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.
[20-08-2025 21.49] PPM 1: Consistent with pulmonary vasculitic Hypertension due to scleroderma
[20-08-2025 21:52] PPM 2: Raynaud's history?
[20-08-2025 21:55] PPM 1: @PPM3 @PPM4 @PPM5 please check tomorrow if the patient's advocate has a WhatsApp number.
Meanwhile @PPM6 please see if you can take a telephonic history tomorrow since her childhood. Today during rounds from what we could gather she kept insisting that her major issue was shortness of breath since infancy coming intermittently with exacerbations.
Will also need to get her Hrct chest images from our console
[20-08-2025 22:04] PPM 4: Okay sir
[20-08-2025 22:57] PPM 2: That's a massive RA there. Are you suspecting Primary PAH here? @PPM1 Sir - Needs ILD ruled out too. Hoping to see a CXR
[20-08-2025 22:58] PPM 2: Can see on the blog that is what you think. Curious to discuss this x-ray further
[20-08-2025 23:00] PPM 2: X-ray does show a dilated left heart with straightened border and possible multichamber cardiomegaly. Echo suggests otherwise!
[21-08-2025 07:31] PPM 1: Can you perform her nail bed examination for vascular telengiactatic changes using an ophthalmoscope? @Meta AI please explain the methodology further and it's sensitivity and specificity to diagnose scleroderma
[21-08-2025 07:31] Meta AI: Yes, an ophthalmoscope can be used to examine nailfold capillaries for vascular changes, such as telangiectasias, that are associated with systemic sclerosis (scleroderma). This method is referred to as nailfold capillaroscopy, though a dermatoscope or specialized capillaroscope is more commonly used. Here's how it works and its diagnostic utility:
### Methodology:
1. Preparation:
- Ensure the patient’s hands are warm to optimize blood flow to the capillaries.
- Place the patient’s hand on a flat surface with the fingers extended.
2. Magnification:
- Use the ophthalmoscope at its lowest magnification setting (commonly 20x to 40x).
- Apply a drop of immersion oil or water to the nailfold to improve visualization of the capillaries.
3. Examination:
- Focus on the skin just proximal to the cuticle (nailfold area).
- Observe the capillary loops for abnormalities such as dilated capillaries, avascular areas, hemorrhages, or "giant" capillaries.
4. Findings in Scleroderma:
- Early: Capillary dilations and a few hemorrhages.
- Active: Giant capillaries, capillary dropouts, and disorganized capillary architecture.
- Late: Severe capillary loss and avascular zones.
### Sensitivity and Specificity:
- Nailfold capillaroscopy is highly sensitive and specific for diagnosing systemic sclerosis (scleroderma), particularly when characteristic findings are present.
- Sensitivity: Studies report sensitivity ranges from 80% to 90%, depending on the stage of the disease and the expertise of the examiner.
- Specificity: The specificity is similarly high, often above 90%, because the specific capillary patterns seen in scleroderma (e.g., giant capillaries and avascular zones) are rarely seen in other conditions.
- However, findings may overlap with other connective tissue diseases, such as dermatomyositis or mixed connective tissue disease, reducing specificity in some cases.
### Limitations of Using an Ophthalmoscope:
- The ophthalmoscope is not the ideal tool due to its relatively low magnification compared to a capillaroscope or dermatoscope.
- It may not capture subtle or early changes accurately, reducing diagnostic sensitivity in early disease stages.
Would you like more details on how nailfold findings correlate with disease progression?
[21-08-2025 08.14] PPM 1: @PPM7 @PPM3@PPM5 @PPM4 please check out with the dermatologists if they can do this using a dermatoscope, if they have one.
[21-08-2025 09:21] PPM 4: Okay sir
[21-08-2025 09:22] PPM 6: ok sir.. will do it by tonight
[22-08-2025 17:00] PPM 1: Is she still in ward? @PPM3?
36f EMR summary from previous admission discharge
Age/Gender: 37 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 17/12/2024 05:18 PM
Name of Treating Faculty
Diagnosis
DIFFUSE CUTANEOUS SS-SCLERODERMA WITH ILD WITH PULMONARY ARTERY
HYPERTENSION.
B/L BRONCHIECTASIS
MODERATE ANEMIA
Case History and Clinical Findings
C/O SHORTNESS OF BREATH SINCE 5 DAYS
C/O COUGH SINCE 5 DAYS
HOPI- PATIENT WAS APPARANTLY ASYMPTOMATIC TILL 5 DAYS BACK, THEN DEVELOPED SHORTNESS OF BREATH, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE FROM GRADE I TO GRADE II-III. AGGREVATED ON WALKING/EXERTION AND RELEIVED WITH REST.
ORTHOPNEA , PND ABSENT
C/O COUGH SINCE 5 DAYS, NOT ASSOCIATED WITH SPUTUM. NO C/O CHESTPAIN,
PALPITATIONS.
C/O PEDAL EDEMA, B/L PITTING TYPE, EXTENDING UPTO THE KNEES, NO AGGREVATING
AND RELIEVING FACTORS.
B/L SWELLING OF UPPERLIMBS AND ALSO INVOLVEMENT OF FACE, NO
AGGREVATING/RELIEVING FACTORS.
NO C/O FEVER,COLD.
NO C/O BURNING MICTURITION/DECREASED URINE OUTPUT.
K/C/O BRONCHIAL ASTHMA SINCE CHILDHOOD AND USES INHALER ONCE A MONTH.
N/K/C/O HTN, TB, DM, EPILEPSY, CVA, CAD
NO OTHER COMORBIDITIES.
Page-2
KIMS HOSPITALS
2
GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, EDEMA
TEMP- 98.6 F
BP: 110/80 MMHG
PR: 86 BPM
RR: 16 CPM
SPO2: 100%
GRBS- 99 mg/dL
APPETITE- NORMAL
BOWELS- REGULAR
MICTURITION- NORMAL
ADDICITIONS- NO ADDICITIONS
SYSTEMIC EXAMINATION :
CVS: S1S2 +
RS: BLAE + NVBS HEARD
P/A: SOFT NON TENDER
CNS: NO FND
DERMA REFERRAL (21-12-24) I/V/O SCLERODERMA ANA POSITIVE
TREATMENT- LIQUID PARAFFIN L/A BD X-------X FOR 2 WEEKS
PULMONOLOGY REFERRAL(20-12-24) I/V/O SOB SINCE CHILDHOOD ON AND OFF AND
BRONCHIECTATIC CHANGES IN HRCT CHEST
TREATMENT- CST
O2 SUPPORT TO MAINTAIN SPO2> 92%
CONSIDER INJ AUGMENTIN 1.2GM IV/TID
COURSE IN HOSPITAL- PATIENT WAS ADMITTED I/V/O ABOVE MENTIONED COMPLAINTS
AND FURTHER EVALUATED, ANA PROFILE SENT- SM PCL- POSITIVE, 2D ECHO-FEATURES
SUGGESTIVE OF PULMONARY ARTERY HYPERTENSION, HRCT CHEST DONEBRONCHIECTASIS IN RIGHT MIDDLE LOBE AND BASAL SEGMENTS OF LEFT LUNG LOWER LOBE, MILD PERICARDIAL EFFUSION, MILD GROUND GLASS OPACIFICATION OF BOTH LUNGS- LUNG CONGESTION AND DIAGNOSED AS, DIFFUSE CUTANEOUS SS-SCLERODERMA WITH ILD WITH PULMONARY ARTERY HYPERTENSION, B/L BRONCHIECTASIS, MODERATE ANEMIA AND MANAGED CONSERVATIVELY WITH ORAL STEROIDS, IMMUNOMODULATORS
AND IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION
Page-3
KIMS HOSPITALS
3
Investigation
InvestigationsName Value Range
Name Value RangeLIVER FUNCTION TEST (LFT) 17-12-2024 05:38: PM Total Bilurubin 0.60 mg/dl
1-0 mg/dl Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dl SGOT(AST) 20 IU/L 31-0 IU/LSGPT(ALT) 14 IU/L 34-0 IU/L ALKALINE PHOSPHATASE 113 IU/L 98-42 IU/LTOTAL PROTEINS 6.5 gm/dl 8.3-6.4
gm/dl ALBUMIN 3.0 gm/dl 5.2-3.5 gm/dl A/G RATIO 0.87
HBsAg-RAPID 17-12-2024 05:38:PM Negative Anti HCV Antibodies - RAPID 17-12-2024 05:38:PM
Non Reactive
COMPLETE URINE EXAMINATION (CUE) 17-12-2024 05:38:PM COLOUR Pale
yellow APPEARANCE Clear REACTION AcidicSP.GRAVITY 1.010ALBUMIN Nil SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil BLOOD UREA 17-12-
2024 05:38:PM 16 mg/dl 42-12 mg/dl
SERUM CREATININE 17-12-2024 05:38:PM 0.7 mg/dl 1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) 17-12-2024 05:38:PM SODIUM 138 mmol/L 145-136 mmol/L POTASSIUM 4.5 mmol/L 5.1-3.5 mmol/L CHLORIDE 98 mmol/L 98-107 mmol/L
T3, T4, TSH 17-12-2024 11:52:PM T3 0.86 ng/ml 1.87-0.87 ng/mlT4 9.59 micro g/dl 12.23-6.32 micro
g/dlTSH 7.40 micro Iu/ml 5.36-0.34 micro Iu/mlT3, T4, TSH 19-12-2024 11:42:PM T3 0.86 ng/ml 1.87-0.87 ng/mlT4 10.33 micro g/dl 12.23-6.32 micro g/dl TSH 3.72 micro Iu/ml 5.36-0.34 micro Iu/ml
ABG 21-12-2024 06:13:AM PH 7.33PCO2 60.5PO2 50.2HCO3 31.5 St.HCO3 28.8BEB 5.2BEecf
5.9TCO2 67.9O2 Sat 76.0O2 Count 8.9BLOOD UREA 22-12-2024 10:37:PM 41 mg/dl 42-12 mg/dl
SERUM CREATININE 22-12-2024 10:37:PM 0.7 mg/dl 1.1-0.6 mg/dl SERUM ELECTROLYTES (Na, K, C l) 22-12-2024 10:37:PM SODIUM 134 mmol/L 145-136 mmol/L POTASSIUM 4.2 mmol/L 5.1-3.5mmol/LCHLORIDE 98 mmol/L 98-107 mmol/L
2D ECHO -ON 27/12/24
D SHAPE LV
SEVERE TR WITH PAH
TRIVIAL AR, MILD PR , NO MR
MILD PE + , NO LV CLOT
DILATED R.A /R.V
MILD DILATED MPA (2.8 CMS)
EF - 62 % , GOOD LV SYSTOLIC FUNCTION
NO DIASTOLIC DYSFUNCTION
HRCT CHEST DONE ON 19-12-24
Page-4
KIMS HOSPITALS
IMPRESSION- BRONCHIECTASIS IN RIGHT MIDDLE LOBE AND BASAL SEGMENTS OF LEFT LUNG LOWER LOBE, MILD PERICARDIAL EFFUSION, MILD GROUND GLASS OPACIFICATION
OF BOTH LUNGS- LUNG CONGESTION AND DIAGNOSED AS,DIFFUSE CUTANEOUS SSSCLERODERMA
Treatment Given(Enter only Generic Name)
TAB MYCOPHENOLATE MOETEFIL 500MG/BD 2 TABLETS IN MORNING 1 TABLET AT NIGHT 2 HRS BEFOR EFOOD
TAB PREDNISOLONE 7.5MG 8AM
TAB TADALAFIL 10MG OD
TAB DYTOR PLUS 10/50
1(8AM)-----------1/2(3PM)
TAB PAN 40 MG OD
SYP ASCORIL D 10ML/TID
SYP CREMAFFIN 15ML/HS
Follow Up
REVIEW TO GEN MEDICINE OPD AFTER 1 WEEK
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendant Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Page-5
KIMS HOSPITALS
Discharge Date
Date: 30-12-2024
Ward: FMW
Unit: II
[22-08-2025 17:08] PPM 3: no sir
[22-08-2025 17:09] PPM 1: Please DM her recent discharge summary
[22-08-2025 17:12] PPM 8: Based on the discharge summary provided, the patient was discharged on December 30, 2024, and was not in the ward as of that date. The summary clearly states "Discharge Type: Relieved," indicating she was released from the hospital.
📊 Key Details from the Discharge Summary:
· Admission Date: December 17, 2024
· Discharge Date: December 30, 2024
· Ward/Unit: FMW/Unit II
· Condition at Discharge: The patient was in a hemodynamically stable condition and discharged with a treatment plan, including medications and follow-up instructions .
💡 Important Notes:
· The patient has a complex medical history, including diffuse cutaneous systemic sclerosis with interstitial lung disease (ILD) and pulmonary arterial hypertension, which requires careful long-term management. ILD associated with systemic sclerosis is a leading cause of mortality in these patients, making consistent follow-up crucial .
· The discharge plan includes a follow-up appointment in the general medicine OPD after one week (which would have been around early January 2025).
· The summary also advises seeking urgent care if any emergency symptoms arise.
❓ If You Are Checking for a More Recent Status:
Since this discharge summary is from December 2024, and today's date is August 22, 2025, her current status may have changed. For the most up-to-date information on whether she has been readmitted or her current health status, it is best to:
1. Contact the hospital directly (KIMS Hospitals) at the number
2. Reach out to the treating faculty, or the hospital's administration for any recent updates.
Please let me know if you need further assistance!
[22-08-2025 17:13] PPM 1: Yes she was readmitted and discharged recently
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