DECEMBER 2024
02/12/2024, 15:46 - cm: Reviewed in ICU OPD
Hb 8
Bilirubin 3
Is on hydroxyurea 500 mg once daily since last 5 years but continues to have a vasocclusive crisis every year
https://chat.whatsapp.com/K0rJ6aNjT5t9LdwziNaXuY
03/12/2024, 09:46 - Pushed Communicator 223: Okay sir
03/12/2024, 11:37 - cm: MOPD Reviewing him right now
03/12/2024, 12:22 - cm: Another good news is that he has started to walk since one month since his craniectomy which was done 3 months back 👇
03/12/2024, 15:38 -cm: @huai26 65M with viral fever precipitating acute LVF mimicking pneumonia in current ICU is apparently getting quite common and you should highlight this in your thesis on heart failure
05/12/2024, 14:22 - cm: By our physiotherapist here. There's no physiotherapy department
.05/12/2024, 21:36 - pajr.in CEO, NHS Endocrinologist: Brilliant work and I'm being serious every IM trainee here would dream of wanting to do such clinical work.
What a topsy turvy world this is. The first worlders are doing social health and occupational therapy referrals while the third world has the brains but no resources!
@huai53
06/12/2024, 11:18 - cm: https://chat.whatsapp.com/Jne3mST9FeDBnqLiTPqofQ
06/12/2024, 21:28 - cm: https://pajrcasereporter.blogspot.com/2024/12/67f-with-striking-cerebral-ptosis.html?m=1
06/12/2024, 21:31 - cm: @huai101 update of this patient?
06/12/2024, 21:31 - cm: https://narmeenshah.blogspot.com/2024/12/57m-tb-cervical-lymphadenopathy.html
07/12/2024, 10:43 - cm: Project: PUO diagnostic uncertainty optimisation through fever pattern recognition
https://chat.whatsapp.com/Jne3mST9FeDBnqLiTPqofQ
👆Now if this fever spike is absent for today but reappears on Sunday we may have to treat him as clinical malaria based on fever pattern driven diagnosis
07/12/2024, 12:32 - cm: https://userdrivenhealthcare.blogspot.com/2024/12/udlco-on-digital-pathology-optimizing.html?m=1
09/12/2024, 09:37 - cm: @huai32 @huai26 @919505766290 there's a long distance patient waiting in the MOPD. Please evaluate her and order the empty stomach investigations if necessary and admit her in SS ward. I'll be reaching soon
09/12/2024, 09:44 - Communicating Learner 1N23: Ok sir
09/12/2024, 11:52 - cm: She works in subdivision hospital and needs to get her Hba1c done outside and can't trust the local labs. Last Hba1c was done one year back and she's trying to search her mobile phone to retrieve that! Says it was apparently in the normal range. She's one patient who didn't buy into our PaJR system and we don't have a good case report/record of her ever since we first met her in 2014! Due to this informational discontinuity we couldn't even optimise her medications properly because she had a habit of suddenly popping up into our WhatsApp text and we would again have to retrieve her information from scratch with many holes as she wouldn't have been able to share them again in sequence and our own irritation with her not getting her data sequentially in one place!
09/12/2024, 11:59 - cm: MOPD: long distance tele history
34M complains of low backache 1 year
Has a standing job and needs to stand continuously 4-5 hours
Pain reduces with rest
Suggested video consultation with @23fpa to evaluate trunkal muscle power
09/12/2024, 12:02 - cm: Similar to this patient👇
09/12/2024, 13:08 - cm: @huai32 @huai65 please check the age of both these two patients admitted and let me know
09/12/2024, 15:09 - cm: https://pmc.ncbi.nlm.nih.gov/articles/PMC10910421/
09/12/2024, 15:36 -cm: 👆ICU 1
10/12/2024, 08:28 - huai45: Let's see if we can pick something up in the blood tests
10/12/2024, 09:32 - cm: @huai105 share his deidentified dermatology and urology notes
here 👇
https://chat.whatsapp.com/LqBvzBi0FfLCxjl7URLDkc
10/12/2024, 11:03 - cm: MOPD
https://chat.whatsapp.com/L8v8hpZfLnJIIsZf5R9hxT
10/12/2024, 12:08 - cm: Update the chart please @huai32 asap
10/12/2024, 20:02 - cm: I welcome all esteemed faculty and other professionals who have joined here from a desire to learn more through real patient centered discussions and perhaps also contribute their own learning into this ecosystem.
Would be nice if you could introduce yourself and your passion for learning here so that every one in the group is inspired to share their own learning journeys
11/12/2024, 09:32 - cm: Thanks.
Nice to see some positive outcomes in this patient of chronic quadriparesis and cauda equina syn due to his toddy climbing occupation that happened 20 years back and climaxed recently with saddle anesthesia sores causing sepsis and hypotension and we hope he shall be coming out of this soon.
What we do here is given in the detailed links in the description box and one could begin by taking a look at our recent Nov 28,2024 presentation here:
11/12/2024, 16:50 - cm: 👆@huai26 can you share the complete neurological findings from what couldn't be shared earlier as he was drowsy and very ill but can be done now as he appears much better today?
11/12/2024, 16:53 - Pushed Comm 1AI23: Ok sir
12/12/2024, 16:55 - huai25: GBS/Syrinx
12/12/2024, 16:56 - huai25: If biceps 4, then why reflex absent?
12/12/2024, 16:57 - huai25: Pain?
12/12/2024, 16:57 - huai25: Get ASIA scaling done
12/12/2024, 17:23 - cm: Currently nil
12/12/2024, 17:24 - cm: Sensory part of the reflex arc has the break?
12/12/2024, 17:25 - cm: It was quite an acute quadriparesis over 24 hours in April 2021
12/12/2024, 17:25 - cm: GBS is LMN peripheral neuropathy
Syrinx is UMN spinal cord
Which one would you pick?
12/12/2024, 17:26 - huai25: Acute phase, GBS possible. But injury in past indicated syrinx
12/12/2024, 17:28 - cm: No history of injury but he did develop a backache two years preceding the illness.
For rehab walk support we are fancying an exoskeleton 👇
12/12/2024, 17:29 - huai25: Go 🐌
However, dreaming is must 🤗
12/12/2024, 18:19 - Patient Advocate 56F Migraine Hypothyroidism 2000: EMR summary pending.
12/12/2024, 18:38 - cm: Yes unfortunately it's only ready during discharge but let's check with @huai65 if it can be shared sooner
12/12/2024, 18:57 -huai25: ADEM🤔
13/12/2024, 08:06 - cm: Could be a probable etiologic diagnosis although slightly unlikely given that in the history there was no other features of inflammation such as fever etc and well it's just limited to a long segment of the spinal cord and we don't have any evidence of involvement of other areas of the CNS
However regardless of etiology, what would be our impression of the gross pathology visible in the spinal cord here if any?
13/12/2024, 08:10 - huai25 Immunodeficiency?
13/12/2024, 08:10 - cm: @cr thanks for updating the hyperlocal PaJR patient update in his global case report
here👇
For those newly joined and wondering what the terms hyperlocal PaJR and global case report mean can click into the first link in our description box here
13/12/2024, 08:11 - cm: He did have diabetes a few years back and has the typical type 2 diabetes metabolic syn phenotype but then it's difficult to explain his spinal cord lesion with that
13/12/2024, 08:13 - cm: 👆 What's your specialist viewpoint about exoskeletons and their future promise in not just alleviating spinal cord mobility miseries but also as a future wearable mobile live in device?
13/12/2024, 08:21 - huai25: Yes, very powerful. However prohibitive cost holds us from prescribing
13/12/2024, 08:22 -huai25: In fact I see IPR as the biggest demon of the Century (perhaps 2 centuries)
13/12/2024, 08:30 - cm: But that website is a made in India exoskeleton retail site apparently from Karnataka! How costly can it be? More importantly how efficacious is it?
13/12/2024, 08:31 - cm: Can also spur innovative workarounds
13/12/2024, 08:35 - huai25: I didn't know a Made in India item. Abroad it was ₹20 Crores (Or Lacs, please excuse maths of a poor doctor). IIT Delhi was designing it's precursor in year 2000
13/12/2024, 08:36 - huai25: PMR is indeed innovative with our innovative Occupational Therapist in the team😌
13/12/2024, 08:38 - cm: Exactly even I wasn't. One our PGs @huai65 searching solutions for this patient's mobility during our bedside point of care learning made us aware of it's India presence and while we asked the patient's son to call the dealer and check the price would be nice if anyone here may be interested to find out and share
13/12/2024, 08:38 - cm: Who's that?
13/12/2024, 08:38 - cm: @23fpa you can simply quickly update this patients textual transcripts without now having to update his food plates but will be looking forward to seeing the image of his BP chart and the recent BP texts in his hyperlocal PaJR case report here👇
And also hoping @se can convert the BP quant text into a graphical image to be also uploaded and updated there?
13/12/2024, 08:40 - huai25: Not now with me, but any occupational therapist in your team will fulfill the dreams of your patients at Narketpally
13/12/2024, 08:42 -cm: There are none currently!
Is it the same person who made a wheelchair for our neighbour's paralysed dog?
13/12/2024, 08:53 - huai25: He is a P&O and can be linked up
13/12/2024, 08:54 - huai25: Occupational Therapist shall be available in all Medical Colleges as per NMC norms
13/12/2024, 10:02 - cm: Morning PaJR updates:
https://chat.whatsapp.com/HnnZ7fKgAm4IBlBABqkJhO
@se Thanks, Any way we can also add the dates to each value?
13/12/2024, 13:05 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done
13/12/2024, 14:13 - pajr.in CEO, NHS Endocrinologist: Well, which MODY sir?
They usually have fasting hyperglycemia (between 100 to 144) and usually normal post prandial sugars. Those sugars are too high to my liking.
You could try the MODY calculator but that was designed for White Europeans.
13/12/2024, 14:13 - pajr.in CEO, NHS Endocrinologist: That phenotype does raise concern for Cushing's or a familial hypercholesterolemia
13/12/2024, 14:15 -cm: Exactly we need to yet discover the particularities of our Telangana modys?
13/12/2024, 14:16 - pajr.in CEO, NHS Endocrinologist: Or even LADA / Type 1?
13/12/2024, 14:32 - cm: I guess you meant GCK MODY2 as they are the ones who have mild hyperglycemia and good outcomes in terms of vasculopathy even without treatment.
On the other hand transcription factor driven MODY such as 3 and 5 are commonly known to have hyperglycemia levels and outcomes similar to type 2.
13/12/2024, 14:32 - cm: Hopefully not but time will tell
13/12/2024, 19:41 - cm: Here's the detailed history and findings👇
14/12/2024, 07:30 - cm: At MIT, collaboration between researchers working in the life sciences and engineering is a frequent occurrence.
The head of MIT neuroscience lab is an electrical engineer from IIT kanpur https://en.m.wikipedia.org/wiki/Mriganka_Sur
14/12/2024, 10:18 - Rakesh Biswas: @923305072858 is perhaps the first to publish such hyperlocal patient data globally?👇
It's also called Deep phenotyping, which has become a popular terminology for what is increasingly being recognized as an essential tool to any medicine and while our team had called it "age old precision medicine" here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/, we have recently seen it addressed as "deep phenotyping" in this paper : https://www.nature.com/articles/s41467-024-45107-3, who's corresponding author, team leader was recently featured in the cover of Time (just a populist distractor).
Hyperlocal recent PaJR conversational transcripts around subtle dose changes in lantus effecting blood sugar outcomes:
[04/12, 10:32] Patient Advocate 2F Diabetes1: 7.30am blood sugar 58
7.30am nuts
7.45am milk
[04/12, 10:40] PaJR moderator: Switch back lantus to 4U! Should not have given more than 4 if 4.5U wasn't possible
[07/12, 16:05] Patient Advocate 2F Diabetes1: Due to some problems I can't update here
[07/12, 16:10] PaJR moderator: What problems?
[07/12, 16:12] Patient Advocate 2F Diabetes1: 7.12.24
7.500am fasting blood sugar 238
7.30am milk
9.45am 3.5u lispro insulin
9.50am rice with pulses, brinjal, tomato, long beans, beans, radish, chayote, papaya, cauliflower, spinach and egg
1.45pm blood suger 368
1.45pm 4u lispro insulin
1.50pm lunch with same previous dish except egg
[07/12, 16:12] Patient Advocate 2F Diabetes1: No problem with the patient
[07/12, 16:15] PaJR moderator: 👆On 4/12/24 there was hypoglycemia with 5U lantus
[07/12, 16:18] PaJR moderator: I'm assuming on 6/12/24 she received 4U and developed hyperglycemia. Although we need to confirm by taking a 3:00 AM blood sugar but it's likely that her blood sugar fluctuations are because of very small changes in her lantus dose (again assuming other factors such as carb intake and exercise are constant but then that data isn't well captured and shared here)
[07/12, 18:50] Patient Advocate 2F Diabetes1: Yes Sir 4u lantus at 8.30pm
[08/12, 00:00] Patient Advocate 2F Diabetes1: 7.00pm oats
9.30pm blood sugar 338
9.30pm 2.5u lispro insulin
9.35pm rice with pulses, carrot, cauliflower, beans, pakoda and salad
[08/12, 00:36] Patient Advocate 2F Diabetes1: 8.45pm 4u lantus
[08/12, 00:43] Patient Advocate 2F Diabetes1: 11.45pm blood sugar 453
[08/12, 07:41] PaJR moderator: After checking the fasting today the morning insulin lispro will need to be increased
[08/12, 07:42] PaJR moderator: This needs to be made 4.5U using a plain syringe as shown in 30F's PaJR
[08/12, 09:14] Patient Advocate 2F Diabetes1: 8.12.24
7.45am fasting blood sugar 238
7.45am milk
[08/12, 16:07] Patient Advocate 2F Diabetes1: 9.30am 5u lispro insulin
9.40am rice with pulses, brinjal, tomato, long beans, radish, chayote, papaya, beans, cabbage spinach, egg and salad
11=45am orange
1.30pm blood sugar 238
1.30pm 4u lispro insulin
1.40pm lunch with same previous dish except egg and include fish
[08/12, 18:13] Patient Advocate 2F Diabetes1: Lantus ki aaj ke 1u bariye debo?
[08/12, 18:22] PaJR moderator: Lantus ta jodi sokaler deeke dewa jai breakfast er por ebong lunch er aage tahole hoito 1U barano jete pare kenoki tahole shara diner barti sugar taake komabe kintu bortoman jemon raate dewa hocche taate abar early morning hypoglycemia te chole jabar sombhabona royeche. Tabe 4.5U dewa jete pare ordinary syringe er shahajje jemon @Patient DM1 MP Advocate 2 unar patient ke dicchen
[09/12, 08:28] PaJR moderator: Today's fasting?
[09/12, 09:39] Patient Advocate 2F Diabetes1: 9.12.24
7.50 am fasting blood sugar 176
7.50am milk
[09/12, 22:28] Patient Advocate 2F Diabetes1: 9.30am 4.5u lispro insulin
9.40am rice with pulses, papaya, chayote, long beans, radish, beans, cabbage, cauliflower, egg and salad
11.45am orange
1.30pm blood sugar 291
1.30pm 4u lispro insulin
1.40pm lunch with same previous dish except egg and include paneer
7.00pm oats
8.30pm 5u lantus insulin
9.30pm blood sugar 210
9.30pm 1.5u lispro insulin
9.35pm dinner with as same as lunch dish
[10/12, 08:50] PaJR moderator: Fasting?
[10/12, 09:26] Patient Advocate 2F Diabetes1: 10.12.24
8.00am fasting blood sugar 213
8.00am nuts
8.15am milk
[10/12, 14:12] Patient Advocate 2F Diabetes1: 9.30am 5u lispro insulin 9.32am rice with pulses papaya, chayote, spinach, carrot, cauliflower, cabbage and salad
11.45am orange
1.30pm blood sugar 327
1.30pm 5u lispro insulin
1.35pm lunch with same previous dish and egg
[11/12, 10:49] Patient Advocate 2F Diabetes1: 7.00pm oats
8.30pm 5u lantus insulin
9.30pm blood sugar 250
9.30pm 2u lispro insulin
9.35pm dinner with as same as lunch dish except egg
[11/12, 10:49] Patient Advocate 2F Diabetes1: 11.12.24
7.45am fasting blood sugar 58
7.45am nuts and dates
8.00am milk
9.30am 3.5u lispro insulin
9.35am rice with pulses, brinjal, tomato, long beans, bitter gourd, beans, radish, chayote, papaya and salad
[11/12, 11:07] PaJR moderator: 5U lantus is dangerous for her.
If we can't make it 4.5 lets keep it at 4
[11/12, 16:05] Patient Advocate 2F Diabetes1: 11.45am apple
1.30pm blood sugar 236
1.30pm 3.5u lispro insulin
1.35pm dinner with same previous dish and chicken
[11/12, 23:03] Patient Advocate 2F Diabetes1: 7.00pm Meggie
8.45 pm 5u lantus insulin
9.30pm blood sugar 154
9.30pm 1u lispro insulin
9.35 pm dinner with as same as lunch dish
[12/12, 07:05] Patient Advocate 2F Diabetes1: 11.45pn blood suger 161
Then 5grm sugar (chini)
[12/12, 09:49] Patient Advocate 2F Diabetes1: 12.12.24
7.45am blood suger 218
7.45am nuts
8.00am milk
[12/12, 11:32] PaJR moderator: 👆
[12/12, 11:35] PaJR moderator: If we review her current cycles with 5U lantus her fasting sugars appear unaffected by it for 2-3 days and then she suddenly goes into hypoglycemia with the same dose? @Inner Strength Engineer1 please confirm
[12/12, 11:36] Patient Advocate 2F Diabetes1: 9.50am 4.5u lispro insulin
9.55am rice with papaya, chayote, bitter gourd, tomato, long beans, radish, beans, cauliflower, cabbage, paneer and salad
[14/12, 07:41] Patient Advocate 2F Diabetes1: 7.00pm oats
8.30pm 5u lantus insulin
9.30pm blood sugar 138
9.30pm 0.50u lispro insulin
9.35pm dinner with as same as lunch dish and include butter
[14/12, 08:37] PaJR moderator: Fasting?
[14/12, 08:39] PaJR moderator: Can you share a graph for this showing the lantus dose in y axis and glucose change with time in x axis?
Let's also check out today's fasting
[14/12, 08:45] Inner Strength Engineer1: Sir for a month?
[14/12, 08:47] PaJR moderator: I guess we noticed this bug (that we are trying to feature) particularly this week but then I can recall it having been there earlier as well over the last few months.
But let's just check the last two weeks
14/12/2024, 11:18 - cm: @huai26 can you share the detailed history including how and since when he developed that deep non healing ulcer?
14/12/2024, 12:16 - Pushed Communicator 1N22: Okay sir
14/12/2024, 12:33 - cm: This is expected. What's the sensitivity of CBNAAT in CSF? For pleural fluid we know it's 40%
14/12/2024, 13:43 - huai91: Saturday night palsy
14/12/2024, 13:44 - huai91: Compression of radial nerve in radial groove of humerus
14/12/2024, 16:57 - cm: 👆 @huai89 Check out the K+ values and include him for your thesis project
@huai98 please share the treatment order chart to demonstrate how we are tackling his hypokalemia and other issues
14/12/2024, 16:59 -huai89: Yes sir
Thank you
14/12/2024, 19:53 - cm: @23fpa shared a 3 month old patient with intermittent obstructive jaundice with intermittent clayish white stools. They got in touch with her today and she has shared through some preliminary data in her case report here👇
Some preliminary review on this case 👇
"Jaundice in choledochal cyst is often intermittent because the obstruction is rarely complete unlike in biliary atresia. Character of jaundice is an important ominous symptom in differentiating obstructive jaundice due to biliary duct cystic dilatation from obstructive jaundice due to biliary atresia. Many of these neonates may have choledochal cysts in conjunction with complete or nearly complete biliary obstruction. Some authors report these patients as having biliary atresia in association with choledochal cyst, whereas others may term these patients as having surgically correctable biliary atresia."
Triangular cord sign (a thickness of the echogenic anterior wall of the right portal vein just proximal to the right portal vein bifurcation) and the presence of biliary sludge are characteristic features suggestive of Congenital biliary atresia rather than choledochal cyst.
https://www.intechopen.com/chapters/60419
16/12/2024, 12:48 - cm: https://chat.whatsapp.com/Lj7Lk4oXABc7Upo90ceD8g
16/12/2024, 12:50 - cm: OPD new 👇
https://chat.whatsapp.com/GlNQpufshzW5pw7blTj9tK
16/12/2024, 13:01 - cm: Previous EHR case report of the same patient by @se 👇
16/12/2024, 13:15 - huai85: I cannot confidently say old infarct is present sir, since there's no Q wave, prominent forces in lateral, anterior leads is also not seen...
Inferior forces are weak, axis rotation can also show such picture sir..
16/12/2024, 13:16 - cm: So what may be the cause for the axis rotation?
16/12/2024, 13:17 - cm: Any comments on V6? @huai85
16/12/2024, 13:29 - pajr.in CEO, NHS Endocrinologist: It was Zain who led that sir.
16/12/2024, 13:33 - cm: Yes and he remained unsung while the BMJ author is who everyone remembers!😅
16/12/2024, 13:33 - huai85: LAFB can cause sir.
Patient is having wide QRS, so definitely conduction is slowed
Weak inferior forces, left axis rotation, poor progression of R wave in chest leads
Inferior MI is one possibility sir, again tell tale signs of IWMI Q wave is not present, so at this point i would consider it a possibility rather than a confirmed diagnosis.
16/12/2024, 15:07 - cm: Or is it possible that "the ECG in this man may have earlier been a QS wave that later evolved to an rS wave in the inferior wall indicating the formation of embryonic R wave suggesting an incomplete inferior myocardial infarction?
Strangely I didn't find much about this entity called "embryonic r" although I see it often used by cardio old timers except this one article here👇
16/12/2024, 15:34 - cm: @cr this patient is readmitted and I realised we hadn't taken her EMR summary last time which I shall share ASAP 👇
17/12/2024, 09:29 - cm: Interesting that this was published just in 1970s and NEJM was apparently called Boston medical journal at that time! I guess this paper may have made us think that the current ceiling dose of furosemide is 800mg although we guess even that could cause cause deafness and while we often see so many of our nephro patients on dialysis are hard of hearing we also may believe we know why.
I dug further and found another loud voice in JAMA in 1988 saying, "there's a possibility that the maximum recommended daily orally administered dose of furosemide is too low and should be raised.A quick review of the medical literature concerning the use of high doses of furosemide demonstrates that its use has been beneficial in various studies other than those of Gerlag and van Meijel.2-5 These studies treated 105,2 28,3 6,4 and 365 patients (respectively) with doses of furosemide, generally over 2 g/d and up to 4 g/d (administered either intravenously or orally). In these studies, there were a total of two cases of ototoxicity observed, with one condition being permanent. No other serious side effects were reported."
17/12/2024, 09:52 - cm: Welcome @huai107 one of our earliest elective trainees during internship as archived here 👇
Currently he's a cardiologist in KEM Mumbai after having finished his DM there
17/12/2024, 10:42 - cm: @huai322 @huai103 any update on his fever chart following yesterday's admission?👇
@cr his uncle says he's actually 21 (although he looks 13) and they may have said 19 earlier
17/12/2024, 11:19 - cm: 👆@huai85 @huai81
17/12/2024, 16:40 - cm: Update:
Was intubated and ventilated since 14/12/24
Still in altered sensorium
Tracheostomy done today
@cr please add to his case report here 👇
@huai32 can you share his updated fever chart?
17/12/2024, 17:25 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done
18/12/2024, 10:51 - Unknown Medical Student: https://snehalmvs.blogspot.com/2023/02/22f-pancytopenia.html
This patient whom we did spleenectomy was doing quite well working at @huai2 sir institution, but since last few month we are not able to trace her.
Can @huai2 sir find out any previous contacts from previous institution as how to obtain her follow up
18/12/2024, 14:25 - pajr.in CEO, NHS Endocrinologist: UMN Quadriparesis?
18/12/2024, 14:29 - cm: Thanks. I guess he also received iv acyclovir and either way one can say that microscopic the meningeal inflammation has reduced although you will need to tell us his clinical improvement.
Also share his fever chart
18/12/2024, 14:31 - cm: Yes
Have shared his EMR summary in the case reporters group for @cr to create the case report
18/12/2024, 14:34 - cm: Marked spastic hypertonia in all four limbs, hyperreflexia and bilateral planter extensor
18/12/2024, 14:34 - pajr.in CEO, NHS Endocrinologist: Seems quite severe for a cortical lesion - any cord involvement? Is this MS?
18/12/2024, 14:34 - Pushed Communicator 1N22: Okay sir
Will try to share
Sir we were not interested in starting Acyclovir
Was it a good decision to start acyclovir ?
Is it helpful in this case ?
18/12/2024, 14:38 - cm: Good questions
Again in an individual patient without a parallel comparator it's always difficult to answer if the response was due to the intervention or was just due to time alone.
However you can review the literature if his clinical and CSF findings can be attributed to HSV encephalitis with reasonable certainty.
Do we have his MRI images?
18/12/2024, 14:42 - Pushed Communicator 1N22: Only CT was done ay admission sir
The emd team repeated ct brain again yesterday
Mri was not done
18/12/2024, 14:43 - cm: Can you review the literature as to what would have been the best way to diagnose HSV encephalitis with reasonable certainty and if there are any trials around empirical therapy of HSV meningitis with acyclovir vs placebo?
18/12/2024, 14:43 - Pushed Communicator 1N22: Sir also
We also thought of TB meningitis at once
Is it still the possibility
And we even started the pt on dexamethasone ,but it was stopped later on .Is it a good decision to stop?
18/12/2024, 14:44 - cm: So the next question is: Did the meningeal inflammation reduce due to the SAID?
18/12/2024, 14:46 - cm: The decision to stop any intervention depends on if the end objective of the intervention has been met, in this case if the inflammation subsided there wouldn't be much point in continuing the anti-inflammatory
19/12/2024, 08:06 - cm: [19/12, 07:51] PG: CBNAAT is negative
[19/12, 08:02]: Then are those pink globi really AFB or even if they are they are likely NTM that won't be picked up on CBNAAT probes with fixed ontologies?
We definitely need to culture this one after Microbiology today confirms these are AFB!
@se please update all the previous PaJR conversations of last two days in the case report👇
19/12/2024, 14:06 - cm: Referred where? Government hospital? Please track what happens to him
19/12/2024, 14:08 - cm: @cr please update this to his case report and @huai35 @huai2@huai3 let's prepare an inventory of the many cryptococci and mucor we have isolated in the last few months
19/12/2024, 14:14 - Pushed Communicator 1N22: Ok sir
How come the micro team have missed it in first sample sir ?
It might not be cryptococcus this time too ?
Will try to share the image if possible
19/12/2024, 14:18 - Pushed Communicator 1N22: The sensitivity of India ink staining of CSF depends on fungal burden and is reported to be 30% to 50% in non–AIDS-related cryptococcal meningitis and up to 80% in AIDS-related disease. False positives can result from intact lymphocytes, other tissue cells and nonviable yeast forms, which further limits the diagnostic utility of direct microscopy of CSF for cryptococcal meningitis.
https://pmc.ncbi.nlm.nih.gov/articles/PMC5808417/
19/12/2024, 14:25 - pajr.in CEO, NHS Endocrinologist: See if any study looks at how and why microscopic examination of Cryptococcus can be difficult?
19/12/2024, 14:26 - pajr.in CEO, NHS Endocrinologist: This is a sensitivity study. What are the factors that led to low sensitivity?
19/12/2024, 15:06 - huai3: Is he immunocompromised @918790889907 ..?
19/12/2024, 15:18 - huai85: It's the same last week case??
19/12/2024, 15:20 - CKD Anemia 2022 Project PI: Yes sir
19/12/2024, 15:37 - huai85: Share photos of his foot ulcers...
19/12/2024, 15:47 - huai72: Patient is 40yr male, Labourer by occupation who is chronic alcoholic & smoker (Nondiabetic & Serology is negative)
What predisposed him for cryptococcus meningitis??
The other clue we are having is ulcer over left foot (40days old) & sinus over right shin of tibia (10day old) Is it a cutaneous cryptococcus dessimination ??
19/12/2024, 15:51 - cm: https://pajrcasereporter.blogspot.com/2024/12/40m-with-meningitis-telangana-pajr.html?m=1
@cr can you also upload his foot ulcer images shared above?
19/12/2024, 16:00 - huai3: Assuming his Chronic smoking can predispose him to PVD at microvascular level leading to non-healing ulcer.
10 days is very acute to form a sinus tract.. is it osteomyelitis..? Any xray..?
Cryptococcus stained in CSF could entered CSF through hematogenous route.. if so PCR could be helpful to rule in dessiminated cryptococosis.
Any other pointers in history or examination favouring immunodeficiency ..?
19/12/2024, 16:06 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done
19/12/2024, 17:00 - cm: This patient 👇
Got admitted again yesterday @cr with increased creatinine this time from 3 to 5 and hyperkalemia of 6.5
They are unwilling for hemodialysis!
@huai103 please share the current dextrose insulin doses administered till now and the K+ chart
19/12/2024, 17:57 - huai85: Patient is suspected to have psoriasis too..
This sort of ulcer appears to be a sign of immunodeficiency...
Hep B, Hep C, HIV sero status??
19/12/2024, 17:58 -huai85: I'm convinced sir that cryptococcus is very likely in this patient...
19/12/2024, 18:01 - cm: He died at his home today morning as gathered from our entire Telangana and Andhra Pradesh community network just by mentioning his village
19/12/2024, 18:03 - cm: @cr please add this closure to his case report. Wish we had more data in his history events even before his cryptococcal events began to be able to get better insights into his overall life events
19/12/2024, 18:35 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done
19/12/2024, 18:46 -cm: 👆@huai32 please share her echocardiography video
19/12/2024, 19:07 - cm: 👆@cr please add the information tagged up there to the top of your case report here 👇
19/12/2024, 19:07 - cm: 👆Also add this below that
19/12/2024, 19:07 - cm: 👆 not sure if you did
19/12/2024, 19:08 - cm: 👆@huai89 what were your thesis insights around his hypokalemia?
19/12/2024, 19:31 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done
21/12/2024, 13:28 - pajr.in CEO, NHS Endocrinologist: Any history of long term steroids use?
21/12/2024, 13:28 - pajr.in CEO, NHS Endocrinologist: I'm also looking at Ayurvedic /Homeopathy use in such cases.
21/12/2024, 16:36 - cm: Brother also reportedly has the same skin changes since childhood @huai101 please get a Dermatology opinion for a biopsy and also get them to evaluate the brother's skin as well
21/12/2024, 16:36 - CKD Anemia 2022 Project PI: Okay sir
21/12/2024, 16:37 - cm: Also review the literature on genetic syndromes of cutaneous coarsening with Pulmonary Hypertension
22/12/2024, 21:49 - cm: Nice medical education tool that reverse engineers interpretation of cardiac electrical axis.
Just rotate the axis vector to sse how the ECG changes.
23/12/2024, 11:01 - cm: @huai32let's admit ASAP and get his USG guided FNA from this suspected metastatic nodule
23/12/2024, 12:24 - cm: OPD patient previously shared above:
After 2 and 1/2 minutes of the 6MWT the patient started having pain as seen in this video captured by our intern
https://youtu.be/1ntMgcPbN5Y?feature=shared
and for the first assessment we made him stand as there's this text book buzz that vasculogenic claudication can reduce simply without any further change in posture just by reducing the muscular demand for blood supply. His pain reduced just 60-70% and then our intern made him walk again following which the pain recurred and then made him sit this time following which he also squatted and his pain got relieved 100%!
He also mentions that he felt like fecal incontinence during the pain.
As this is favoring more of a lumbar canal stenosis we are getting his Lumbo sacral MRI inspite of the vascular priors gleaned by the previous evaluators elsewhere
23/12/2024, 12:34 -cm: We tested his climbing abilities on our ramp and in less than one minute he developed the pain again and climbing down relieved the pain!
23/12/2024, 12:36 - pajr.in CEO, NHS Endocrinologist: Neurogenic vs vascular?
23/12/2024, 12:38 - pajr.in CEO, NHS Endocrinologist: What is the problem? - Claudication
Where is the problem? - Neurological (needs clinical localisation) vs vascular (risk factors + clinical assessment for vascular insufficiency)
Why is there a problem?
What is the etiological agent and natural history of his life that led to his problem?
Medicine is very simple isn't it @cm 😅
23/12/2024, 12:44 - cm: Very simple if only one can have data capture robots or IOT gathering event data for all citizens in real time!
23/12/2024, 12:56 - cm: Previous follow up patient from 2022 having Lupus and many events related to the disease and it's treatment
reviewed in OPD just now:
Complains of epigastric pain and vomiting 5 times and hasn't eaten since yesterday morning due to severe anorexia since the vomitings.
@huai85 previously @huai2 was very interested in these rheumatology patients before he started becoming an endocrinologist! 😅
23/12/2024, 13:08 -cm: 👆@9huai41 if the lumbar canal stenosis causing neurogenic claudication hypothesis here draws a blind end structurally on the MRI and we are left with this CT angiography offered arterial blockages alone to explain his symptoms would you like to balloon and stent these peripheral vessel occlusions? What would be your cost estimate?
23/12/2024, 15:26 -cm: On reading the first individual trial mentioned in figure 2 one can figure out that those numbers are essentially of study participants who developed an event and the total number of participants.
If we go through each study we may realise none of these are differences are clinically significant
23/12/2024, 15:27 - cm: 👆@huai85 see if you can find some similar data for beta blockers in acute myocardial infarction
24/12/2024, 09:32 - cm: Here's a video by my EBM teacher on his retirement 👇
There are lots of pointers in his own life story format here for many who are looking toward a career in EBM and in my own low key career as a rural medicine pharmer, this teacher was always there to hand hold my inadequacies in my initial journey as an assistant professor in a rural Manipal college of medical sciences, Pokhara since 2000.
24/12/2024, 10:33 - cm: Plan @huai101 @9huai98 to evaluate current glycemic control with four point fasting, and two hours post prandial along with RFT, LFT, Chest X-ray, ECG, fundoscopy and physiotherapy for adhesive capsulitis shoulder strengthening exercises and palliation
24/12/2024, 14:15 - cm: 👆@cr were you able to get in touch with this patient to know what happened to him after we ordered the tests yesterday?
24/12/2024, 14:23 - Patient Advocate 56F Migraine Hypothyroidism 2000: Phone switched off. Trying.
26/12/2024, 10:21 - cm: 👆@huai101 @huai98 let's discharge him and send him to Gandhi hospital where @huai108 may be able to help as his HRCT and bronchoscopy biopsy may need redoing before one can pronounce him as a lung malignancy with mets as otherwise at this stage of the diagnostic uncertainty it could even turn out to be an infectious lesion
26/12/2024, 11:06 - CKD Anemia 2022 Project PI: Okay sir
26/12/2024, 12:26 - cm: OPD encounter with long distance IPD patient admitted yesterday.
Videoed and signed informed consent taken before archiving in the link below thanks to @huai32
Patient is from WB but his problem is something that is often seen in Nalgonda and Narketpally in terms of etiology of the problem!
His son is an MSc Math in Kolkata while the parents live in a rural area and he appears to have discovered a (new for me) neurological sign! @919604701505 @919652955915 should be able to review the literature on the sign and share here.
Have shared that in the video!
26/12/2024, 21:11 - cm: Afternoon session bedside clinical imageology:
27F with PUO, Pain abdomen @huai47 's thesis that turned out to be pyothorax with large pericardial effusion and intestinal obstruction!👇
27/12/2024, 12:32 - cm: https://pajrcasereporter.blogspot.com/2024/12/50m-with-hypokalemic-periodic-paralysis.html?m=1
27/12/2024, 12:39 - cm: Also diabetic since 5 years. On glimiperide 1 mg before breakfast and metformin 850mg after dinner.
Was operated for a corneal dystrophy in January 2024
27/12/2024, 16:57 - cm: Planned for laminectomy and screw fixation but these lateral mass instruments are costing 70,000!👇
28/12/2024, 10:54 - cm: OPD review of our 27M follow up patient earlier project logged and shared here👇
28/12/2024, 11:07 - pajr.in CEO, NHS Endocrinologist: Is it only me or is there significant wasting of the hand muscles? Lumbricals and interossei (both)?
28/12/2024, 11:08 - pajr.in CEO, NHS Endocrinologist: What is the current working diagnosis? @cm sir
28/12/2024, 11:08 - cm: There is
28/12/2024, 11:09 -cm: None yet.
Check out his EMR summary in the project link above
28/12/2024, 11:11 - pajr.in CEO, NHS Endocrinologist: I'm absolutely sure Dr. Bob Varkey or Dr. Aditya Ganguly (a DM Neuro final year resident) will make a breakthrough in this case. Both can be reached on Twitter
28/12/2024, 11:11 - pajr.in CEO, NHS Endocrinologist: Dr. Varkey is a movement disorder master.
28/12/2024, 11:14 - cm: Please host this in your Twitter page and tag them
28/12/2024, 11:17 - pajr.in CEO, NHS Endocrinologist: Can you please share the video with me on PM sir?
28/12/2024, 11:26 - cm: 👆Check this link for the head video of this patient marked as patient 2 @huai2
The forearm video is just now linked here👇
28/12/2024, 22:33 - PaJR Physicist: Endothelial dysfunction - SLE?
29/12/2024, 16:11 - cm: Which patient?
29/12/2024, 17:01 - PaJR Physicist: This case.
29/12/2024, 17:21 - cm: Yes serositis can be a key criteria in Lupus although presenting with pyothorax as here is uncommon in Lupus although not impossible.
29/12/2024, 18:28 - PaJR Physicist: Thanks. Appreciate helping me with some basic stuff.
29/12/2024, 18:43 - PaJR Physicist: Was just exposed to a case of LSE with complications/co- morbidity of ACHF. Can this condition be managed by primary care physicians - how Audicor can help in a triage for referral?
29/12/2024, 19:40 - cm: Yes
Although unfortunately medical education in the country is still not geared to enable real patient care competence in primary care physicians.
It wouldn't be very difficult to streamline if policy makers allow medical educators to teach real patient care
30/12/2024, 09:37 - cm: OPD right now:
22F with sensory seizures manifesting as tongue and peri oral tingling with first episode at 2014 and second episode since last three days. 2014 CT head attached
She was on anti convulsants since 2014 and initially it was carbamazepine which she took 20 together 8 months back as a suicidal bid and then she was switched to levetiracitam and when she complained of giddiness after one month she was switched to Valproate 200 mg twice daily! @se this patient is for your follow up. Will pm you the signed informed PaJR consent and number
30/12/2024, 10:17 - cm: OPD right now:
19F type 1 diabetes since November 2023
On mixtard from her nearest government PHC thrice daily!
Occasional nocturia once or twice a week.
An interesting natural history of different innovations in insulin dose and interval delivery that happens in the third world @huai2 @huai85 that most of the first world educated physicians remain oblivious of! Being a rural medicine pharmer has it's advantage in that one gets a ringside view of innovations that often don't percolate into the siloed world of evidence based guideline driven medicine although it's a fantastic opportunity for data driven medicine to check if patient outcomes are actually better even if due to system errors (that often remain invisible below the iceberg)!
30/12/2024, 12:06 - Inner Strength Engineer1: Sure sir Ok. 👍
30/12/2024, 12:59 - pajr.in CEO, NHS Endocrinologist: Agree. I was initially pitching for NPH in Type 1 as well. It is neck and neck with Detemir and Glargine but has rebound hyperglycemia too often.
Some form of Insulin is better than none at all!
30/12/2024, 14:22 - cm: And what about its thrice daily schedule as implemented by the PHC and patient accidentally due to lack of information continuity? <This message was edited>
30/12/2024, 14:45 - pajr.in CEO, NHS Endocrinologist: Well spontaneous order is generating new ideas and discoveries! Let's see how this plays out.
30/12/2024, 14:56 - Pushed1Comm22: Fbs 218, Hba1c 7.1
30/12/2024, 14:56 - cm: Can they get admitted to see if mixtard thrice can be optimised?
30/12/2024, 14:58 - Pushed1Comm22: No sir they r not willing to
But they have glucometer at home sir
30/12/2024, 15:11 - cm: Alright ask them to share their blood sugars FBS, and two hours ppbs after every meal and prepare their PaJR groups after obtaining signed informed consent
30/12/2024, 15:40 - pajr.in CEO, NHS Endocrinologist: VBG/ABG and Urine K+ with Urine Ca and Na, Cl and Cr
BP?
30/12/2024, 16:15 - cm: @huai69@huai65 @huai89 please share the serial abgs and urinary potassium values
01/01/2025, 10:28 - cm: This body of research describes contemporary practice and raises concerns that 1) current systems of declarations do not effectively achieve transparency and 2) the role of transparency in reducing conflicts of interests requires to be delineated to ensure that the intended purpose is met. The potential benefits from transparency as well as the risks, unintended consequences, burden and evidence gaps in current declaration systems is discussed, with questions raised as to whether transparency can reduce bias or, counter-intuitively, worsen it.
Unquote
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