Sunday, August 31, 2025

Narketpally syn CBBLE:Participatory medical cognition Web 2.0-3.0, March 2025

 
NARKETPALLY SYN CBBLE: PARTICIPATORY MEDICAL COGNITION WEB2.0-3.0 MARCH 2025.

[01/03, 08:19] apm: In summary, the cumulative exposure to CYC that results in ovarian failure varies by age. To avoid amenorrhea, female patients < 20 years old should likely receive < 15 to 20 g of total exposure, patients aged 20 to 30 should receive < 15 g of total exposure and those > 30 should likely receive < 10 g of total exposure. We did not make a recommendation for maximum exposure to prevent infertility in patients > 40 as this group already has a low baseline fertility rate, worsened by disease activity. In males, the maximum CYC exposure for patients who still wish to conceive is lower at approximately 10 g.
[01/03, 08:23] apm: We are just calculating the cost of tablets sir.  Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
[01/03, 08:26] pm: So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
[01/03, 08:28] pm: As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!
[01/03, 08:31] apm: Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based..
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
01/03/2025, 13:04 - Ex BRAMC: Thank you cm
01/03/2025, 13:13 - cm: Welcome Ma'am.
Please go through the description box here and do share your queries on our workflow.
We generally keep sharing certain portals to our patient centred medical cognition workflow here from time to time and depends on one's interest a group member is free to provide their own inputs on the patient here or even get into the group marked for that particular individual.
For example I'm resharing a conversational transcript posted today morning about one of our current inpatients here 👇
Morning PaJR session on a young patient with indolent lupus nephritis responsive to azathioprine and yet developing possible pancreatitis due to cumulative dose toxicity looking for other lower cost alternatives such as cyclophosphamide and yet she's a young unmarried woman where cyclophosphamide runs the risk of gonadal toxicity:
[27/02, 07:30: Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating
However having said that I guess we should stop azathioprine for now
Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission
[27/02, 14:35] pg: Can we plan renal biospy for her sir?!
[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.
Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today
So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!
Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!
[28/02, 14:24] pm: @huai3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @huai51 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.
We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @919505766290 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet
[28/02, 15:55]apmalum : Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.
[28/02, 15:59] apmalum: Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir
[01/03, 08:19] apm: In summary, the cumulative exposure to CYC that results in ovarian failure varies by age. To avoid amenorrhea, female patients < 20 years old should likely receive < 15 to 20 g of total exposure, patients aged 20 to 30 should receive < 15 g of total exposure and those > 30 should likely receive < 10 g of total exposure. We did not make a recommendation for maximum exposure to prevent infertility in patients > 40 as this group already has a low baseline fertility rate, worsened by disease activity. In males, the maximum CYC exposure for patients who still wish to 
conceive is lower at approximately 10 g.
[01/03, 08:23] apm: We are just calculating the cost of tablets sir.  Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..
[01/03, 08:26] pm: So the harms appear to be worth a try!
Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil
[01/03, 08:28] pm: As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks
[01/03, 08:31] apm: Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...
So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...
In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....
01/03/2025, 16:55 - cm: This PaJR case report and conversational transcripts were shared with another general medicine global CBBLE and @cr can you add those conversations clarifications also to her PaJR case report here👇 https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1 also including the actual further discussions also in the patient's PaJR group today?
Other CBBLE group conversations to be added👇
[01/03, 10:06] rk: How this case relevant to META AI or LLM ???
[01/03, 10:06]ek: Just curious
[01/03, 16:50] cm: The opening comment about meta AI (LLM) comes after a few more inputs visible in sequence in the case report where the team based learning members of the patient's PaJR group were discussing the diagnostic uncertainty around the patient's pain abdomen and vomiting where the team had initially gone in the direction of inflammatory bowel disease causing intestinal obstruction and vomiting and pain before one of the members clarified using meta AI that possibly it was her steroids and cumulative dose of azathioprine that was precipitating her pancreatitis and we were actually dealing with a smoldering pancreatitis which made the treating team stop her azathioprine resulting in her recovery!
The subsequent conversations today are around the next step to find a pharmacological replacement for her azathioprine that had to be stopped
01/03/2025, 17:00 - Patient Advocate 56F Migraine Hypothyroidism 2000: Names(initials)can be added?
01/03/2025, 17:00 - cm: rk and cm? Yes
01/03/2025, 21:54 - Ex BRAMC: First ECG 
P waves not regular
But RR interval appears normal
01/03/2025, 22:10 - cm: Yes
There also appears to be some artifacts between the rr intervals?
01/03/2025, 22:15 - huai46: I have prepared 2 page summary of the article for the physician community
By using ChatGPT or similar tools you can get the analysis of issues relating to PHR, different data and other standards and clinical informatics applications from this article
01/03/2025, 22:17 - huai46: cm you can analyse the article from the patient or patient journey or patient perspective point of view It's a very good article
01/03/2025, 22:20 -cm: Thanks
02/03/2025, 08:17 - SBB: I am surprised that the article fails to mention Rector & Nolan's work on the Problem Oriented Medical Records (POMR). That forms the basis of the Subjective-Objective-Assessment-Plan (SOAP) approach that most EMRs tend to take.
A very telling observation I found was that the "current EHRs do not meet the needs of today’s distributed systems and of the rapidly changing healthcare environment. The ability of applications to communicate, interpret, and act intelligently upon complex healthcare information has 
assumed paramount importance."
I am happy to note that hospitals have begun to routinely use EMRs to share information amongst colleagues. Unfortunately, the insistence on free text entries instead of coded means that the users continue to rely on having busy practitioners to read through and form an opinion regarding next steps. It must be working, else it would have been long since junked. However, this approach fails to make the maximum use of technology and informatics. For example, machine-interpretability would have ensured the highlighting of important information, raising appropriate alerts and warnings, even initiating follow on or task delegations, etc.
02/03/2025, 08:26 - PaJR Physicist: Love the word 'problem oriented medical record',  especially when the EMR itself is stuffed with subjective and biased data? BTW the 'problem' refers to which or who?
02/03/2025, 08:28 - SBB: The problem that the patient reports. It could be something like fever or cough and cold or pain or whatever. It could also be a diagnosis like diabetes mellitus type 2 or hypertension or viral fever or whatever.
02/03/2025, 08:34 -huai46: Dr Bhattacharya
Can you please query the article from the technical angle of EMR like using the SOAP approach / standards etc.
The article do mention about various standards of an EMR
You can enlighten all of us with your efforts
While reading the article, I found some newer terms and I will have to study them further to fully understand them
The article also mentions the use  of clinical informatics to create Learning Health systems
02/03/2025, 08:53 - SBB: The first thing to do is to ensure that the content is semantically interoperable. Taking the SOAP approach already achieves syntactic interoperability to a certain degree, making the use of technology to get the contents FHIR compatible easier. The major challenge is the content, for it is here the real "magic" of healthcare happens. Clinicians use information to manage patients. *Information* is *data with context*. Syntactic interoperability is fairly impressive in transporting data. The data then has to be processed using the correct context for each. It is here that things can go very wrong if the correct matching does not happen. Healthcare information management is critical as it contributes high morbidity and mortality. Now, these cannot be clearly appreciated by those who do not have domain knowledge. It actually is unfair to expect this of those who lack it.
02/03/2025, 09:17 - huai46 As I see it 
EMR, PHR and Clinical Informatics applications (ability to query them) and public health informatics should be available 24 x 7.
However, unlike some countries who are using data science and other emerging technologies, in India we are not organising and using public health / clinical data strategically. Our system is working in silos
02/03/2025, 09:51 - SBB: Actually, innovation is not encouraged in India, yet. We all remain transfixed by the _jugaad_ culture. That's not enough and is counterproductive in many instances. The government's intent is to ensure 24x7 access to healthcare information. The entire effort of EHR Standards, health stack, ABDM, NHCX, etc., is geared towards this. Unfortunately, until and unless things are made "mandatory" in India, there will be zero effort by the industry to make the continuous access a reality. Just consider this. Designing an EMR to capture free text is so easy. Provide an input or, better still, a textarea. Nothing else is required, SNOMED CT or LOINC or any other controlled medical vocabulary be damned. Now, use the information captured. Good luck even trying to do that. What is required for that? An initial investment of $1 million and a recurring expense of $50,000 annually. Welcome to nightmare. I am amazed that no one talks about Net Present Value (NPV), free cash flows, and IRR. Everyone is looking for quick payback time and remain fixated on RoI. Complete lack of awareness of financial management. Is it any wonder that most fail or get taken over? Software vendors (fail), hospitals (taken over).
02/03/2025, 10:42 - cm: It refers to the patient's problem list
02/03/2025, 11:04 - cm: More about the A of SOAP here 👇
02/03/2025, 11:12 - cm: For our first year PGs who joined our CBBLE (pronounced cable) here yesterday and are naturally finding all the discussions overwhelming and tangential, please filter whatever you like and see if you can share some deidentified patient data from our trenches there as shared here in the past and archived in individual patient learning portfolios here for newcomers to see 👇
medicine department dashboard (1000s):
02/03/2025, 11:46 -huai46: cm, You all are doing something novel and less appreciated job due to ignorance of many.
Can you please explain the whole concept in a Zoom meeting session.
It will educate us, clear lots of doubts and in future we will be on the same page in our discussions
02/03/2025, 11:50 - cm: Sure will try to take out time
03/03/2025, 08:10 - cm: Amazing work and title for a digital user driven healthcare ecosystem in diabetes reversal goal management from apparently a pre AI LLM era where stuff was done more slowly but surely!
It's also interesting to draw comparison with our regular digital user driven diabetes patient relatives (immediate caregiver users) where we have sensed their care giver burden often due to micro management by our own team based learning ecosystems @huai2and while the people who published the above study, did the qualitative analysis using traditional coding, for us the data analysis has been relatively much more simpler and automated, with us just having to ask the LLM to do the thematic analysis of the entire data in the EHR case report URLs beginning with the coding, categorisation and extraction of learning insights from the data. @se 
We would like to do a follow up with the full text supplemental questionnaires, apparently freely available from the article page for some of our own patients ranging from 3 years old https://narmeenshah.blogspot.com/2024/07/3-year-old-child-type1-diabetes-insulin.html?m=1 , 30 years old https://patientnewhealthreport2024.blogspot.com/2024/12/patientnewhalthreport2024.html?m=1
03/03/2025, 09:23 - cm: In user driven healthcare digital ecosystems, patients and relatives often end up doing more hard work in having to capture patient data and feed it to the health professional users for their feedback who reward their hard work of patient data capture and sharing by giving them more hardwork of now administering the doses decided by the team in a shared decision making ecosystem and while health professionals end up sharing more of the collective cognitive burden, patients and their relatives are saddled with the physical implementation burden and responsibility toward their own outcomes!
03/03/2025, 20:51 - Patient Advocate 56F Migraine Hypothyroidism 2000: This too 55M?
03/03/2025, 20:53 - cm: Yes
03/03/2025, 20:53 - Patient Advocate 56F Migraine Hypothyroidism 2000: Okay
04/03/2025, 08:32 - cm: Morning asynchronous PaJR session: Diabetes reversal and individual patient inquiry answered by AI
Summary:
PaJR patient on regular follow up for diabetes reversal is intrigued by a social media reel of a celebrity general physician of Kolkata and asks the PaJR physician about it for an explanation for reason why the celebrity physician is asking protein to be consumed first before carbohydrates. The PaJR physician is unable to answer because even he would need to look into the scientific data behind the statements and in the meantime the patient asks an AI LLM! 
Conversational Transcripts:
[03/03, 16:49] Patient Advocate Diabetes 44F WB: Sir kdin age reels dekchilam amra j khabar age khai seta naki age poripak hoy ,tai jonno 1st protein,then fat or sabji ekdom ses e carb diye olpo veggies khaoa bhalo ..er mane thik bujhte parlamna kno?jodi sombhob hoy tahole ektu bolben er reason ta ki?
[03/03, 16:54] pm: Reel a link ta share korben
[03/03, 16:55] Patient Advocate Diabetes 44F WB: Ei re .dekhchi jodi pai pathachi
[03/03, 17:17] Patient Advocate Diabetes 44F WB: https://www.facebook.com/share/v/1BhD9vo4aJ/
[03/03, 20:06]pm: Khub bhalo bolechen
👏👏
[03/03, 20:06] Patient Advocate Diabetes 44F WB: Kintu karon ta bujhte parini r tahole ki eibhabei khabo?
[03/03, 23:17] Patient Advocate Diabetes 44F WB:
 https://chatgpt.com/share/67c5eb13-d238-8006-adc6-45a2d758cd4c
[03/03, 23:19] Patient Advocate Diabetes 44F WB: Yes, sir .I have received this answer from chatgpt..
ChatGPT
This is a copy of a conversation between ChatGPT & Anonymous.
You said:
What is the actual reason of eating protein 1st then have to eat others...
ChatGPT said:
The idea of eating protein first before other foods is based on how it affects digestion, metabolism, and blood sugar levels. Here are the key reasons:
Better Blood Sugar Control – Protein slows down the digestion and absorption of carbohydrates, preventing sudden spikes and crashes in blood sugar levels. This helps in maintaining steady energy levels.
Increased Satiety (Fullness) – Protein keeps you fuller for longer by reducing hunger hormones like ghrelin and increasing satiety hormones like peptide YY. This helps in controlling overall food intake.
Improved Digestion and Nutrient Absorption – When protein is eaten first, it activates digestive enzymes and stomach acids, which help in breaking down food more effectively.
Muscle Maintenance and Growth – Eating protein early in the meal ensures that the body gets enough essential amino acids to repair and build muscles, especially for those who are physically active.
Weight Management – Since protein helps control appetite and reduces cravings, eating it first may lead to consuming fewer calories overall.
So, starting your meal with protein (like dal, tofu, paneer, or beans in a vegetarian diet) before moving to carbs and fats can have multiple health benefits.
You said:
Pl translate in Bengali 
ChatGPT said:
প্রথমে প্রোটিন খাওয়ার পিছনে মূল কারণগুলি হল:
রক্তে শর্করার নিয়ন্ত্রণ উন্নত হয় – প্রোটিন ধীরে হজম হয় এবং কার্বোহাইড্রেটের শোষণকে কমিয়ে দেয়, ফলে রক্তে শর্করার মাত্রা হঠাৎ বেড়ে যাওয়া বা কমে যাওয়া থেকে রক্ষা করে। এটি শক্তি স্থিতিশীল রাখতে সাহায্য করে।
তৃপ্তি বেশি থাকে – প্রোটিন ক্ষুধার হরমোন (ঘ্রেলিন) কমিয়ে দেয় এবং পেট ভরানোর হরমোন (পেপটাইড ওয়াইওয়াই) বাড়ায়, যার ফলে দীর্ঘ সময় ক্ষুধা লাগে না।
হজম ও পুষ্টি শোষণ ভালো হয় – প্রথমে প্রোটিন খেলে হজমকারী এনজাইম ও পাকস্থলীর অ্যাসিড সক্রিয় হয়, যা খাবার ভাঙতে সাহায্য করে।
পেশি গঠনে সহায়তা করে – শরীরের পেশি গঠনের জন্য প্রয়োজনীয় অ্যামিনো অ্যাসিড প্রোটিন থেকে পাওয়া যায়, তাই প্রথমে প্রোটিন খেলে পেশির যত্ন ভালোভাবে হয়।
নিয়ন্ত্রণে সাহায্য করে – প্রোটিন বেশি সময় পর্যন্ত পেট ভরা রাখে এবং অতিরিক্ত ক্যালোরি গ্রহণ কমাতে সাহায্য করে, ফলে ওজন নিয়ন্ত্রণ করা সহজ হয়।
তাই খাবারের শুরুতে প্রোটিন (যেমন ডাল, সোয়া, পনির বা বিন্স) খেলে তা স্বাস্থ্যের জন্য উপকারী হতে পারে।
04/03/2025, 09:07 - huai46 Haru - The Honda Robot talks to people with expressions and has immense potential to find solution in the healthcare industry
04/03/2025, 09:08 - cm Waiting eagerly for our upcoming batch of Honda robot residents!
04/03/2025, 12:20 - cm: @huai105 @huai98@huai83this patient's discharge 👇
Needs to be readied so that they can leave early morning tomorrow
04/03/2025, 12:52 - Kolkata Medical College Intern: Any more symptoms / co morbidity...!
04/03/2025, 13:02 - Kolkata Medical College Intern: myelopathy, present.
04/03/2025, 13:05 -  Kolkata Medical College Intern: Cervical OPLL with spinal canal stenosis
Consideration of cervical myelopathy if neurological deficits this  present.
04/03/2025, 13:10 - cm: No myelopathy
OPLL is very common in our elderly patient population here assumed to be due to fluorosis
04/03/2025, 13:16 - Kolkata Medical College Intern: serum and urine fluoride levels check.
04/03/2025, 18:44 - pajr.in CEO, NHS Endocrinologist: Long term steroids?
04/03/2025, 20:58 - huai70: Sir does it require surgical intervention ?
04/03/2025, 20:59 - cm: Was on budesonide intermittently since her Crohn's diagnosis
04/03/2025, 20:59 -cm: Would be very risky to provide anesthesia in her current critically ill state
04/03/2025, 21:00 - huai70: Yes Sir.
05/03/2025, 11:56 - cm: Inputs from all India general medicine residents group:
[05/03, 11:21] b: Lathyrism?
[05/03, 11:21] a: Check for cerebellar signs
[05/03, 11:43]cm: Because of broad based gait ataxia? Well no she doesn't
[05/03, 11:44]cm: What features? Lathyrism is an etiology? What about the neurology localisation?
[05/03, 11:44] a: Actually it feels that she is falling on right side
[05/03, 11:44] a: While walking
[05/03, 11:49] cm: Well observed 👏👏
[05/03, 11:51] cm: Alright let me share what I found on examining her right lower limb and left.
The right lower limb had marked hypertonia much more than the left confirming the impression we made by the scissoring components of her gait. The reflexes were hyper exaggerated again right more than left.
05/03/2025, 12:03 - pajr.in CEO, NHS Endocrinologist: Lichen?
05/03/2025, 13:01 - pajr.in CEO, NHS Endocrinologist: Ohhh yes!!!
05/03/2025, 13:27 - Kolkata Medical College Intern: Oooo....
05/03/2025, 13:28 - Kolkata Medical College Intern: Possibility - chronic lead poisoning (plumbism). And peripheral neuropathy. 
05/03/2025, 13:32 - Kolkata Medical College Intern: Yes sir ,  dermatological lesions can sometimes be a manifestation of a paraneoplastic syndrome.
05/03/2025, 14:19 - cm: We are thinking Fluorotic teeth here along with fluorosis as the cause of her compressive cervical myelopathy as it's relatively common here
05/03/2025, 14:49 - huai25: What more...
05/03/2025, 14:49 - cm:  👆
05/03/2025, 15:00 - huai109: X rays of this patient 👆👆
05/03/2025, 15:09 - cm: 👆There is OPLL in the cervical vertebrae as expected. The likely reason for her spastic quadriparesis through cervical spinal cord compression
05/03/2025, 15:09 - cm: 👆 Unable to visualise the dorsal area where there is high likelihood of osteoporotic fractures
05/03/2025, 19:47 - cm: Tomorrow's Academics
Staff clinical meet 
Venue - LT1 
Timings - 8 AM
Unit - OBG
Case 1 - "Pregnancy in 21 years, G2P0010, Liver transplant recipient for Wilson's disease"
Presenter - Dr. Amanjot Kaur
Case 2 - "Pregnancy in 22 years PGR with transfusion dependant thalassemia intermedia"
Presenter : Dr. Snigdha Kumari 
Chairperson - Prof. Seema Chopra 
The session will also be available on online webEx platform. The link has been sent below. 
Thank you
06/03/2025, 07:17 -cm: @huai4: This patient may be of interest to your group and you may like to join the PaJR group linked here and invite others from your oncology team for effective patient related outcomes as well as per your snippet yesterday also trying to ensure that they don't discontinue treatment 👇
https://chat.whatsapp.com/LK1rtKHq02LGNnJwy3SUPE
The history is mentioned in the description box in the patient's own language and currently he's planned to visit us for neurorehab @huai25 and @cr would be great if you could prepare the case report from the data there of clinical images etc which I shall again forward as you may have been added later
06/03/2025, 11:55 - Kolkata Medical College Intern: 1) Kayam Churna-  Ayurvedic remedy often used constipation.
2) Chronic constipation-  senna, a stimulant laxative. Long-term use of senna (over 2 years) lead to potential side effects such as dehydration,low potassium), or laxative dependence.
3)Prolomate XI-proton pump inhibitor or antacid
4) posible Review Senna Use,reduce dependency.
5) consuming enough fiber,
6)COPD is well-managed with appropriate inhalers  bronchodilators &  beta-agonists or anticholinergics.
• Optimize COPD management this pesent, ensuring & wach proper inhaler use and considering pulmonary rehabilitation.
06/03/2025, 12:24 - Kolkata Medical College Intern: My opinion - posterior longitudinal ligament (PLL), body of the axis (C2) down to the sacrum. primarily functions to prevent excessive flexion of the spine and limit posterior disc herniation.
06/03/2025, 12:27 - Kolkata Medical College Intern: I think - Fracture Neck of Femur or Intertrochanteric Fracture,
•• diabetic history .? 
06/03/2025, 12:32 -cm: Needed inputs on this patient's posterior longitudinal ligament
06/03/2025, 12:36 - Kolkata Medical College Intern: 1) PLL shows abnormal ossification, suggestive of early-stage OPLL
2) young age (26F) and recent onset of symptoms, metabolic or genetic factors should be considered ,No gross deformity.
3) indicate muscle spasm due to chronic pain or stiffness.
06/03/2025, 13:56 - Patient Advocate 56F Migraine Hypothyroidism 2000: Added
06/03/2025, 14:39 - pajr.in CEO, NHS Endocrinologist: Looks clean to me
06/03/2025, 14:53 -cm: Thanks
06/03/2025, 14:59 - cm: Agree but why is the area around the posterior longitudinal ligament, essentially the posterior border of her cervical vertebrae appearing to be hyperdense?
06/03/2025, 15:10 -Kolkata Medical College Intern: Acute Respiratory Distress Syndrome (ARDS).
Reason:-
1) bilateral diffuse infiltrates are characteristic.
2) pneumonia, trauma.
06/03/2025, 15:14 - cm: It's just pulmonary edema which can be cardiogenic or non cardiogenic (non cardiogenic is also called ards). In this patient it is cardiogenic pulmonary edema. So the diagnosis and distinction between cardiogenic and non cardiogenic pulmonary edema is more to do with the additional data around the patient and not a pure radiology diagnosis.
06/03/2025, 16:04 - cm: Gram positive bacilli sir
06/03/2025, 16:04 - cm: If you look at the above picture you can see gram positive cocci also sir ( few in singles)
06/03/2025, 16:04 - cm: In this field you can see gram positive cells and mononuclear cells also sir
06/03/2025, 16:07 - cm: 👆@cr the above data is of this patient: https://pajrcasereporter.blogspot.com/2025/02/22f-with-crohns-colitis-and-cachexia.html?m=1
06/03/2025, 16:08 - cm: Microscopic examination of her peritoneal fluid revealed these organisms suggestive of anerobic gut bacteria
06/03/2025, 16:24 - pajr.in CEO, NHS Endocrinologist: Surely there's some pericardial effusion here?
06/03/2025, 16:24 - pajr.in CEO, NHS Endocrinologist: Apart from the obvious heart failure and cardiomegaly
06/03/2025, 16:25 - pajr.in CEO, NHS Endocrinologist: The only 2 clinically relevant Gram positive bacillii I know are Neisseria and Moraxella
But if chronic,
Actinomyces, Nocardia and our old friend TB come to mind.
06/03/2025, 16:39 - cm: Yes some mild posterior pericardial effusion noted yesterday on echo. May have had more earlier
06/03/2025, 16:41 - pajr.in CEO, NHS Endocrinologist: But if anaerobic then Bacterioides fragilis is the commonest
06/03/2025, 16:44 - cm: And considering that it may have come from the gut, which one would it be?
06/03/2025, 16:46 - huai58: E coli?
06/03/2025, 16:52 - cm: The four dominant bacterial phyla in the human gut are Bacillota (Firmicutes), Bacteroidota, Actinomycetota, and Pseudomonadota.[23] Most bacteria belong to the genera Bacteroides, Clostridium, Faecalibacterium,[6][7] Eubacterium, Ruminococcus, Peptococcus, Peptostreptococcus, and Bifidobacterium.[6][7] Other genera, such as Escherichia and Lactobacillus, are present to a lesser extent.[6] Species from the genus Bacteroides alone constitute about 30% of all bacteria in the gut, suggesting that this genus is especially important in the functioning of the host.
Unquote
06/03/2025, 17:00 - pajr.in CEO, NHS Endocrinologist: Micro or macroperforation. Especially in the background of IBD Crohn
06/03/2025, 17:02 -cm: Clinically macro
06/03/2025, 17:21 - pajr.in CEO, NHS Endocrinologist: Then needs exploratory laparotomy and repair.
06/03/2025, 20:27 - Kolkata Medical College Intern: Raised PT and APTT post-thrombolysis with tenecteplase is uncommon but can occur in symptomatic ICH, fibrinogen depletion, or early DIC-like states.
06/03/2025, 20:29 - Kolkata Medical College Intern: 1) Massive Hemorrhagic Transformation of Right MCA Infarct Post-Thrombolysis Symptomatic Intracranial Hemorrhage.
 2) Tenecteplase-Induced Coagulopathy Prolonged PT, APTT, INR.
3)  Consumptive Coagulopathy/DIC-Like State with Progressive Bleeding
06/03/2025, 21:46 - cm: In rabbits, tPA increased the prothrombin time and the thrombin time but not the partial thromboplastin time. There was no correlation between these changes in blood coagulation and the finding of cerebral hemorrhage. 
06/03/2025, 21:48 - cm: She had severe hypotension, was on inotropes due to her neutropenic sepsis
06/03/2025, 21:59 - Kolkata Medical College Intern: ICH post-thrombolysis is likely due to the stroke severity and infarct characteristics, with fibrinogen depletion playing a secondary role.
07/03/2025, 07:09 - cm: Our patient didn't have intracranial hemorrhage ICH post thrombolytic. He just had mild tracheobronchial bleed 
07/03/2025, 11:45 -  Kolkata Medical College Intern: tenofovir reduce cirrhosis risk in chronic HBV but offer little benefit over placebo in true inactive carriers normal LFTs, low HBV DNA. The REVEAL study showed cirrhosis risk correlates with high HBV DNA (>10,000 IU/mL). Guidelines (AASLD, EASL) do not recommend treatment for asymptomatic carriers unless fibrosis or high viral load is present. In low-risk patients, antivirals may not significantly improve long-term outcomes over natural history.
07/03/2025, 11:51 - cm: Thanks. Please do share the journal URL to the statements that are made 
07/03/2025, 12:01 -Kolkata Medical College Intern: https://www.aasld.org/practice-guidelines/chronic-hepatitis-b
07/03/2025, 12:03 - MD.AKRAM Kolkata Medical College Intern: https://jamanetwork.com/journals/jama/fullarticle/202137
07/03/2025, 12:21 - cm: Used this link to get into an article linked there and I quote:
"Question 2. Effectiveness of Antiviral Therapy in Patients With Immune‐Tolerant Chronic HBV Infection
Two studies67 evaluated antiviral therapy in HBeAg‐positive patients with normal ALT levels. Detailed study characteristics and risk of bias are described in Tables 1 and 2.
One RCT67 compared tenofovir (64 patients) to a combination of tenofovir and emtricitabine (62 patients) for 192 weeks. Although no long‐term clinical outcomes were reported, tenofovir and emtricitabine versus tenofovir showed a statistically significant increase in viral suppression (RR = 1.4, 95% CI 1.1‐1.8, moderate‐quality evidence) but no statistically significant increase in HBeAg loss (RR = 0.3, 95% CI 0.03‐2.2), HBeAg seroconversion (RR = 0.1, 95% CI 0.01‐2.8), or HBsAg clearance (RR = 1.0, 95% CI 0.3‐3.9). The quality of evidence was low due to indirectness and imprecision."
Overall not much evidence to answer the question
07/03/2025, 13:12 - pajr.in CEO, NHS Endocrinologist: Dystonia Myoclonus complex
07/03/2025, 13:13 - pajr.in CEO, NHS Endocrinologist: Common suspicion would be Acquired Hypoparathyroidism due to a Total Thyroidectomy
07/03/2025, 13:13 - pajr.in CEO, NHS Endocrinologist: So would check Serum Calcium and Phosphate and perhaps a PTH if warranted.
07/03/2025, 13:14 - cm: Yes she definitely has that since 25 years and can't live without her calcium tablets
07/03/2025, 13:16 - cm: She has intermittent episodes of classic hypocalcemic tetany in the past.
Her dystonia Myoclonus complex could be a part of a separate issue? https://pubmed.ncbi.nlm.nih.gov/21496608/
07/03/2025, 13:16 - Ex BRAMC: Chorea
07/03/2025, 13:17 - cm: Difficult to explain only distal involvement alone
07/03/2025, 13:18 - pajr.in CEO, NHS Endocrinologist: Although known with Hereditary Hypoparathyroidism, there is also literature on Basal Ganglia and subcortical or extrapyramidal calcifications with Acquired Hypoparathyroidism
07/03/2025, 13:23 - pajr.in CEO, NHS Endocrinologist: Basal Ganglia calcifications causing Myoclonus Dystonia complex
07/03/2025, 13:27 - pajr.in CEO, NHS Endocrinologist: https://pmc.ncbi.nlm.nih.gov/articles/PMC6817747/
This should clinch it
"Over the years, a variety of names have been associated with this condition; in 1974, the term “idiopathic basal ganglia calcification” (IBGC) was used for the first time [8], reporting two cases of familial idiopathic basal ganglia calcifications exhibiting features of “dystonia musculorum deformans” and used for brain calcification of unknown origin "
07/03/2025, 13:28 - pajr.in CEO, NHS Endocrinologist: Also notice very carefully it is bilateral but more on the left.
Are you planning to get a CT/MRI head @919121046928?
07/03/2025, 13:58 -Kolkata Medical College Intern: Not strong evidence that antivirals prevent cirrhosis in true inactive carriers normal ALT, low HBV DNA. Studies show tenofovir improves viral suppression but not seroconversion or HBsAg clearance, with no reported long-term clinical outcomes. Guidelines (AASLD, EASL) do not recommend treatment unless fibrosis or high viral load is present.
It's a normal study.
07/03/2025, 15:56 - cm: @huai83 share his chest X-ray PA view and CT head
07/03/2025, 16:13 - pajr.in CEO, NHS Endocrinologist: OMG why Hypoglycemia?
07/03/2025, 16:14 - cm: @huai83 please share his history.
Past diabetes? Any oral hypoglycemics?
07/03/2025, 18:45 - pajr.in CEO, NHS Endocrinologist: What's the diagnosis for this?
07/03/2025, 18:47 - pajr.in CEO, NHS Endocrinologist: What's the update on this lady?
07/03/2025, 19:20 - Zetapsych PG 2023: Patient initially went to a doctor outside for general checkup and for back & neck pain, where he was found to have gross hydrouretronephrosis. Then he was referred to KIMS hospital for urologist opinion. 
There he was advised for CT Kub, which the patient did not get it done right then.
He also had neck pain for which he was referred to ortho, where he was admitted for ? cervical spondylosis. 
During his stay in ortho wards, he developed sudden onset of fever spike with respiratory distress. After shifting to sicu, his grbs was found to be ~30 mg/dl with seizure like activity - ? hypoglycemic seizures with altered sensorium. After correction with IV dextrose, patient sensorium improved and he could perform his routine activities.
But after a while his blood glucose levels started dropping again, and was transferred to GM dept. 
Here dextrose maintenance fluids were started, but patient had recurrent hypoglycemic episodes. 
In the afternoon patient sensorium turned to worse as he became irritable, altered with was making incomprehensible sounds. On examination kernigs sign seemed positive with neck rigidity+ (? meningitis, ? cervical fluorosis)
On Auscultation - right sided coarse crepts +.
No previously known T2dm, htn, tb, epilepsy,cad, cva sir.
Haven't used any OHAs or injectibles.
07/03/2025, 19:21 - Zetapsych PG 2023: Community acquired pneumonia 
?Hypoglycemic seizures 
Post renal aki with gross hydrouretronephrosis 2° to right upper ureteric calculi Sir
07/03/2025, 19:39 - pajr.in CEO, NHS Endocrinologist: What is the diagnosis for that Hypoglycemia?
Is there an endocrinological cause for sudden onset Hypoglycemia (for patients not known to have diabetes or on insulin)?
07/03/2025, 19:40 - pajr.in CEO, NHS Endocrinologist: What is the cause of sudden onset Hypoglycemia? Everything else is secondary now.
07/03/2025, 19:41 - pajr.in CEO, NHS Endocrinologist: All of these are post blood or imaging diagnoses. None correlate with the clinical history you gave.
Does a CAP come in with such an xray at all?
07/03/2025, 19:43 - pajr.in CEO, NHS Endocrinologist: I wish I could see the pituitary gland here!
07/03/2025, 19:46 - huai25: Fluorosis Or DISH
08/03/2025, 12:19 - pajr.in CEO, NHS Endocrinologist: Is TB being considered? Is that a Tubercular Empyema?
08/03/2025, 12:19 - pajr.in CEO, NHS Endocrinologist: Ultrasound of the Lungs?
08/03/2025, 12:20 - pajr.in CEO, NHS Endocrinologist: Surely a C-peptide and ketones would have told us if this is Insulin mediated or non-insulin mediated. Possible?
08/03/2025, 12:26 - cm Yesterday done. Confirmed the loculated effusion both anteriorly and posteriorly however the fluid appeared to less to tap
08/03/2025, 12:41 - cm: 👆was on 10 once daily!
08/03/2025, 12:42 - pajr.in CEO, NHS Endocrinologist: I mean why USG guided FNAC when we know this is Graves'?
08/03/2025, 12:43 - pajr.in CEO, NHS Endocrinologist: Surely she needs at least double or even 25mg
08/03/2025, 12:49 - cm She was complaining of a recent nodule
08/03/2025, 12:49 - Rakesh Biswas: Yes 10 tid now to be reviewed in a month
08/03/2025, 12:50 - pajr.in CEO, NHS Endocrinologist: Which has now been ruled out.
08/03/2025, 12:50 - pajr.in CEO, NHS Endocrinologist: Carbimazole is usually BD dosing sir. Would check BNF Methimazole can be TDS is what I know of.
08/03/2025, 13:04 - cm: They may have FNA ed her cervical lymph nodes
08/03/2025, 13:18 - pajr.in CEO, NHS Endocrinologist: What value is it adding for an already established diagnosis of Graves'
08/03/2025, 13:22 - cm:: Thanks for that pointer and drive to review this which I have been procrastinating ever since one of our medicine students brought a patient with thyrotoxicosis who had given up her antithyroid meds just because she wanted it once daily while our medical student reviewed in the OPD at that time and found that the once daily preparation was only available in UK for cats but not tested in humans ( and I recalled providing some inputs for one of our UK batchmate's cat with thyrotoxicosis)!
However here's this beautiful paper that waters down quite a few of my past constructs around carbimazole and to quote 👇
"Carbimazole has a plasma half-life of ~5.3 h (35), and traditionally was prescribed in divided doses (36). However, several studies have demonstrated that a single dose of carbimazole is just as effective at inducing euthyroidism (16, 37–40). Furthermore, methimazole is concentrated in thyroid follicular tissue (41, 42) and has a longer biological duration of action than suggested by pharmacokinetic levels. Moreover, compliance is increased by once daily dosing of ATD (43). In the present study, we did not find any evidence that splitting the dose or adjusting the dose for body weight significantly altered the fall in the thyroid hormones following carbimazole."
Also "carbimazole is entirely metabolized to methimazole" in the body!
Wish I could tag that student here to ask her patient to start taking her carbimazole once daily at same dosage @huai47
08/03/2025, 13:23 - huai58: Neoplasia?
08/03/2025, 13:23 - cm: There's always a paranoia around thyroid swelling and malignancy! One of your PG batchmates had the same paranoia and even got operated!
08/03/2025, 13:25 - pajr.in CEO, NHS Endocrinologist: Yes absolutely. Once euthyroid state is reached, we usually step down from a BD dose to once daily Carbimazole.
08/03/2025, 13:26 - pajr.in CEO, NHS Endocrinologist: Yes, also aware that Carbimazole is entirely metabolized to Methimazole but I think BNF quotes that there is much higher risk of Pancreatitis and hypersensitivity reactions with Methimazole directly.
08/03/2025, 13:26 - pajr.in CEO, NHS Endocrinologist: What is the risk of Neoplasia in Graves' disease?
08/03/2025, 13:27 - Pushed Communicator 1N22: Will try to find out sir
08/03/2025, 14:00 -huai58:  As said sir
08/03/2025, 14:01 - pajr.in CEO, NHS Endocrinologist: Are you sure?
08/03/2025, 14:02 - huai58: Google searched honestly
08/03/2025, 14:02 - huai58: There can be a possibility
08/03/2025, 14:03 - pajr.in CEO, NHS Endocrinologist: Do you think this statement helps any patient?
Put yourself in the patient shoes and ask what information would they want to know ideally?
That is the information the doctor too should be looking for.
08/03/2025, 14:05 - huai58: Etiology n treatment insight
08/03/2025, 15:09 - cm You need to click into those links shown by Google AI and not trust what it churns out blindly
08/03/2025, 15:17 - CKD Anemia 2022 Project PI: No sir
08/03/2025, 16:15 - cm: Let's also get his pleural tap
08/03/2025, 16:17 - cm: Case report prepared by @cr👇
08/03/2025, 16:25 -cm: The patient's EHR case report 👇
Again we are seeing the same recurrent pattern of normal CSF cell count (reported by pathology as just 5 cells) and potential TBM in CSF by noticing hypoglycorrhaecia
and increased proteins!
09/03/2025, 08:39 - cm: Beautiful presentation! Also such a remarkably positive outcome! Well done team Yashoda Pulmonology 👏
https://www.facebook.com/share/p/1BMZtZ2RPy/?mibextid=oFDknk
10/03/2025, 04:20 - huai58: null
10/03/2025, 08:02 - cm: @huai32@huai101 can you share the blood sugar charts of this patient since admission to check how many hypoglycemia events he has had since admission? Were we able to get his pleural fluid and repeat CSF?
10/03/2025, 17:03 - cm: 👆@huai41 non STEMI
10/03/2025, 18:14 - huai61: Yes sir 
Even the trop I is apparently above 600
10/03/2025, 18:14 - huai61: The pg dealing with this case has contacted us
10/03/2025, 18:15 - Ex BRAMC: Is right ventricular leads ecg taken
10/03/2025, 23:43 -huai102: What is type 3 Diabetes?
11/03/2025, 06:34 - huai58: Alzheimer's
11/03/2025, 07:02 - huai102: Thx
11/03/2025, 08:34 - cm: Current ward patient:
22F on her second admission with DKA, hypertriglyceridemia and pancreatitis, the first one having been in 2022!
We didn't get consent to share her case report and hence sharing another similar global case report especially for the hypothesis postulated around the pathophysiology in such cases @huai2 and I quote:
"diabetes increases the risk of hypertriglyceridemia (HTG) which can induce acute pancreatitis AP. 
The mechanism by which HTG causes AP is still not completely understood. Many animal models have yielded some theories [6–8]. The first theory postulates that pancreatic lipase hydrolyses excess TG with the accumulation of free fatty acids in the pancreas. Free fatty acids then cause acinar cell and pancreatic capillary injury. The resultant ischemia creates an acidic environment, which further enhances free fatty acid toxicity.
The second hypothesis suggests that the hyperviscosity which is due to elevated levels of chylomicrons in these pancreatic capillaries leads to ischemia. HTG has also been shown to contribute to and accelerate the inflammatory cascade in animal models of AP.
Unquote
https://onlinelibrary.wiley.com/doi/10.1155/2020/7653730
11/03/2025, 08:37 - cm:  Sorry in the above patient shared yesterday, I meant type 3c diabetes!
Thanks Sir @huai102 for the query and @huai58 for the correction. 
More about type 3c here: 
https://en.m.wikipedia.org/wiki/Type_3c_diabetes
11/03/2025, 11:02 - cm: OPD now:
Reviewing 43F currently in OPD:
In NYHA II also complaining of pruritus over her abdomen 
11/03/2025, 15:29 - huai58 U r welcome sir
11/03/2025, 16:42-cm: Given the past limb arterial embolism and current renal arterial embolism I guess a better look at his echocardiography would become imperative @huai41?
11/03/2025, 21:40 - cm Did the patient reach you for coronary angio?
12/03/2025, 09:47 - cm: During attempt at dolls eye reflex elicitation he appears to be having a strong conjugate eye deviation to the right
12/03/2025, 12:28 - cm: 👆Also appears to have developed a varicella infection since one week
12/03/2025, 12:33 - cm: 👆@huai116 @13055398941 check out multiple causes and effects above
12/03/2025, 16:45 - cm: Was waiting for him to get admitted from OPD to check out his pleural effusion with our point of care ultrasound but not sure what happened
@huai98, @huai101
12/03/2025, 22:18 - pajr.in CEO, NHS Endocrinologist: Hmmm is it the same chap with acute hypoglycemia sir?
12/03/2025, 22:18 - pajr.in CEO, NHS Endocrinologist: Pneumococcal Waterhouse-friedrichson? 😁
13/03/2025, 07:20 - cm: Morning PaJR CBBLE session:
[13/03, 06:48] cm: This long distance patient is visiting us today and will be admitted as inpatient for a few days 👇
What contextual causes and effects can we find in his multi modal data in the link above?
@13055398941 are you working in similar oncology projects at Moffitt?
[13/03, 06:58] huai11: I am not working on neuroepithelial tumors sir. In previous job I use to work in neuro-oncology with a focus on brain mets and glioblastoma and in connection to breast cancer. Now working in gynecologic cancers including low grade serous ovarian cancer which is a cousin of breast cancer.
[13/03, 06:58] huai11: But I can look up guidelines and other evidence around diagnostic and treatment options
[13/03, 07:02]cm: Yes that would be very useful. What in the current case report available data is useful in terms of contextual causes and effects?
[13/03, 07:07] huai11: Contextual Causes and Effects from Multi-Modal Data
1. Primary Neurological Condition:
• Cause: The patient has a history of a right frontal recurrent dysembryoplastic neuroepithelial tumor (DNET) with focal atypical features, hemorrhage, and focal cortical dysplasia.
• Effect: Multiple brain surgeries (2010, 2012, and 2021) were performed for tumor excision and hematoma evacuation, leading to residual neurological deficits, including focal seizures and left-sided paralysis.
2. History of Recurrent Surgeries and Its Effects:
• Cause: The patient underwent three major craniotomies and surgical resections, with the latest in December 2021, after a pre-coma state due to a massive intracranial hemorrhage and blood clot formation.
• Effect:
• Resulted in left-sided paralysis (hemiparesis) and inability to use fingers of the left hand.
• Persistent neurological symptoms, including seizures, requiring antiepileptic drugs (Levipil).
• Likely neurocognitive impairments, seen as lethargy, lack of concentration, and sleep disturbances.
3. Structural Brain Changes and Cognitive Dysfunction:
• Cause: MRI shows:
• Large cystic lesion in the right fronto-parietal region communicating with the lateral ventricle.
• Gliotic changes with hemorrhagic foci in the right fronto-temporal region.
• Old hemorrhage in the occipital horns of the bilateral lateral ventricles.
• Effect:
• The right frontal lobe involvement is strongly linked to cognitive decline, impaired executive function, lack of focus, and behavioral changes.
• Damage to the fronto-temporal regions could explain the lethargy, laziness, and lack of motivation.
4. Post-Surgical Sequelae and Medications:
• Cause: Ongoing need for antiepileptic drugs (Levipil, Tetrafal Plus).
• Effect: Chronic use of antiepileptic drugs may contribute to cognitive slowing, fatigue, and concentration issues.
5. Vitamin D Deficiency and Possible Systemic Impact:
• Cause: Documented low vitamin D levels and mild thrombocytopenia.
• Effect:
• Vitamin D deficiency is associated with fatigue, depression, muscle weakness, and could contribute to sluggishness and reduced motivation.
• Mild thrombocytopenia might be secondary to chronic illness or medication effects.
6. Lifestyle and Sleep-Wake Disturbance:
• Cause: Habit of sleeping late and waking up late.
• Effect: Irregular sleep cycles can exacerbate cognitive dysfunction, emotional instability, and reduced focus.
7. Family History and Genetic Predisposition:
• Cause: Strong family history of metabolic disorders (diabetes, hypertension, fatty liver, liver cirrhosis).
• Effect: Increased risk of metabolic dysregulation, which could further impact neurological recovery and cognition.
Support Credit: ChatGPT LLM.
[13/03, 07:13] cm: Excellent! I guess till the advent of AI LLMs tackling contextual multi-modal causes and effects data may have been a major manual challenge but that has currently changed and AI may have a lot to do with changing the current single cause and effect research paradigm to a multiple complex causes and effects research paradigm? @huai24
13/03/2025, 13:11 - Zetapsych PG 2023: Okay sir
13/03/2025, 13:12 - huai25: Frequent stretching exercises for finger and wrist flexors. May be considered for BoNT after showing to local PMR - AIIMS Bibinagar
13/03/2025, 13:13 - cm: BoNT?
13/03/2025, 13:13 - cm: Would a splint help?
13/03/2025, 13:13 - huai25: Botulinum Neuro Toxin
13/03/2025, 13:13 - huai25: May not. Depends how much is spasticity. Exercise will surely help
13/03/2025, 13:15 - huai25: 4-6 times a day. Cryotherapy is dicy as it may induce Raynauds but may be tried.
13/03/2025, 13:26 -Kolkata Medical College Intern: Duration of cough and shortness of breath, Productive or dry cough, Fever, chest pain, or weight loss?
 Any lung disease previous time Any heart disease or previous surgeries?
Smoking history?
Leg swelling 
If have this question answer please share sir.
13/03/2025, 14:45 - PaJR Physicist: CXR looks Takutsoba CM. ACHF - HFpEF? Maybe an Audicor would show us an EMATc of around 17-18%.
13/03/2025, 14:54 -Kolkata Medical College Intern: possible features of pulmonary congestion, Acute decompensated heart failure (ACHF) with heart failure with preserved ejection fraction (HFpEF) is a reasonable differece.
13/03/2025, 14:57 - Kolkata Medical College Intern: ECHO shows apical ballooning, no CAD on angiography → Takotsubo CM.
• diastolic dysfunction with EMATc ≥ 17-18%, raised BNP → HFpEF.
13/03/2025, 15:35 - cm: 5 years.
It's a classical chest X-ray of emphysema COPD
13/03/2025, 15:49 - cm: Took the history again with @huai101's help:
Two years back, first episode her husband noticed that suddenly while doing housework she started rotating along with pill rolling movements of her fingers in both hands and then after few rotations she fell down and became unconscious and recovered in 5 minutes spontaneously.
Second episode 3 months later while cooking she kept holding the hot vessel with one hand and fell on her cheeks followed by spontaneous recovery
Third episode, one month later after serving lunch for her husband, she became unconscious and then once she recovered she again insisted on his having lunch.
Since the last two years she keeps having similar episodes once every month and was once admitted here with us one year back when we diagnosed her to have subdural hematoma.
She was on AEDs since 2 years but stopped since last three months.
The last episode 3 days back,  husband sleeping on the floor, observed her cot shaking at 4:00 AM and thinking it was a storm he asked her to go and close the door and after an hour later when he woke up and found she hadn't closed the door and discovered her unresponsive on bed along with paralysis of her right upper and lower limbs. @cr for the case report. Will also try to fish out the previous admission EMR summary
13/03/2025, 15:53 - Kolkata Medical College Intern: I think final diagnosis - Chronic Obstructive Pulmonary Disease (COPD) – Emphysematous Type, GOLD Stage TBD.
13/03/2025, 15:59 - Patient Advocate 56F Migraine Hypothyroidism 2000: https://pajrcasereporter.blogspot.com/2025/03/44f-with-right-hemiparesis-telangana.html
14/03/2025, 13:23 - pajr.in CEO, NHS Endocrinologist: Hopefully yes
15/03/2025, 09:31 - cm: Yesterday's afternoon session
https://youtu.be/9jBJbk-mnsk?feature=shared
First year PGs @919618591366 @919347505324 @919494214158 can also check out the previous echo shared in the same channel above from our ward patients to check out the normal mitral inflow pattern
15/03/2025, 09:32 - huai7: Okay sir
15/03/2025, 09:38 - Medical Student CBBLE: Okay sir
15/03/2025, 09:42 - cm: Yesterday's afternoon session
Our PGY1's echocardiography learning prowess on her very first attempt 👏👏
15/03/2025, 09:53 - Anonymous Pm: Ok, thank you sir
15/03/2025, 12:09 - cm: @918886202111 this is the link to the current 19F with type 1 diabetes 👇
17/03/2025, 10:08 - cm: Conversations to be mixed in the upcoming commentary: @huai4 @13055398941 @cr
[17/03, 10:00]ms: Yes sir ne had a raised jvp
But we have not treated his heart failure 
How will it reduce?
Without treating?
[17/03, 10:02]cm: What is the best treatment for heart failure?
Bed rest!
[17/03, 10:03]ms: Is it possible with good lv function?
[17/03, 10:05]cm: Yes Hfpef can easily do that as we keep seeing from time to time!
Need to see his echo video to check out the magnitude of LVH and LA diameter over Aortic root to put more weight to Hfpef as a cause
ms: medical student 
cm: CBBLE moderator
17/03/2025, 13:44 - pajr.in CEO, NHS Endocrinologist: Hmmm. Does it fit a chorea by definition? If you split the abnormal movements into Body parts involved (B), Frequency (F), amplitude of movements (A) and timing of the abnormal movement (T)?
17/03/2025, 13:45 - pajr.in CEO, NHS Endocrinologist: Can your PGs describe the movement in this form?
17/03/2025, 15:44 - cm: Afternoon update:
Took the history now:
Was admitted here two years back with 500 sugars and fevers (couldn't locate the two year old file yet) and although our team reduced his sugars and his fever subsided after 5 days he developed this choreiform movement disorder which kept progressing after few days of hospitalization for which they went to Yashoda and got further treatment and slowly over two years the intensity of his chorea reduced although even before this current exacerbation six days back he actually had a slight choreiform movement in his lower limbs!
Since the last two years his sugars were not alarming (150 fasting and 300 post prandial) although he wasn't on any medications. 
So I guess are we dealing with a striatopathy unrelated to his metabolic syn or is this a very atypical metabolic striatopathy?
There's no family history of similar movement disorder
17/03/2025, 16:49 - cm: One of our PGs discovered this video of his taken presumably on 2023 march! 👇
I had to crop it but it also showed prominent "jack in the box" tongue!
17/03/2025, 16:50 - cm: @13055398941 @huai24 would it be possible to prompt the premium chat gpt with this video to answer @huai2's question?
18/03/2025, 10:07 - huai24: Don't need premium.. even free can analyze videos. However it just converts to individual frames and analyzes images, get transcript etc. not quite the video analysis of the human eye yet :-)
Today we found more leads in his history from his daughter into his altered sensorium!
18/03/2025, 16:58 - cm: Afternoon session with hypersplenism patient with intermittent splenic sequestration crisis currently reviewed for pedal edema:
today's presentation was for pedal edema and appears to be due to his anemia driven high cardiac output failure.
His presumed pituitary dwarfism is likely much more complex and includes anemia due to hypersplenism which in turn could be a part of his q deletion syn
first visit in October 2023:
18/03/2025, 20:09 - cm: The summary conveys the turmoil of a first time mother who became critically ill with liver disease, having to deliver a dead fetus possibly while on the ventilator!
Tomorrow's academics:
Staff CPC
Venue - LT-1
Time - 8 AM 
The session will also be available on the Webex platform. Kindly follow the link below to join.
In case you join in thru WebEx, kindly ensure that your microphone and camera are switched off and PLEASE DO NOT SHARE YOUR SCREEN.
The Clinical handout of the case to be discussed is attached herewith. 
The clinical protocol will be discussed by Dr. Vaneet Jearth 
Autopsy pathology will be presented by Dr. Ritu 
Clinician incharge - Dr. Madhumita 
Chairperson - Prof. Sanjay Jain
Thank you
19/03/2025, 06:45 - cm: I just discovered this cutaneous sign that could fit the bill in this patient @huai109 who had seen this patient with us in OPD.👇
Thanks to the nurture oncology group post @huai4 which made me reminisce about a 20 year old patient I had encountered 25 years back and at that time one of my colleagues had mentioned this sign although in that patient all I recollect is the presence of a striking acanthosis nigricans (another cutaneous marker of malignancy) without metabolic syn but with a large gastric carcinoma on upper GI endoscopy
19/03/2025, 10:40 - Patient Advocate 56F Migraine Hypothyroidism 2000: Hospital name is seen on the bedsheets. Is it okay to upload the video? 
19/03/2025, 10:52 - cm: Can.
19/03/2025, 10:54 - Patient Advocate 56F Migraine Hypothyroidism 2000: Okay
19/03/2025, 10:57 - cm: Sometimes we can even try to edit institutional names at a later date @huai2@huai24 by hiring editing experts?
19/03/2025, 11:02 - huai24: AI can easily remove the names from images.. let me check for videos.
19/03/2025, 11:53 -huai4: Yes sir definitely
19/03/2025, 16:35 - cm: @huai25 yesterday's afternoon session with this 28M having hypothyroidism diagnosed since 12 although not similar to your patient of congenital hypothyroidism came quite close!
Bedside:
Case report with bench findings: 
19/03/2025, 16:38 - pajr.in CEO, NHS Endocrinologist: Sydenham? 🫣
19/03/2025, 16:50 - cm At this age would be very rare!
19/03/2025, 16:54 - cm: Although again these guys from Germany reported the impossible!👇
20/03/2025, 11:23 - huai58: Can be neuropathy sir...
20/03/2025, 11:58 - cm: What is the gait of a patient with neuropathy (foot drop) called?
20/03/2025, 11:59 - cm: 👆 This is another past OPD patient with a neuropathic gait. Let us have your thoughts on what differences between the two you can observe
20/03/2025, 12:05 - huai58: Looks like a broad based gait sir
20/03/2025, 12:07 - huai58: Instead the 29M shows weakness and slight stomping in his gait
20/03/2025, 13:18 - pajr.in CEO, NHS Endocrinologist: Antalgic gait on the left.
20/03/2025, 13:55 - huai58: Arthritis related?
20/03/2025, 16:59 - Rakesh Biswas: Possibly enthesitis although we were suspecting avascular necrosis of tarsal bones
@huai47 can you find out from@huai118 if his x-rays were reported by our radiology?
20/03/2025, 17:10 - Pushed Communicator 1N22: Not yet reported sir
Will ask them and share here sir
21/03/2025, 12:06 - cm: 👆 yesterday's OPD patient EMRed @huai31
21/03/2025, 12:16 - cm: Also his gait YouTube video was added after securing his signed informed consent by our PaJR coordinator @cr
21/03/2025, 14:09 - pajr.in CEO, NHS Endocrinologist: We published on it didn't we. Yes.
21/03/2025, 16:23 - cm: Let's hope the son get's in touch with us for this
22/03/2025, 11:12 - cm: 👆@13055398941's first case was on diaphragmatic palsy with Chelaiditi syn and while this chest X-ray looks very similar, clinically the patient's presentation resembles this one 👇
who we reported way back in 2004, Manipal before I met @huai102 in Bangalore the same year!
22/03/2025, 12:11 - Patient Advocate 56F Migraine Hypothyroidism 2000: https://pajrcasereporter.blogspot.com/2025/03/70m-rta-december-2024-comatose-with.html
25/03/2025, 17:18 - cm: Morning OPD today:
Long distance patient review visit after last admission in December 2024👇
Evaluated by @huai34 and @huai14
25/03/2025, 17:31 - Kolkata Medical College Intern: Right upper lobe fibro-cavitary changes (because - old TB) with right lower lobe consolidation (infection posible)
25/03/2025, 17:33 - Kolkata Medical College Intern: 1) Motor polyneuropathy, suspected Guillain-Barré Syndrome (GBS).
2) MSK Genu valgum with knee OA, possibly linked to Narketpally syndrome.
3) Tachypnea (RR = 30), high risk of respiratory compromise.
27/03/2025, 08:46 - cm: OPD update from Tuesday:
We reviewed him in our Tuesday OPD two days back for pedal edema along with @huai14 @G ceo @huai34 
His altered sensorium evaluated in the previous OPD visit weeks ago was much better and even at that time it was attributed to poor blood sugar control and metabolic encephalopathy and once his patient advocate was informed of the need to be more diligent with sharing his blood sugars so that we could titrate his insulin more meticulously he followed the advice for a few days and his blood sugars and sensorium optimised!
@huai103 @huai34 would you be able to share the report of his serum albumin and chest X-ray, ECG we obtained on Tuesday to evaluate for hypoalbuminemia and chronic heart failure?
28/03/2025, 09:31 - cm: Virtual OPD PaJR link to our today's long distance patient who has reached our brick and mortar OPD 👇
https://chat.whatsapp.com/G1O98w0OkJx3feqdqJOUyy
29/03/2025, 08:55 - cm: Narketpally fever project data for the fever chapter in our "Textbook of Data driven healthcare" @huai24 @huai4 @huai11 @huai2 @huai54
Check out a conversational learning exercise by our last elective student @huai50 and the case based reasoning fever database attempted in multiple logged fever patients by @huai60 here 👇
29/03/2025, 09:45 - cm: 👆This broken hemodialyzer is part of a second product discovery project if you can recall @huai24@huai2 that we probably abandoned. On Thursday afternoon this was used as usual to introduce the PGY1s to understand the rudiments of hemodialysis
29/03/2025, 09:50 - cm: In view of his AKI and acute peripheral neuropathy we thankfully didn't have to discharge and refer him to Gandhi hospital for iv IG toward addressing the guillain barre diagnosis but he could rest here in the comfort of the association between uremia and it's causal association with acute peripheral polyneuropathy 
This case also highlights the importance of tapping into the global case based reasoning database aka Google driven journal case report searching! @huai24
29/03/2025, 10:07 - cm: Another long distance patient of cirrhosis seen by us in 2016 and currently blood vomiting wanting to come over for a 2000 kms visit to Narketpally 👇
https://chat.whatsapp.com/Bl8GP0ZffMKJkJEHQgWTuA
@huai31 @huai118 @huai24the goal of our cable (CBBLE https://pmc.ncbi.nlm.nih.gov/articles/PMC6163835/ ) and PaJR (https://userdrivenhealthcare.blogspot.com/2022/09/current-pajr-workflow-and-how-to-make.html?m=1)
is to prevent such patients from coming over and get better optimization from their local doctors through our cable PaJR. For this the first step is to be able to network with the local doctors there and provide them manual cable PaJR CDSS support so that they can Conti to manage such patients in their local PHCs. We are still looking for ways to network with the local physicians there and progress has been slow to say the least!
29/03/2025, 11:18 - cm: 👆@cr @huai14 all elements of his case report are available above before we can collect the EMR summary after discharge
29/03/2025, 13:11 -cm: EHRed @huai31 👇
29/03/2025, 16:24 - cm: Afternoon session:
29/03/2025, 22:41 - huai4: We had a case a few days back- it was looking like pleural effusion but then after antibiotics the effusion/consolidation subsided and the consultant identified elevate diaphragm due to diaphragmatic palsy causing difficultly in breathing in the patient..there were several co-morbidities which I don't remember clearly since I just saw this case on rounds standing at the back 😅😅 but I will use this demonstration to see if that patient also has such abdominal movements…
30/03/2025, 07:10 - cm: Then it will become a "proof of concept" for CBBLE (cable)!@huai24 @huai2
30/03/2025, 07:23 - cm: Morning PaJR:
[29/03, 09:22] Patient Advocate 3F Diabetes1:
29.03.25
7.45am fasting blood sugar 150
7.45am nuts 
8.00am milk
[29/03, 23:45] Patient Advocate 3F Diabetes1: 9.30am 4u lispro insulin 
9.35am rice with pulses carrot tomato, beans, bitter gourd, chayote, pumpkin, beetroot, brinjal, papaya, green banana , drumstick, 1/2 egg and salad 
12.00noon grapes 
1.30pm blood sugar 210
1.30pm 4u lispro insulin 
1.35pm lunch with same previous dish except egg and papad
6.30pm sour curd 7.00pm banana 
9.00pm 4u lantus insulin 
9.15pm blood sugar 211
9.15pm 1.5u lispro insulin 
9.20pm dinner with as same as lunch dish
[30/03, 07:14]cm: The mild highs of 210 and 211 appear to be due to the snacks (grapes 210, banana curd 211) that were not covered by lispro
[30/03, 07:18]cm: @⁨Meta AI⁩ how much lispro would be necessary to cover the 12:00 noon grapes to achieve a 1:30PM blood sugar of 140 instead of 210 as pasted below and how much lispro would be necessary to cover the sour curd and banana to achieve a blood sugar of 140 instead of 211 as what is pasted below:
9.30am 4u lispro insulin 
9.35am rice with pulses carrot tomato, beans, bitter gourd, chayote, pumpkin, beetroot, brinjal, papaya, green banana, drumstick, 1/2 egg and salad 
12.00noon grapes 
1.30pm blood sugar 210
1.30pm 4u lispro insulin 
1.35pm lunch with same previous dish except egg and papad
6.30pm sour curd 7.00pm banana 
9.00pm 4u lantus insulin 
9.15pm blood sugar 211
9.15pm 1.5u lispro insulin 
9.20pm dinner with as same as lunch dish
[30/03, 07:18] Meta AI: To calculate the necessary lispro insulin, we'll consider the carbohydrates in grapes, sour curd, and banana, and your target blood sugar level of 140.
1. Grapes at 12:00 noon:
Assuming 1 cup of grapes contains approximately 27 grams of carbohydrates. To achieve a blood sugar of 140 instead of 210, you may need additional insulin. A common starting point is to use 1 unit of lispro for every 15 grams of carbohydrates. So, for 27 grams of carbohydrates, you might need 2 units of lispro (1.8 units, rounded up to 2 units).
2. Sour curd and banana:
Assuming 1 cup of sour curd contains approximately 10-15 grams of carbohydrates and 1 medium banana contains approximately 27 grams of carbohydrates. So, the total carbohydrates would be around 37-42 grams. Using the same calculation as before (1 unit of lispro for every 15 grams of carbohydrates), you might need 2.5-3 units of lispro (2.8-3.4 units, rounded to 3 units).
Keep in mind that these are rough estimates and may vary depending on individual factors, such as insulin sensitivity, diet, and physical activity. It's essential to consult your healthcare provider or registered dietitian for personalized guidance on insulin dosing.
01/04/2025, 10:19 - cm: This book was on integrating medical education and practice in the times of Web 2.0
The next book will be about integrating medical education and practice in the current Web 3.0 era that's growing exponentially by leaps and bounds and may not remain bound by paper volumes!

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