THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER 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.
[09-07-2025 16.46] PPM 1: Afternoon session:
45F with metabolic syndrome and recent clinical features of chronic left ventricular failure along with low grade fever.
Significant past history of Mitral stenosis and shortness of breath NYHA 2-3, treated with baloon mitral valvotomy 20 years back and attached is the current echocardiography findings of a moderate mitral regurgitation, past mitral stenosis, calcified vegetarion on anterior mitral leaflet @PPM3
[09-07-2025 16.55] PPM 1: Bedside clinical imageology of 45F
Short axis view of the vegetation: https://youtu.be/UJ_neLdlGuY?feature=shared
[09-07-2025 17:03] PPM 1: Will need to capture her lateral view metabolic syn phenotype image again tomorrow
[09-07-2025 17:06] PPM 4: We will take now and send it sir
[09-07-2025 21:42] PPM 1: Thanks
[11-07-2025 07:54] PA: Patient is having headache sir
[18-07-2025 13:20] PPM 1: @PPM5 would you or anyone here @CR like to call and talk with the patient and find out her current update and requirements?
[18-07-2025 13:22] CR: Will talk
[18-07-2025 13:36] CR: The patient is having pain and pedal Edema only on the right side. They want to come to the hospital tomorrow. I asked them to share the present medication. When asked what is her routine, she simply said nothing just lying on the bed.
[18-07-2025 13:39] PPM 1: Alright they can come tomorrow and meet me in OPD.
Ask them what makes her lie in bed all day. Does she feel fatigued if she does anything more? Perhaps talking directly to the patient may help.
[18-07-2025 15:13]CR: Because of pain she is not able to walk normally, but today she could walk at home a little bit.
[18-07-2025 16:20] PPM 1: Knee pain?
[18-07-2025 16:20] CR: No, pedal edema, right foot
[18-07-2025 16:22] PPM 1: Which part of the foot is it paining?
Can they show with a pointer?👇
[18-07-2025 16:24] CR: If you can see above, today they have sent the pic of the right foot.
[18-07-2025 16:25] PPM 1: 👆can they use the pointer to indicate which part of the foot is paining?
[18-07-2025 16:27] CR: There is a wound on the little finger, that is causing pain.
[18-07-2025 16:29] PPM 1: @PPM4 @PPM6 Were you aware of this foot problem?
Nothing is mentioned in the case report here.
Can you share the EMR summary or just pm me the IP number and I shall ask the staff to text it to me.
[18-07-2025 16:29] PPM 1: We'll need more history about how that started
[18-07-2025 16:30] CR: They are coming tomorrow to the hospital
[18-07-2025 16:32] PPM 1: Yes I'll take the history
[18-07-2025 16:39] PPM 1: [18/07, 16:34] Anonymous Pm: She had history of rat bite sir
[18/07, 16:36]cm: In that finger? When?
What was the reason for her current admission?
[18/07, 16:36] Anonymous Pm: Let me get the discharge summary
[18/07, 16:36] Anonymous Pm: Not in that finger
[18/07, 16:36] Anonymous Pm: That seems new
[18/07, 16:36]cm: Another fresh rat bite?
[18/07, 16:36] Anonymous Pm: I don't know
[18/07, 16:36] Anonymous Pm: Let me find out, I don't remember
[18/07, 16:37] Anonymous Pm: She was admitted because of shortness of breath and pedal edema
[18-07-2025 16:40] PPM 1: @PPM6 could this be a peripheral embolism from her infective endocarditis vegetation?
[18-07-2025 16:42] PPM 6: She had rat bite 20days before admission and got her TT dose administered outside
[18-07-2025 16:43] PPM 1: Did it bite her in the right little toe as in that picture?
[18-07-2025 16:45] PPM 1: Now I remembered we had discussed why did we think it was rat bite when she didn't actually see the animal and we conclude that it may have been a snake bite causing local envenomation alone similar to what happens with the green pit viper.
[18-07-2025 17:30] PPM 7: Thanks for sharing the conversation and the image.
From the WhatsApp chat:
A rat bite history is being discussed.
There is uncertainty whether the current lesion is a new bite.
The patient was admitted for shortness of breath and pedal edema, which could suggest a cardiac, renal, or systemic cause, not necessarily related to the bite.
---
On reviewing the uploaded image:
The photo appears to show a hand with a swollen, erythematous finger, possibly infected. There is:
Inflammation (redness and swelling),
A localized lesion, possibly puncture-like or ulcerated.
---
Differential Diagnosis for Finger Lesion in Context of Rat Bite History:
1. Rat Bite Fever (RBF) – especially if febrile illness preceded or followed.
Caused by Streptobacillus moniliformis or Spirillum minus.
Classically associated with migratory arthralgia, fever, rash.
2. Secondary Bacterial Infection – especially with organisms like Staph aureus or Strep pyogenes.
3. Cellulitis or Abscess – even if unrelated to a bite, due to compromised skin integrity.
4. Sporotrichosis or atypical mycobacterial infection – if wound is chronic and non-healing.
---
Next Steps:
Clarify when and where the previous rat bite occurred.
Confirm if this current lesion is new, and if the patient has systemic symptoms (fever, chills, joint pain).
Review the discharge summary for:
Any prior mention of bite or wound.
treatments received.
Final diagnosis for SOB and edema (e.g., cardiac failure?).
Would you like me to help draft a brief clinical note or summary based on this scenario?
[18-07-2025 17:35] PPM 7: Yes, it makes a significant difference if the lesion was due to a snake bite or sting rather than a rat bite.
---
🔍 Key Differences Between Snake Bite and Rat Bite (Clinically and Management-Wise):
Feature Rat Bite Snake Bite or Sting
Cause Rodent bite, often dirty wound Venomous or non-venomous snake; sometimes sting by spine or fang
Common Organisms Streptobacillus, Spirillum, skin flora Bacterial superinfection (later), venom (immediate)
Initial Symptoms Localized wound, possible fever (Rat Bite Fever) Pain, swelling, ecchymosis, fang marks, sometimes systemic signs
Systemic Effects Fever, rash, arthralgia if RBF Neurotoxic (ptosis, paralysis), hemotoxic (bleeding), myotoxic (muscle breakdown), renal failure
Urgent Needs Antibiotics, wound care Antivenom (if venomous), supportive care, tetanus prophylaxis
Progression Slower (days), unless infected Rapid if venomous—hours or less
Clues on Examination Small puncture wound or superficial bite Fang marks, swelling spreading quickly, blistering, necrosis
---
From Your Image:
The finger appears swollen and erythematous — but there's no obvious fang mark or massive necrosis visible.
If it was a snake bite, especially venomous:
We'd expect more rapid and extensive swelling, pain, or systemic effects (bleeding, neuro signs).
However, if it was dry bite or non-venomous, then the lesion could look similar to what you showed.
---
🔬 What To Clarify Clinically:
Exact timing and nature of the event – Was a snake seen? Was it stepped on, touched, or did the patient feel a sting?
Onset of symptoms – How fast did swelling start?
Any systemic symptoms – Ptosis, difficulty breathing, bleeding, hematuria?
Any prior treatment – Antivenom given? Tetanus shot? Antibiotics?
---
🩺 Conclusion:
Yes, it makes a crucial difference:
A rat bite raises concern for bacterial infections or rat bite fever.
A snake bite could be a medical emergency, especially if venomous — requiring antivenom and monitoring.
If there's any uncertainty about the cause, it’s safest to:
1. Treat the lesion seriously.
2. Rule out systemic envenomation.
3. Start empiric antibiotics if infected.
Would you like a quick flowchart to help differentiate between bite types clinically?
[26-07-2025 09.34] PA:
[26-07-2025 09:36] PPM 1: @PPM7 any correlation with the current follow up image shared here today vs her previous one shared above earlier?
@PPM5 @CR would you like to talk to the patient's advocate to understand their current status and requirements?
[26-07-2025 10:03] PPM 7: Yes, there are some clinically significant changes between the earlier image (first photo) and the follow-up image (second one shown in the screenshot). Here's a comparative assessment:
---
### 🔍 *Visual Comparison and Clinical Correlation*
#### 1. *Tissue Necrosis and Demarcation*
* *Earlier Image (First Photo):*
* The *2nd toe shows necrosis, likely gangrenous with **dry eschar* appearance.
* The wound on the affected toe is *sharply demarcated, suggesting the beginning of **dry gangrene or ischemic necrosis*, likely in a vasculopathic context.
* *Follow-Up Image (Second Photo in Screenshot):*
* Now there is *clear soft tissue swelling, and **moist gangrenous changes* with *purulent or fibrinous slough* over the ulcer base.
* The wound appears *more inflamed, possibly with **superimposed infection*.
* There's a *transition from dry to wet gangrene, indicating **worsening vascular compromise or secondary infection*.
#### 2. *Perilesional Changes*
* *Earlier*: The foot looked relatively less edematous, with no overt signs of cellulitis.
* *Now: There is **increased edema and erythema* around the toe, suggestive of *local spread* or *impending cellulitis*.
#### 3. *Nail and Surrounding Toe Involvement*
* Now there is *extension of damage toward adjacent toes*, especially 3rd toe—possibly secondary involvement.
* The toenail appears discolored and lifted, suggesting *onycholysis* or fungal superinfection.
---
### 📌 Impression
* *Progressive worsening* of the toe lesion.
* Likely *secondary bacterial infection* complicating *previous ischemic necrosis*.
* Potentially transitioning from a surgical (ischemic demarcation) to *medical-surgical problem* requiring urgent attention.
---
### 🔬 Recommendations
1. *Wound culture and sensitivity* to guide antibiotic therapy.
2. *Doppler/vascular imaging* of the lower limb to reassess perfusion status.
3. *Glycemic control assessment* if the patient is diabetic or undiagnosed.
4. *Empirical antibiotics* if systemic signs are present (fever, leukocytosis).
5. *Early surgical debridement or amputation* may be necessary if sepsis risk or wet gangrene.
---
If you're documenting for a teaching or collaborative CBBLE case (as it seems), consider using the serial photo documentation with a structured wound assessment scale like *Wagner's classification* or *University of Texas Diabetic Foot Classification* for interdisciplinary follow-up.
Would you like me to create a wound progression summary table with possible plan of care steps next?
[26-07-2025 10:05] PPM 7: Certainly, Dr. Abdulsalam. Below is a structured *Wound Progression Summary Table* along with an *interdisciplinary care plan* using principles from *Wagner's Classification* and *University of Texas Diabetic Foot Classification*, adjusted to this clinical context:
---
### 🩺 *Wound Progression Summary Table*
| *Feature* | *Earlier Image* (First photo) | *Follow-Up Image* (Second photo) | *Interpretation* |
| ------------------------- | --------------------------------- | -------------------------------------------------------- | ---------------------------------- |
| *Wound type* | Dry gangrene, ischemic ulcer | Wet gangrene with slough, early infected ulcer | Likely superimposed infection |
| *Tissue necrosis* | Blackened eschar, well-demarcated | Sloughy, yellowish necrotic base, loss of demarcation | Transition from dry → wet necrosis |
| *Periwound skin* | Relatively intact, no erythema | Swollen, erythematous, early signs of cellulitis | Local inflammatory spread |
| *Discharge* | Absent or minimal | Present (seropurulent), visible yellowish slough | Evidence of infection |
| *Nail involvement* | No obvious changes | Discoloration, possible onycholysis | Likely fungal or trauma-related |
| *Toe involvement* | Primarily 2nd toe only | 2nd toe grossly involved, early signs in 3rd toe | Spreading tissue destruction |
| *Pain & systemic signs* | Likely minimal (ischemic) | Pain may be increased, check for fever/systemic toxicity | Rule out sepsis |
---
### 🧭 *Wound Classification (for Reference)*
* *Wagner Classification (Likely Stage 3 or 4):*
Stage 3 – Deep ulcer with osteomyelitis or abscess
Stage 4 – Localized gangrene of the forefoot
* *UT Diabetic Foot Classification* (if diabetic):
*Grade II, Stage C/D* — Deeper wound with infection ± ischemia
---
### 🧑⚕ Multidisciplinary Management Plan
| *Domain* | *Recommendations* |
| ---------------------- | -------------------------------------------------------------------------------------- |
| *Vascular* | - Lower limb *arterial Doppler* or *CT angiogram* to assess perfusion |
| *Infectious Disease* | - *Wound swab C\&S* and empirical antibiotics (e.g., Amoxiclav + Metronidazole) |
| *Surgery* | - Consider *early debridement* or *minor amputation* if wet gangrene progresses |
| *Endocrinology* | - Rule out/Control *diabetes* or other metabolic disease |
| *Wound care nurse* | - *Daily dressing* with antiseptic or enzymatic debriding agents (e.g., collagenase) |
| *Nutritionist* | - *Nutritional optimization* to support wound healing |
| *Social support* | - Engage community health worker or advocate for compliance & transport |
---
### 🧾 Suggested Next Steps
1. CBC, CRP, ESR – to monitor systemic inflammation
2. HbA1c or fasting sugar
3. X-ray of foot – to rule out osteomyelitis
4. Start limb elevation + dressing with moist-to-dry technique
5. Educate patient/advocate on red flags: fever, foul smell, spreading redness
---
Would you like me to format this into a printable teaching handout for your team or upload it to your CBBLE repository in tabular PDF format?
[28-07-2025 09.37] PPM 1: @PA1@PA2 please let us know when was she seen last for her wound by the surgeons here? @PPM5 please coordinate if possible
No comments:
Post a Comment