and medical history.

[28-06-2025 20:26] PA: Does she need to test T3, T4, TSH and hemoglobin?

[28-06-2025 20:30] PPM 1: I have a feeling it will turn out to be normal but not much harm in testing once I guess

[28-06-2025 20:32] PA: Ok

[28-06-2025 20:33] PA: Day after tomorrow she will get done.

[29-06-2025 05:53] PA: Fasting blood sugar level is 106

[29-06-2025 06:51] PA: BP 122/77, PR 80. After 3 min standing BP is 87/60, PR 94

[29-06-2025 07:24] PPM 1: This is a very significant postural drop @PPM5 @PPM10 @CR @PPM2 @PPM3 @30F PA

Let's ask the patient to continue to monitor this also perhaps confirming this with another BP instrument and approach the local doctor in case she needs iv fluids.

@PA how is she feeling today? Does she have a lot of giddiness especially after standing from lying down?

[29-06-2025 07:26] PPM 1: @PPM5 as far as I can recall and @CR may know from her archived data this is probably the first time we are seeing this postural drop in this patient and as @PPM3 may LLM inform us that while this can be due to machine error, it generally commonly indicates hypovolemia and rarely dysautonomia.

[29-06-2025 07.31] PA: BP 127/85, PR 94, BP 84/59, PR 97

[29-06-2025 07:31] PPM 5: By any chance can it also be Addison's disease?

[29-06-2025 07:31] PA: As per Last week BP monitor

[29-06-2025 07:34] PPM 5: LLM output on ruling out these -

To rule out or confirm hypervolemia, dysautonomia, and Addison’s disease, you need to use a combination of:

Clinical signs and symptoms

Vital signs (especially blood pressure, heart rate)

Basic and targeted lab tests

Sometimes imaging or autonomic function tests

Here's a side-by-side approach to help differentiate and rule each one out:

---

🩸 1. Ruling Out Hypervolemia (Fluid Overload)

✅ Key Signs to Look For:

Swelling in legs, feet, face (edema)

Rapid weight gain (2–3 kg over a few days)

Shortness of breath, especially when lying down

High or normal BP

Jugular venous distension (JVD)

🧪 Tests:

Test What it shows

Chest X-ray Fluid in lungs (pulmonary edema)

BNP or NT-proBNP Elevated in heart failure (fluid overload)

Electrolytes, BUN/Creatinine Kidney function

ECG, Echocardiogram Underlying heart function

Urine output monitoring Low output in fluid overload with kidney failure

🚫 Hypervolemia is unlikely if:

No edema or weight gain

No crackles in lungs

Chest X-ray is clear

BNP is normal

No JVD

---⚡ 2. Ruling Out Dysautonomia

Key Signs to Look For:

Dizziness when standing

Heart rate jumps on standing (especially in POTS)

Fatigue, fainting, brain fog

GI issues, sweat changes

🧪 Tests:

Test What it shows

Orthostatic vitals Measure BP & HR lying, sitting, standing (after 3–10 min)

Tilt table test Definitive test for orthostatic hypotension or POTS

24-hr Holter/ECG HR variability, arrhythmias

QSART (sweat test) Tests autonomic nerve function

Valsalva test Measures autonomic reflexes

🚫 Dysautonomia is unlikely if:

BP and HR remain stable on position change

No dizziness or tachycardia with standing

Autonomic function tests are normal

---

🧬 3. Ruling Out Addison’s Disease (Primary Adrenal Insufficiency)

✅ Key Signs to Look For:

Extreme fatigue

Low BP (especially diastolic)

Darkened skin (esp. gums, scars)

Weight loss, nausea

Salt craving

Low blood sugar

High potassium, low sodium

🧪 Tests:

Test What it shows

8 AM Serum Cortisol Low (<3 µg/dL suggests Addison’s)

ACTH stimulation test (Synacthen test) No cortisol rise confirms Addison’s

Plasma ACTH High ACTH = primary (Addison’s); low = secondary cause

Electrolytes Low sodium, high potassium, low glucose

Renin and aldosterone High renin, low aldosterone in Addison’s

🚫 Addison’s is unlikely if:

Cortisol is normal or increases after ACTH stimulation

ACTH is not elevated

Electrolytes and blood sugar are stable

---

🧠 Summary Table:

Condition Key Signs First Tests Rule Out If...

Hypervolemia Edema, SOB, high BP BNP, Chest X-ray No fluid signs, normal imaging

Dysautonomia Dizziness on standing, HR jumps Orthostatic BP/HR, tilt table BP & HR stable on position change

Addison’s Fatigue, low BP, hyperpigmentation AM cortisol, ACTH stim Cortisol normal, no electrolyte changes

---

📌 If you are evaluating a real patient:

You can start with:

1. Orthostatic BP/HR check

2. AM cortisol + electrolytes

3. Chest X-ray + BNP if suspecting fluid overload

4. Refer for autonomic function testing if needed

Let me know the patient's age, history, and exact symptoms if you’d like a more focused diagnostic pathway.

[29-06-2025 07:41] PA: Please sir, don't suggest Iv fluids. Last Oct. 60 bottles of fluids were given. Even today she is terrified, whatever medicines or advice you give, she will follow but please don't say to iv again.

[29-06-2025 07:44] PA: Today is feeling better than Yesterday when she lays on the bed but after standing feeling weak and vision turns dark .. vomiting tendency is there.

[29-06-2025 07:47] PA: Today her schedule is very tight not possible to lie down on the bed all day.

[29-06-2025 07:56] PPM 5: @PPM1 Sir AI output

Prompt -

This patients vision turns dark if she stands up from a sleeping posture. Also has vomitting tendency.

AI output -

Thanks — that's a very important clinical detail. The fact that her vision turns dark when standing up from lying down, along with vomiting tendency, strongly points toward orthostatic hypotension, which may be due to:

---

Likely Causes Based on These Symptoms:

1. Addison’s Disease (Primary Adrenal Insufficiency) – HIGHLY SUSPECTED

Postural (orthostatic) hypotension

Fatigue, nausea, vomiting

Dark vision on standing = brain hypoperfusion

Possible hyperpigmentation

Low cortisol + low aldosterone = poor vascular tone, salt loss

2. Dysautonomia (e.g., Neurogenic orthostatic hypotension or POTS)

Especially if she also has GI symptoms and HR increase on standing

Nervous system unable to regulate BP correctly when changing position

3. Volume Depletion (hypovolemia) – less likely if BP is persistently low

Due to vomiting, diarrhea, poor intake, diuretics

But doesn’t fully explain persistent postural symptoms unless dehydration is severe

---

Step-by-Step Diagnostic Plan You Should Ask Her Doctor to Perform:

1. Orthostatic Vital Signs

Measure BP & HR:

Lying down (5 min)

Immediately on standing

After 3 min standing

Diagnostic if:

Systolic drops ≥20 mmHg or diastolic ≥10 mmHg

HR rise >30 bpm (suggests POTS)

Lightheadedness, vision darkening, nausea on standing

2. Basic Blood Tests

Test What It Detects

Serum Electrolytes (Na, K) Addison’s = Low Na, High K

8 AM Cortisol Low (<3 µg/dL) = suspicious

ACTH High with low cortisol = Addison’s

Glucose Often low in Addison’s

Renin & Aldosterone High renin, low aldosterone in Addison’s

3. ACTH (Synacthen) Stimulation Test

Confirms adrenal insufficiency if cortisol does not rise after stimulation

4. ECG / ECHO / Chest X-ray

To rule out cardiac cause or hidden fluid overload (if needed)

Optional Autonomic Tests (if cortisol is normal):

Tilt table test

Valsalva test

QSART (sweat test)

---

🧠 Working Hypothesis Based on What You've Shared:

> "Probable Addison’s disease or orthostatic hypotension due to dysautonomia, given postural symptoms, vomiting, and low diastolic BP."

---

🩹 What Can Help Temporarily (Until Tests Are Done):

Increase salt intake (unless contraindicated)

Drink oral rehydration or electrolyte-rich fluids

Slow posture changes (lie → sit → stand gradually)

Raise head of bed slightly during sleep

Avoid prolonged standing or heat

---

[29-06-2025 08:58] PA: She just completes her breakfast with upma and fruits then takes metformin 500 half tab

[29-06-2025 10.04] PA: BP 107/66, PR 85

[29-06-2025 10:07] PA: After having breakfast she took rest still now, then checked BP that is 107/66

[29-06-2025 10:09] PA: After 3 mints standing BP is 102/70

[29-06-2025 10:40] PPM 11: What medicines are she on apart from metformin?

[29-06-2025 10:41] PA: 2hours later sugar level is 153

[29-06-2025 10:45] PA: She takes metformin 500 half tab after breakfast, lunch and dinner.

[29-06-2025 10:45] PPM 11: Any other medicines?

[29-06-2025 10:46] PA: No sir

[29-06-2025 14:16] PPM 5: No darkness in vision after standing? When does that happen? Only in the morning when waking up?

[29-06-2025 14.35] PA: 126mg/dl

[29-06-2025 15:29] PPM 2: But again the heart rate is 'fixed' at 94 to 97 while the BP drops.

Certainly raises the case for Dysautonomia

[29-06-2025 15:30] PPM 2: What phenotype of Diabetes does she have you think sir? @Rakesh Biswas Sir

[29-06-2025 15:30] PPM 2: @PA has the patient been losing weight or lost weight before she was diagnosed with Diabetes?

[29-06-2025 15:57] PA: BP 122/81, PR 108Yes sir now she feels better even from yesterday takes lemon water with salt several times.

[29-06-2025 15:59] PA: She also feels that lemon water with salt and black tea enhances her energy when it feels weak.

[29-06-2025 16:02] PA: Most of the day she notices that either morning or evening feels weak, sweating etc.

[29-06-2025 16:08] PPM 1: Type 2 although monogenic is always a fallback possibility

She had a metabolic syn phenotype earlier which she worked upon and changed to what is her current DP.

@PA can the patient share the deidentified views of her previous abdomen and arms lateral view before she worked out and made significant changes to her body?

[29-06-2025 16:10] PA: No sir, It has been a weight loss since last sept. Before that she looked like round and chubby.

[29-06-2025 16:15] PPM 1: When was she first diagnosed to have diabetes?

[29-06-2025 16:17] PPM 1: Since last September the weight loss was because the patient was proactive about her health and while she needed glimiperide before that she's currently off glimiperide and with fair amount of sugar control.

Recent Pics

[29-06-2025 16:33] PPM 1: Please share images of her at the time she developed diabetes 3 years back

[29-06-2025 16:35] PPM 2: Does she have a salt craving?

[29-06-2025 16:35] PPM 2: But that should have made her diabetes better?

2 years before

[29-06-2025 17:06] PPM 1: It is

[29-06-2025 17:09] PPM 1: Not hyper, it was meant to be hypovolemia

[29-06-2025 17:23] PPM 2: I mean given the significant change in metabolic status, the Diabetes should have resolved.

[29-06-2025 17:39] PPM 1: She began PaJR in September 2024 and became a picture of optimal weight loss (although perhaps her sarcopenia too needed addressing) by March 2025 (full marks to her).

Even bariatric surgery as well as very focused weight loss programs achieve complete remission in some percentage of their patients in 1 year while many achieve partial remission. She appears to have achieved partial remission. @PA please share this patient's last 3 monthly Hba1c values.

@PPM3 @PPM5 it may be a good idea to get a perplexity style RCT data support regarding the spectrum of remission onset and duration in interventions for diabetes reversal?

[29-06-2025 17:55] PPM 2: Would be keen to see this patient's serial HbA1c data

[29-06-2025 19:14] PPM 1: It should be in the case report archives but we may need an LLM to extract it @PPM5

[29-06-2025 19:18] PPM 3: She began PaJR in September 2024 and became a picture of optimal weight loss (although perhaps her sarcopenia too needed addressing) by March 2025 (full marks to her).

Even bariatric surgery as well as very focused weight loss programs achieve complete remission in some percentage of their patients in 1 year while many achieve partial remission. She appears to have achieved partial remission. @PA⁩ please share this patient's last 3 monthly Hba1c values.

it may be a good idea to get a perplexity style RCT data support regarding the spectrum of remission onset and duration in interventions for diabetes reversal?

The patient who began PaJR in September 2024 and achieved optimal weight loss by March 2025 likely attained *partial remission of type 2 diabetes*. This aligns with data from the Diabetes Remission Clinical Trial (DiRECT), which showed that about 46% of patients with type 2 diabetes of less than 6 years' duration can achieve remission at 12 months through structured weight management, with many others achieving partial remission[1][3].

Complete remission is defined as maintaining HbA1c below 6.5% without glucose-lowering medication for at least 3 months, but partial remission (improved glycemic control without full normalization) is common and still clinically significant[5]. Bariatric surgery and focused weight loss programs also show similar remission rates, with sustained weight loss being a key factor for remission durability[1][3].

Regarding sarcopenia, it is important to address muscle loss or weakness, especially post-weight loss or bariatric surgery, as inadequate protein intake and muscle mass loss can affect outcomes and quality of life[4][6].

For more precise assessment, sharing the patient's last three monthly HbA1c values would help confirm the remission status.

*RCT data summary on remission onset and duration in diabetes interventions:*

- Remission rates are highest within the first year post-intervention, especially with weight loss >10-15 kg[1][3].

- Remission tends to decline over time; for example, DiRECT showed a drop from 46% remission at 1 year to 13% at 5 years[3].

- Most trials focus on patients with diabetes duration under 6 years, as earlier intervention improves β-cell function reversibility[3].

- Interventions include lifestyle changes, bariatric surgery, and pharmacological approaches, with multi-modal obesity care recommended[2][5].

In summary, the patient’s partial remission by March 2025 fits well within current evidence on diabetes remission timelines and outcomes after weight loss interventions. Addressing sarcopenia alongside glycemic control is advisable for holistic management.

Please share the patient's recent HbA1c values for further evaluation.

Citations:

[1] 5-year follow-up of the randomised Diabetes Remission Clinical ... https://www.thelancet.com/journals/landia/article/PIIS2213-8587(23)00385-6/fulltext

[2] Preparing Patients for Their Weight Management Journey https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools-and-Practice-Support/Quality-Programs/Weight-Management-Roundtable/Tchang_ACC-Roundtable-Session-2.pdf

[3] Registered clinical trials targeting type 2 diabetes remission ... - Nature https://www.nature.com/articles/s41598-025-00080-9

[4] Impact of Bariatric and Metabolic Surgery on Sarcopenia-Related Parameters According to the EWGSOP2 Consensus Criteria in Persons Living with Obesity https://pmc.ncbi.nlm.nih.gov/articles/PMC12065728/

[5] Reversal and Remission of T2DM – An Update for Practitioners - PMC https://pmc.ncbi.nlm.nih.gov/articles/PMC9206440/

[6] Inadequate Protein Intake after Bariatric Surgery: Effects on Body ... https://bariatrictimes.com/inadequate-protein-intake-bariatric-surgery-nursing/

[7] Dietary weight-management for type 2 diabetes remissions in South ... https://www.sciencedirect.com/science/article/pii/S2772368222001287

[8] Impact of Bariatric and Metabolic Surgery on Sarcopenia-Related ... https://pubmed.ncbi.nlm.nih.gov/40164918/

[9] Special Article https://guidelines.diabetes.ca/GuideLines/media/Docs/cpg/DC-SA-Remission-of-Type-2-Diabetes-JCJD_1609.pdf

[29-06-2025 19:35] PPM 1: Deep seek in perplexity mode?

[29-06-2025 21:37] PA: After dinner she took metformin 500 half tab and 2hours later sugar level is 143mg/dl

[29-06-2025 21:39] PA: Jackfruits do not suit her after eating she feels abdomen pain in neval and upper abdomen

[29-06-2025 21:43] PA: Again weakness and darkness returns back.

[29-06-2025 21:45] PA: Please mention the test if needed.

[29-06-2025 21:48] PA: If she closes her eyes it feels good. How to recover from this situation?

[29-06-2025 21:50] PA: How many times does she take lemon water with salt?

[29-06-2025 21:52] PA: After lunch she did different types of work like cutting, stitching and painting.

[30-06-2025 06:33] PA: Morning Tea with puffed rice

[30-06-2025 07:59] PPM 1: 👍

[30-06-2025 08:53] PA: 1slice brown bread and salad

[30-06-2025 09:04] PA: Any relation with mild abdomen pain, vomiting tendency, weakness and blood pressure and sugar level in the morning.

[30-06-2025 16:46] PA: ChatGPT keeps bringing up Addisons @PPM1Sir @PPM2 is Addisons something to be tested for?

Yes — those symptoms can be closely related and they strongly suggest a possible endocrine or systemic cause like Addison's disease, especially when seen together:

---

🔗 How They’re Connected in Addison’s Disease (Primary Adrenal Insufficiency):

Symptom Likely Cause in Addison’s

Mild abdominal pain Cortisol deficiency can cause vague GI symptoms — often described as discomfort, cramping, or "sour feeling"

Vomiting tendency Common and can worsen during stress or early in the day (low morning cortisol)

Weakness, fatigue From low cortisol, low BP, and sometimes low blood sugar

Low blood pressure (especially morning) Cortisol and aldosterone both help maintain BP; lowest in the early morning

Low morning sugar Cortisol helps maintain blood glucose during fasting — without it, hypoglycemia can occur

---

🕰 Why are symptoms worse in the morning?

Cortisol levels are naturally highest at 6–8 AM in healthy people — it helps you wake up, maintain blood pressure, and stabilize blood sugar.

In Addison’s, this morning surge is absent → leads to:

Morning weakness

Low BP and blood sugar

Nausea or vomiting

Crashing fatigue after getting up

---

🧪 Blood Sugar + BP Clue:

Low BP + low fasting sugar + nausea/vomiting strongly point to a hormonal cause (not just dehydration or infection).

Addison's classically missed because early symptoms are subtle and spread across systems: GI + BP + energy + sugar.

---

🧠 Summary:

> Yes, there’s a strong physiological link between abdominal pain, vomiting tendency, morning weakness, low BP, and low blood sugar — and this constellation of symptoms is characteristic of adrenal insufficiency (Addison’s).

[30-06-2025 17:18] PA: Pl suggest which test has to need to detect Addision disease

[30-06-2025 17:19] PPM 2: As an Endocrinologist, I do not think she has Addison's yet.

[30-06-2025 17.30] PA: BP 109/65, PR 102

[30-06-2025 17:36] PA: 3mints after standing. 102/62, PR 117

[30-06-2025 17:58] PPM 5: Thanks for the clarity.

[30-06-2025 17:58] PA: She had to travel by train today. After that started feeling unwell, hand and leg cramps.

[30-06-2025 18:04] PA: Felt uneasy so ate sweets and water, and she felt a bit relief. In this situation is the rest necessary? Is it okay to go to gym?

[30-06-2025 18:07] PA: She also noticed that after eating sweet she felt mild cramps in the abdomen.

[30-06-2025 20.47] PPM 1: She may not have had any documented low blood sugar yet.

[01-07-2025 06.02] PA: BP 89/55, PR 88

[01-07-2025 06:07] PA: After 3 mints standing BP 98/57, PR 93

[01-07-2025 07:11] PPM 1: 👍

[01-07-2025 08:40] PA: This morning while returning from the toilet she experienced intense darkness in front of her eyes, dizziness, couldn't maintain her balance while standing. After waking up there was a tingling sensation in the left side of her head, so she got up slowly and sat up on the bed while before going to bathroom that's why she checked her BP nd sugar level.

[01-07-2025 08:40] PA: Fasting sugar 121mg/dl

[01-07-2025 09:06] PA: Lots of respect, gratitude and best wishes for the future to all the Doctors and Medical students in this group. Happy Doctor's Day.

[01-07-2025 09:43] PA: Lunch

[01-07-2025 09:53] PPM 1: 👍

[01-07-2025 09:53] PPM 1: For us it is happy patients day. No doctor can be happy if their patients aren't happy

[01-07-2025 09:55] PPM 1: @Meta AI @PPM3 @PPM5 how would you frame the patient's experience below in terms of what is known in this space such as micturition syncope etc?

This morning while returning from the toilet she experienced intense darkness in front of her eyes, dizziness, couldn't maintain her balance while standing. After waking up there was a tingling sensation in the left side of her head, so she got up slowly and sat up on the bed while before going to bathroom that's why she checked her BP and sugar level which turned out to be normal

[01-07-2025 09:55] Meta AI: Based on the patient's experience, it seems like she might have had a vasovagal episode, possibly related to micturition syncope or post-micturition syncope. This condition is characterized by a sudden drop in blood pressure and heart rate, often triggered by straining during urination or bowel movements.

The symptoms she described, such as:

1. Intense darkness in front of her eyes

2. Dizziness

3. Loss of balance while standing

4. Tingling sensation in the left side of her head after regaining consciousness

are consistent with a vasovagal episode. The normal BP and sugar levels suggest that other potential causes, like hypotension or hypoglycemia, might not be the primary issue.

Other possibilities to consider:

1. Orthostatic hypotension (drop in BP upon standing)

2. Transient ischemic attack (TIA) or minor stroke (less likely given the normal BP and specific symptoms)

A thorough medical evaluation would be necessary to determine the underlying cause.

[01-07-2025 09:56] PPM 1: @Meta AI tell us something more about what is known about the pathophysiology of micturition syncope, also framing it in the context of the patient

[01-07-2025 09:56] Meta AI: Micturition syncope, also known as post-micturition syncope, is a type of neurally-mediated syncope. The exact pathophysiology isn't fully understood, but it's thought to involve a complex interplay between the nervous system, cardiovascular system, and pelvic organs.

Key mechanisms:

1. Activation of the vagus nerve: During urination, the vagus nerve is stimulated, leading to increased parasympathetic activity. This can cause a sudden drop in heart rate and blood pressure.

2. Vasodilation and decreased venous return: The parasympathetic response causes blood vessels to dilate, reducing venous return to the heart. This decreases cardiac output, leading to a drop in blood pressure.

3. Orthostatic stress: Standing up after urinating can further exacerbate the drop in blood pressure, making it more likely for the patient to experience symptoms.

In the context of the patient:

Given the patient's symptoms occurred while returning from the toilet, it's possible that the act of urinating triggered a vasovagal response, leading to a sudden drop in blood pressure and subsequent loss of consciousness. The tingling sensation on the left side of her head after regaining consciousness might be related to transient cerebral hypoperfusion (reduced blood flow to the brain).

Other factors that might contribute:

1. Straining during urination: Increased intrathoracic pressure during straining can further reduce venous return and cardiac output.

2. Dehydration or volume depletion: Reduced blood volume can exacerbate the drop in blood pressure.

3. Underlying cardiovascular or neurological conditions: Certain conditions, such as autonomic dysfunction or cardiac arrhythmias, might increase the risk of micturition syncope.

A thorough medical evaluation would help determine the underlying causes and identify potential contributing factors.

[01-07-2025 12:02] PPM 3: Based on the description, the patient's experience strongly aligns with *Vasovagal Syncope (Neurally Mediated Syncope), potentially triggered by **micturition, making **Micturition Syncope* a very specific and likely diagnosis. Here's the breakdown:

1. *Core Event: Near-Syncope (Pre-Syncope)*

* *Symptoms:* Intense darkness before eyes, dizziness, inability to maintain balance.

* *Mechanism:* These are classic symptoms of cerebral hypoperfusion (reduced blood flow to the brain), indicating she was on the verge of fainting (syncope) but did not fully lose consciousness.

2. *Key Trigger: Post-Micturition*

* The event occurred immediately after returning from the toilet.

* *Micturition Syncope:* This is a well-recognized subtype of vasovagal syncope where fainting/near-fainting occurs during or immediately after urination. The trigger involves:

* *Vagal Stimulation:* Urination, especially with a full bladder, can stimulate the vagus nerve.

* *Valsalva Maneuver:* Straining to empty the bladder increases intrathoracic pressure, briefly reducing venous return to the heart and subsequently cardiac output.

* *Peripheral Vasodilation:* After emptying a full bladder, there can be sudden relaxation and dilation of blood vessels in the abdomen/pelvis.

* *Orthostatic Stress:* Rising from the toilet (sitting to standing) adds orthostatic stress.

* The combination of these factors can lead to a transient drop in blood pressure (hypotension) and/or heart rate (bradycardia), causing reduced brain blood flow and pre-syncope/syncope.

3. *Post-Recovery Symptom: Left-Sided Head Tingling*

* This is also a common feature in vasovagal episodes.

* *Mechanism:* As blood flow rushes back to the brain after the hypotensive/low-flow state, it can cause unusual sensory sensations like tingling (paresthesia), often described in the head, face, or extremities. It's part of the neurological "recovery" process and not typically indicative of a separate problem like a stroke in this context, especially given the classic pre-syncopal symptoms and trigger. It resolves spontaneously.

4. *Normal BP and Sugar:*

* *Relevance:* This is crucial information and consistent with vasovagal/micturition syncope.

* *Why Normal?* The hypotension and bradycardia causing the symptoms are transient and reflex-mediated. By the time she checked her BP and sugar (after sitting down and recovering), the reflex had subsided, and her body had compensated, returning her vitals to normal. This effectively rules out persistent hypotension (like severe dehydration or shock) or hypoglycemia as the primary cause.

*Framing the Experience:*

* *Primary Diagnosis:* *Vasovagal Syncope (Neurally Mediated Syncope), specifically triggered by urination: **Micturition Syncope (Near-Syncope variant)*.

* *Sequence:*

1. *Trigger:* Voiding a full bladder, likely combined with standing up.

2. *Vasovagal Reflex:* Activation leads to transient hypotension/bradycardia.

3. *Cerebral Hypoperfusion:* Causes pre-syncopal symptoms (darkness, dizziness, imbalance).

4. *Recovery:* Sitting/lowering herself prevented full syncope.

5. *Post-Recovery:* Reactive cerebral blood flow changes caused transient left-sided head tingling.

6. *Normalization:* Vital signs (BP, sugar) returned to normal once the reflex resolved and she was resting.

*Important Considerations & Next Steps:*

* *Safety:* The main risk is injury from falling during an episode. Education on recognizing warning signs (prodrome) and getting down safely (sitting/lying down) is key.

* *Hydration:* Increasing fluid intake (especially water) and electrolyte balance can help maintain blood volume and reduce susceptibility.

* *Avoid Triggers:* Arise slowly from the toilet. Consider sitting to urinate if standing. Avoid prolonged standing immediately after.

* *Medical Evaluation:* While this presentation is classic, it's essential to:

* Confirm the history details with the patient.

* Rule out other potential causes of syncope (cardiac arrhythmias, orthostatic hypotension from other causes, neurological issues) through a clinical exam and possibly an ECG. However, the very specific trigger makes vasovagal/micturition syncope the overwhelming likelihood.

* Assess for any medications that might lower BP or contribute.

* *Red Flags (Less likely here, but always consider):* Absence of prodrome, chest pain, palpitations, fainting while seated/lying down, significant injury, focal neurological deficits persisting after recovery, or abnormal heart findings would warrant more urgent and extensive investigation.

*In summary:* This is a textbook description of near-syncope triggered by the physiological events surrounding urination, fitting perfectly within the diagnosis of Micturition Syncope, a common form of Vasovagal Syncope. The normal vitals after recovery and the transient tingling are consistent features of this benign (though potentially injurious) reflex.

[01-07-2025 19:50] PA: Dinner rice with mixed vegetable curry.

[01-07-2025 20:16] PPM 1: 👍

[01-07-2025 20:36] PPM 5: It's amazing you had to finally come up with this as an option. AI didn't suggest this at all earlier. @PPM1sir

[01-07-2025 21:00] PPM 2: Again we are pivoting towards Autonomic involvement.

[01-07-2025 21:45] PA: From the evening her eyes have turned red, there is lot of irritation, slight pain and heaviness in the right eye. The left eye is now okay. she has applied Lotepred twice a day in the left eye. Should she apply Lotepred in the right eye or use a hot compress? Why is this happening repeatedly? it's really affecting her work badly and also confidence level.

[02-07-2025 06:55] PA: This morning.

[02-07-2025 07:13] PPM 1: Can we again revise the history?

When was the first time she noticed intermittent redness of her eyes? How many years back or if she can remember an exact date that would be very useful

[02-07-2025 07:26] PA: Yesterday evening suddenly she noticed that her vison was becoming hazy and eyes were filling with water.

[02-07-2025 07:27] PA: Difficult to see, and there was slight pain.

[02-07-2025 07:56] PA: From last Feb of this year she repeatedly suffered with this problem.

[02-07-2025 08:02] PA: Many years ago, whenever there was a high fever, or sometimes when her eyes turned red like this, applying eye drops would reduce it

[02-07-2025 08:40] PPM 1: How many years ago?

Since then how many times?

Once a month? Once a year?

[02-07-2025 08:54] PA: More than 10 to 12 years ago

[02-07-2025 08:57] PA: PTK done 2018.

[02-07-2025 08:59] PA: After that she has no problem regarding redness or any others except side vison nd light sensation.

[02-07-2025 09:26] PA: 2 years ago when she went to Haridwar, Rishikesh, Gangotri, Tehari for 14 days, at that time she bathed in the Ganga, and the very next day started the same eye problem. It was a 2 days train journey in sleeper class. There was severe pain in the eye. after returning back went to doctor, He said it was a viral infection and prescribed Lotepred eye drops systene ultra and Azithromycin ointment. After that it cured.

[02-07-2025 09:30] PA: After that last year when she suffered the same problem,with viral fever with high temperature 104 F

[02-07-2025 09:33] PA: Lastly from last Feb of this year 2025, suffering several times. Almost 7 times repeatedly.

[02-07-2025 09:34] PA: Madam apni ki aj achen?chokh ta ki ei obosthay dekhben?ekhon kintu ami systane ultra use korchi ..Apni pl ektu bhalo kore din.

[02-07-2025 09:34] PA: Discharge achhe?

[02-07-2025 09:34] PA: Aj ektu kom .

[02-07-2025 09:34] PA: Pain hoche bes .

[02-07-2025 09:34] PA: Conjunctivitis laagchhe

[02-07-2025 09:34] PA: Paracetamol khabo?

[02-07-2025 09:34] PA: Ki korbo Lotepred debo?

[02-07-2025 09:34] PA: Zylopred

[02-07-2025 09:34] PA: Pl ektu thik kore din.ber ber hoche khub kosto hoche

[02-07-2025 09:34] PA: Kotober debo zylopred?both eyes?left eye Lotepred ki cholbe?

[02-07-2025 10:33] PA: Another device she takes BP,109/73

[02-07-2025 19:25] PA: 97% Is this O2?

[02-07-2025 19:36] PPM 1: Looks like yes 👍

[02-07-2025 19:43] PPM 1: LLM driven PaJR patient centered learning today @PPM5 @PPM7 for the paper:

[02/07, 17:14] Patient Advocate Diabetes 44F WB: Sir, immunity barano ki jay?pl ektu bolben ..

[02/07, 17:17] Patient Advocate Diabetes 44F WB: Amr chokher photo pathiechilam Dr. Madam k . zylopred diyechen .r amr immunity kom r chokh hat di bole ber infection hoche . tahole ki korbo?

[02/07, 19:41]cm: Immunity kom bola jabe na hoito.

Byapar ta immune system dwara mediated.

[02/07, 19:39]cm: Please provide a simplified understanding of how recurrent allergic conjunctivitis is mediated by the immune system in response to environmental antigens and translate it in Bengali

[02/07, 19:39] ChatGPT: Simplified Understanding (English):

Recurrent allergic conjunctivitis happens when the immune system overreacts to harmless substances like pollen, dust, or pet dander. These substances are called allergens. When they come in contact with the eye:

1. The immune system mistakenly sees them as harmful.

2. It activates mast cells in the conjunctiva (the thin layer covering the white part of the eye).

3. Mast cells release chemicals like histamine, which cause itching, redness, swelling, and watering of the eyes.

4. With repeated exposure, the immune system becomes more sensitive, leading to recurring symptoms.

This is a type I hypersensitivity reaction, which is fast and IgE-antibody mediated.

---

বাংলা অনুবাদ (Bengali Translation):

পুনরাবৃত্ত অ্যালার্জিক কনজাংকটিভাইটিস হয় যখন শরীরের রোগ প্রতিরোধ ব্যবস্থা পরিবেশের নিরীহ বস্তু যেমন পরাগ, ধুলা বা পোষা প্রাণীর লোমকে ক্ষতিকর ভেবে অতিরিক্ত প্রতিক্রিয়া দেখায়। এই বস্তুগুলোকে অ্যালারজেন বলা হয়। যখন এগুলো চোখের সংস্পর্শে আসে:

1. রোগ প্রতিরোধ ব্যবস্থা এগুলোকে বিপজ্জনক মনে করে।

2. তখন চোখের সাদা অংশের উপর পাতলা আবরণ (কনজাংকটিভা)-তে থাকা মাস্ট সেল সক্রিয় হয়।

3. এই মাস্ট সেল থেকে হিস্টামিন নামক রাসায়নিক বের হয়, যা চোখে চুলকানি, লালভাব, ফুলে যাওয়া ও পানি পড়ার কারণ হয়।

[02/07, 19:39] ChatGPT: 4. বারবার সংস্পর্শে আসলে শরীর আরও সংবেদনশীল হয়ে পড়ে এবং লক্ষণ বারবার দেখা যায়।

এটি টাইপ I হাইপারসেন্সিটিভিটি প্রতিক্রিয়া, যা দ্রুত ঘটে এবং IgE অ্যান্টিবডি দ্বারা পরিচালিত হয়।

Let me know if you'd like this in chart, infographic, or study-note form.

[02-07-2025 20:37] PPM 4: Please keep your nails short. And I think you should use drinking water for cleaning your eyes instead of wipes.

There must be an external source of infection.

Have you started using Zylopred eye drop in the right eye?

[02-07-2025 21:53] PPM 1: Further learning:

[02/07, 21:48]: Please translate the content below to English and try to explain how the described allergens could be emanating from the grass weeding in terms of simplified immunology first in English then in Bengali

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Acha,, allergy thekeo erokom hote pere ki?

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Kal onkdin por chade uthechilam ,bes kichu gacher tub bristir jole bhore gechilo r prochur ghas hoyechilo ,ek odbhut typer ghas jatio agacha ja age kokhono dekhini .pray 20 moton tub mati clean korechilam .kno janina ter por dupure khub ghum pachilo ,konodin dupure ghumer ovayas konodin nei .kal pray 30 mint ghumie gechilam ter por thekei constant nak oswasti ,pray henchei jachi ,bhetor dike itching hoche thik jmn thanda lagle hoy serokom ..chokher problem tao kintu ter por thekei arise koreche ..

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Amr mone hoy tahole oi tub mati ba ghas e kichu chilo .,thik er ager ber o jokhon agacha clean korechi tokhon o khub sneezing hoyechilo . Khub hat pa itching hochilo .kintu bujhbo ki kore? Mati theke hoche na oi agachagulo theke?

[02/07, 21:48] ChatGPT: English Translation:

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Okay… could this have happened due to an allergy?

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Yesterday, after a long time, I went up to the terrace. Several tubs had filled with rainwater, and there was a lot of grass growth — a strange kind of grass or weed that I had never seen before. I cleaned the soil from about 20 tubs. After that, I felt very sleepy in the afternoon, which is unusual for me as I don’t normally sleep during the day. I ended up sleeping for about 30 minutes, and since then I’ve had persistent nasal discomfort, sneezing constantly, and internal itching — just like when we catch a cold. Even the eye problem seems to have started after that.

[02/07, 21:43] Patient Advocate Diabetes 44F WB: I feel like there was something in that soil or the grass. Even the last time I cleaned weeds, I had severe sneezing and itching in my hands and feet. But how do I know whether it’s coming from the soil or the weeds?

---

Explanation in Simplified Immunology (English):

Yes, this could very likely be an allergic reaction. Here's why:

1. Grass and weeds produce pollen, tiny airborne particles that can be strong allergens.

[02/07, 21:49] ChatGPT: 2. Molds grow in damp soil and wet conditions (like tubs with rainwater). Mold spores are also allergens.

3. When cleaning or disturbing this material, allergens like pollen, mold spores, or dust particles become airborne.

4. In sensitive individuals, the immune system misidentifies these harmless substances as threats.

5. It then releases histamine and other chemicals, causing symptoms: sneezing, nasal irritation, eye discomfort, and skin itching.

6. This is a Type I hypersensitivity reaction, immediate and IgE antibody-mediated.

So, it’s not just the soil or the weed — it’s the particles or spores released from them during weeding that likely caused the immune response.

---

Simplified Bengali Explanation (বাংলায় সহজ ব্যাখ্যা):

হ্যাঁ, এটা খুব সম্ভব যে এই উপসর্গগুলো অ্যালার্জি থেকে হয়েছে।

1. ঘাস ও আগাছা থেকে পরাগরেণু (pollen) বের হয়, যেগুলো বাতাসে উড়ে এবং অনেকের জন্য অ্যালার্জির কারণ হয়।

2. ভেজা টবের মাটি ও জমা জলে ছত্রাক (mold) জন্মাতে পারে। ছত্রাকের স্পোরও অ্যালার্জি তৈরি করতে পারে।

3. আগাছা পরিষ্কার করার সময় এই পরাগরেণু, ছত্রাকের স্পোর বা ধুলা বাতাসে ছড়িয়ে পড়ে।

4. শরীর যদি এগুলোকে ভুল করে ক্ষতিকর মনে করে, তখন ইমিউন সিস্টেম প্রতিক্রিয়া দেয়।

[02/07, 21:49] ChatGPT: 5. তখন হিস্টামিন এবং অন্যান্য রাসায়নিক বের হয় — যার ফলে হাঁচি, নাক চুলকানো, চোখে জ্বালা, ও চামড়ায় চুলকানি হয়।

6. একে বলে টাইপ I হাইপারসেন্সিটিভিটি প্রতিক্রিয়া, যা IgE অ্যান্টিবডি দ্বারা ঘটে।

সুতরাং, এটি সরাসরি মাটি থেকে নয়, বরং মাটি বা আগাছা থেকে ছড়ানো অ্যালারজেনের জন্য হয়ে থাকতে পারে।

[03-07-2025 10:10] PA: In lunch time, Rice with mix veg curry, boiled potato and kheera pieces

[03-07-2025 14:29] PPM 1: 👍

[03-07-2025 14:30] PA: Today the patient feels better

PPM 1: 👍

[05-07-2025 07.57] PA: BP 146/90, PR 93, 3 mins later 138/95

[05-07-2025 09:50] PA: She has 100.4F body temperature with a body ache, headache and nose blockage.

[05-07-2025 17:06] PPM 1: Keep sharing 4 hourly

[05-07-2025 17:18] PA: 12 o clock 100F. 4 pm 100F

[05-07-2025 17:19] PA: Discomfort in throat.

[06-07-2025 07:00] PA: Fasting blood sugar level is 105

[06-07-2025 07:09] PA: BP 99/66, PR 101, BP117/52, PR 95, 3 mins later

[06-07-2025 10:14] PA: At breakfast idly and peanut chutney and kheera slices

[06-07-2025 10:29] PA: She completed her breakfast at 10 .30 am then took metformin 500 half tab

[06-07-2025 12.32] PA: Post breakfast sugar 128mg/dl

[06-07-2025 14.50] PA: BP 99/73, PR 50

[07-07-2025 08:46] PPM 1: No other readings after 12:00 PM? Assuming she was fine after that?

[07-07-2025 14:40] PA: Since yesterday afternoon there has been fever around 100 °F along with severe body pains. The patient had splitting headache and constant sneezing.

[07-07-2025 14:49] PA: Feels like keeping the eyes closed all the time. Due to blocked nose the patient couldn't sleep for 2 days. Still doing all the household work out of compulsion with the help of her daughter. Since last night there has been a severe muscle cramp in the right leg along with a strange uneasy feeling inside. The patient is experiencing dry mouth and skin.

[07-07-2025 14:53] PA: Please advise for regaining strength and couldn't check her sugar levels due to weakness.

[07-07-2025 17:04] PPM 1: Fever charting and sharing the values here 4 hourly would have made it easier to evaluate her current problem which on the surface appears to be a viral URTI and tablet paracetamol 650 every six hours for 1 day should be useful for her along with tablet cetrizine 10 mg one hour before dinner

[07-07-2025 17:12] PA: Yesterday she took paracetamol 650, 2 times

[07-07-2025 17:15] PA: From this morning she has no fever but other pains and symptoms.

[07-07-2025 17:17] PA: 7 am 99.6. 12noon 99.4. 4 pm 99

[07-07-2025 22:48] PA: Starts Severe pain in right eye. Continuing warm moist fomentation, zylopred and Systane Ultra Eye drops 4 times.

[08-07-2025 09:56] PPM 4: If the pain is really severe, it could be diffuse scleritis.

Is it referred to somewhere else? Like headache, jaw pain, etc

[08-07-2025 10:24] PPM 4: She may take oral analgesics, but analgesic/anti-inflammatory eye drops are harmful to the cornea. It's not preferable in her case.

[08-07-2025 10:40] PA: Yes, there is headache and throat pain beside the jaw area.

[08-07-2025 10:56] PA: I think the pain is mainly in the right eye and swelling is there. After taking paracetamol pain is reduced but the left sided tonsil pain is there

[08-07-2025 11:01] PA: What is the cause of recurring scleritis and episcleritis in both eyes alternatively? If she closes her eyes feels comfortable. She doesn't take any analgesic tab or eye drops. Only takes paracetamol.

[08-07-2025 11:52] PPM 4: The eye pain could be a referred pain from tonsillitis or a sinusitis

[08-07-2025 11:52] PPM 4: She may use genteal gel in-between.

[10-07-2025 07:13] PPM 1: More lid edema but possibly with associated sclero conjunctival inflammation @PPM4?

[10-07-2025 08:28] PPM 4: Possibly.

I strongly feel that it's a case of viral conjunctivitis. which is associated with the upper respiratory tract infeccion.

Something like a Pharyngoconjuctival fever.

Scleritis won't respond to only topical medicine.

[10-07-2025 08:28] PA: The severe pain has reduced but mild now. She feels heavy in right side, difficulty seeing due to swelling and itching also. Comparitively better from last 3 days

[10-07-2025 08:29] PA: Now she has no throat pain

[10-07-2025 08:30] PPM 4: Don't worry.

Start using genteal gel/ drop in between .

[10-07-2025 08:31] PA: Last night she used Gen Teal gel and other eye drops also

[10-07-2025 08:33] PPM 4: After 7 days, Zylopred needs to be replaced with lotepred. And taper slowly.

[10-07-2025 08:34] PA: Can she stop Lotepred in left eye?

[10-07-2025 08:36] PPM 4: Please taper

[10-07-2025 08:39] PA: Since 4 weeks continuing medicine1st week 4 times,2 nd week 3times ,3rd week twice a day and this week once a day after Saturday can she stop it?

[10-07-2025 09:43] PPM 4: Yes

[10-07-2025 16:58] PPM 1: @PPM5 @PPM7 @PPM3 Further AI LLM driven explorations into the patient's root cause quest for her recurrent allergic conjunctivitis:

[02/07, 19:41] cm: Immunity kom bola jabe na hoito.

Byapar ta immune system dwara mediated.

[02/07, 19:39]cm: Please provide a simplified understanding of how recurrent allergic conjunctivitis is mediated by the immune system in response to environmental antigens and translate it in Bengali

[02/07, 19:39] ChatGPT: Simplified Understanding (English):

1. The immune system mistakenly sees them as harmful.

2. It activates mast cells in the conjunctiva (the thin layer covering the white part of the eye).

3. Mast cells release chemicals like histamine, which cause itching, redness, swelling, and watering of the eyes.

4. With repeated exposure, the immune system becomes more sensitive, leading to recurring symptoms.

This is a type I hypersensitivity reaction, which is fast and IgE-antibody mediated.

---

বাংলা অনুবাদ (Bengali Translation):

1. রোগ প্রতিরোধ ব্যবস্থা এগুলোকে বিপজ্জনক মনে করে।

Let me know if you'd like this in chart, infographic, or study-note form.

[02/07, 21:50]cm: [02/07, 21:48]: Please translate the content below to english and try to explain how the described allergens could be emanating from the grass weeding in terms of simplified immunology first in English then in Bengali

[02/07, 21:43] Patient Advocate Diabetes 44F WB: Acha, allergy thekeo erokom hote pere ki?