Narketpally Syndrome CBBLE: Participatory Medical cognition Web2.0-3.0

 

NARKETPALLY SYNDROME CBBLE: PARTICIPATORY MEDICAL COGNITION WEB 2.0-3.0

JANUARY 2025

01/01/2025, 13:17 - Ajay Reddy 2022 Med PG Kims: It's done sir 

This is his 24 hrs UPCR report

01/01/2025, 13:26 - Rakesh Biswas: Thanks.

01/01/2025, 13:28 - Rakesh Biswas: The mild proteinuria albeit non significant is still suggestive of a mild glomerular involvement or perhaps this is also related to his tubular injury due to multifactorial causes since his fracture?

01/01/2025, 13:29 - Rakesh Biswas: Please share his serial ABGs since admission

01/01/2025, 13:39 - Rakesh Biswas: Was his ANA done?

01/01/2025, 14:59 - Patient Research Collaborator left

01/01/2025, 15:26 - pajr.in CEO, NHS Endocrinologist: Thanks for sharing. What is the current working Hypothesis? Do we have an ABG or have I missed it?

01/01/2025, 15:30 - Dr Ramji SR Medicine: Typical Clinical diagnosis of ACS expected to be made.

Ecg shows changes hope our pg's have not missed the boat...

01/01/2025, 15:47 - Ajay Reddy 2022 Med PG Kims: Sir we are suspecting the case to be hypokalemic periodic paralysis secondary to type I RENAL TUBULAR ACIDOSIS - secondary to SJOGRENS syndrome

01/01/2025, 15:49 - Ajay Reddy 2022 Med PG Kims: In suspicion of sjogrens syndrome we got a ophthalmology opinion where no evidence of dry eye was found and schrimmers was also normal 

We planned to get ANA profile, but patient attenders are not affordable

01/01/2025, 16:12 - pajr.in CEO, NHS Endocrinologist: Hypokalemic periodic paralysis is a myopathic disorder. Recurrent Hypokalemic paralysis (RHP) due to renal wasting of potassium is a neurological disorder.

01/01/2025, 16:13 - pajr.in CEO, NHS Endocrinologist: What's the patient's age? Is he a glue sniffer or does he use any form of recreational drugs at all?

01/01/2025, 16:13 - pajr.in CEO, NHS Endocrinologist: Where is he from? What water does he drink?

01/01/2025, 16:25 - Ajay Reddy 2022 Med PG Kims: Patient age is 50 yrs sir 

No history of any recreational or drug usage

01/01/2025, 16:26 - Ajay Reddy 2022 Med PG Kims: He is from kodada sir 

And drinks mineral water

01/01/2025, 16:27 - pajr.in CEO, NHS Endocrinologist: Alright. It does look like RTA doesn't it?

Which Type though. 1 or 2?

01/01/2025, 16:27 - pajr.in CEO, NHS Endocrinologist: He had recurrent fractures?

01/01/2025, 16:27 - pajr.in CEO, NHS Endocrinologist: Any review of literature on etiologies of RTA in 50 year old men?

01/01/2025, 16:29 - Ajay Reddy 2022 Med PG Kims: Yes sir it is RTA type 1

01/01/2025, 16:29 - pajr.in CEO, NHS Endocrinologist: How and why?

01/01/2025, 16:30 - Ajay Reddy 2022 Med PG Kims: Only once history of fall 3 months ago and had IT  fracture sir 

But in 50 yr old male IT fracture can be considered abnormal..

01/01/2025, 16:32 - pajr.in CEO, NHS Endocrinologist: In simple terms - fall from patient's own height and then having a fracture is termed a pathological fracture.

So assuming this is a low impact pathological fracture - does this mean the patient have osteoporosis?

01/01/2025, 16:32 - pajr.in CEO, NHS Endocrinologist: What in your assessment are common causes of Osteoporosis?

01/01/2025, 16:34 - Rakesh Biswas: I guess that was due to a recall bias as one of our previous patients (we even kept her for the final exams) was having that etiology. However in this patient there are other associations to account for

01/01/2025, 16:40 - Rakesh Biswas: Can you share more details as to how he sustained the fracture?

01/01/2025, 16:43 - Ajay Reddy 2022 Med PG Kims: Symptoms of type 1 RTA can begin in infants or as late as adulthood. Not everyone will experience the same symptoms as they can vary depending on such factors related to the specific gene change, level of acidosis (acid in the blood), age of the individual, and even how advanced the disease is. Secondary dRTA usually occurs later in life.

This patient has  hypokalaemia,  features of polyuria, muscle weakness, hypercalcinuria, renal calculi

01/01/2025, 16:46 - pajr.in CEO, NHS Endocrinologist: Well I understand what you are saying but how do we make a definitive diagnosis? Any urine anion gap or Urine pH or Ammonium chloride stimulation test?

01/01/2025, 16:47 - pajr.in CEO, NHS Endocrinologist: Such a wonderful group this is. So much conversational learning. I want to contribute to your department fund sir. Please let me know how

01/01/2025, 16:49 - Rakesh Biswas: @918317669334 is the treasurer

01/01/2025, 17:24 - pajr.in CEO, NHS Endocrinologist: UPI ?

01/01/2025, 17:25 - +91 88975 53432 left

01/01/2025, 19:04 - PI Portal Hypertension Project 2022: 8317669334334@ybl sir 

All the Gen Med PGs and Biswas sir contribute ₹100 monthly sir

Currently we have ₹19,100/- with us <This message was edited>

01/01/2025, 19:05 - Rakesh Biswas: I have tagged him in that group.

02/01/2025, 11:10 - Rakesh Biswas: Her clinical complexity of current DILI is made complex by the fact that she also has intermittent chronic hemolysis noticed since she was 14 and which has aggravated since 2020 while she first became symptomatic for cough, cold and fever every two months since 2003!

02/01/2025, 11:37 - Rakesh Biswas: Reviewing in OPD

Currently on lowest dose prednisolone 5mg and 2.5 mg along with Azathioprine 50 mg for her Lupus nephritis 

Anasarca

BP 140/80

Other findings wnl

Anuric since morning

Constipation since morning 

Plan

Admit in wards

Monitor 

intake output

RFT 

May need to watch out for RPGN 

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

02/01/2025, 16:17 - Rakesh Biswas: Afternoon session:

64F with chronic abdominal pain, intermittent fever since two years after a trip to Kedarnath with marked reduced appetite since three months.

On examination an enlarged spleen on palpation and on  cardiovascular auscultation a pan systolic murmur by @918277432650

https://youtu.be/CYLkB2OVoS8?feature=shared

03/01/2025, 11:19 - Rakesh Biswas: This is a good PhD opportunity for our current 3 case reporters who have been doing a fantastic job evidenced by their online learning portfolio 👇

https://www.exeter.ac.uk/study/funding/award/?id=5303 

 

Deadline for applications: 12:00 GMT Tuesday 14 January 2025 

 

The Faculty of Humanities, Arts and Social Sciences is launching its UK Global Majority studentship for 2025/26. We recognise the sector-wide underrepresentation of UK Global Majority – sometimes referred to as Black, Asian and Minority Ethnic (BAME) - students at PhD level in Humanities, Arts and Social Sciences, and the Studentship represents our commitment to expanding the opportunities for the most able students irrespective of background or financial circumstances.  

 

Details at  https://www.exeter.ac.uk/study/funding/award/?id=5318 

 

Please share these studentship opportunities with your students and networks. Thanks.

 

Best wishes

 

Suchith

Professor Suchith Anand

Professor of Practice in Science Policy | Senior Adviser to Governments and International Organisations | Scientist | Global Citizen | Science Diplomacy |  SDG Volunteer and Advocate

https://www.exeter.ac.uk

https://ethicaldatainitiative.org 

@918597778887 @923305072858 @918074725352

03/01/2025, 21:40 - pajr.in CEO, NHS Endocrinologist: 38F with recurrent Hypokalemic paralysis, acute severe hypocalcemia and chronic pancreatitis?

Any interested discussants?

Many thanks.

03/01/2025, 22:24 - Rakesh Biswas: Patient in UK?

03/01/2025, 22:38 - pajr.in CEO, NHS Endocrinologist: Yes sir but too interesting to ignore. Perhaps some of your PGs may enjoy it.

03/01/2025, 23:02 - Savant Reddy Chityal 2017 Kims: Sir is there a possibility of polyendocrine syndrome?

04/01/2025, 00:44 - pajr.in CEO, NHS Endocrinologist: Yes. Reason out through the case.

04/01/2025, 00:44 - pajr.in CEO, NHS Endocrinologist: This is the VBG. Please note units for gases in kpa

PH 7.50 pco2 5.4 HCO3 29.2 Lac 2.4 Glu 7.1

Na 126 K 2.6 Cl 91

04/01/2025, 00:45 - pajr.in CEO, NHS Endocrinologist: Also had previous Thyroidectomy a few years ago.

04/01/2025, 08:00 - Rakesh Biswas: Are these from the portable ABG autoanalyzer (where the electrolyte electrodes get dysfunctional soon as widely believed to happen frequently in the third World) or are these done in another autoanalyzer?

04/01/2025, 09:15 - Rakesh Biswas: A leaf off the Patient centered medical cognition learning repository 👇

Previous assumption:

"just one genome, perfectly replicated in every cell of our body."

New find:

"Two adjacent cells, seemingly identical under the microscope, can have about 1,000 differences in their genomes."

Original case report of a 25 patient series where the authors adopted a genotype driven rather than the usual phenotype driven approach (although deep phenotyping may include genotypes too) and subsequent story published for the first time here with a vexing name:

https://www.nejm.org/doi/10.1056/NEJMoa2026834

They named this new 2020 published disorder as the VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome.

It continues to vex everyone ever since:

"Since then, Dr. Tantra­vahi and his colleagues have diagnosed several more men with the disorder.

“Many of these men also demonstrate cytopenias, mostly anemia and thrombocytopenia. Recognizing the characteristic constellation of systemic autoimmune manifestations, cytopenias, and vacuolization of the erythroid and myeloid progenitors in the marrow is critical for the diagnosis of VEXAS"

Unquote

https://ashpublications.org/ashclinicalnews/news/5960/The-Vexing-VEXAS-Syndrome

Thanks for sharing @919604701505 <This message was edited>

04/01/2025, 11:25 - Rakesh Biswas: EMR summary updated:

https://pajrcasereporter.blogspot.com/2024/12/50m-with-hypokalemic-periodic-paralysis.html?m=1

04/01/2025, 14:08 - pajr.in CEO, NHS Endocrinologist: Well maintained and get regularly checked. Hence reliable.

04/01/2025, 16:22 - Rakesh Biswas: Reviewed in the afternoon:

Current autoimmune inflammatory indicators: 

24 hour significant proteinuria 1.2 g suggestive of active glomerular inflammation

Persistent bowel symptoms in this admission and thickening on imaging suggestive of possible IBD

Reviewed the major events in the entire history from September 2022:

1st admission with altered sensorium, serositis, nephrotic proteinuria and ANA +++ suggestive of Lupus and started on high dose steroids with azathioprine as adjuvant and unfortunate anticoagulants (thinking of cardiac embolism) 

December 2022 

2nd admission with complications of minor IC bleed due to anticoagulant

Lost to follow up in 2023 till June 2024 

Not sure if she achieved glomerular remission

Stopped all Rx in December 2023

June 2024 presented with flare of arthritis and proteinuria

Restarted steroids and adjuvants and developed pyopneumothorax because of which immunosuppressives were again quickly tapered off to prednisolone 5mg and Azathioprine 50 mg once daily with poor follow up and this time in Jan 2025 she appears to have developed glomerular injury again along with possible IBD this time!

https://chat.whatsapp.com/KzES8cbXOIOEkkFsPh9SKg

04/01/2025, 16:51 - Chandana KIMS 2020 SR: 1.Hypokalemic paralysis and metabolic alkalosis- 

Is it HPP or non-HPP?

For non HPP - renal vs GI loss of K+?

Rule out thyrotoxic paralysis as I presume she is on supplements.

Is she using any drugs?-diuretics, insulin, salbutamol, laxatives ?

Any history suggestive of GI loss?

2.hypo Na+- 

if not hypervolemic- ?adrenal (autoimmune) or ?hypothyroid (what was the reason for thyroidectomy?)

3.Hypo Ca2+  

DDs: post thyroidectomy hypopara (vs) vitamin D def due to chronic pancreatitis (vs) autoimmune hypopara

4.Pancreatitis-?alcohol history ?autoimmune

I think she needs serum PTH levels, vitamin d levels, serum magnesium, urine potassium, and evaluation for hyponatremia (adrenal, thyroid, renal), random blood sugar, urine sodium, serum and urine osmolality

For APS- To Look for clues of other autoimmune conditions- vitiligo, alopecia, pernicious anemia, candidiasis etc

Serum IgG4 can be considered if not alcoholic

Autoimmunity can explain adrenal, thyroid, parathyroid, pancreatic involvement

04/01/2025, 17:23 - pajr.in CEO, NHS Endocrinologist: PTH 54 (UK units) and Vit D >75

04/01/2025, 17:27 - pajr.in CEO, NHS Endocrinologist: Mg 0.88 mmol and Phosphate is 0.9 mmol.

04/01/2025, 17:29 - pajr.in CEO, NHS Endocrinologist: Why do you want to rule out thyrotoxic paralysis when she had a Thyroidectomy?

What is the single most important pivot point in this case?

04/01/2025, 17:30 - pajr.in CEO, NHS Endocrinologist: Which of these do you want to chase the most?

A. Hyponatremia

B. Hypokalemia

C. Hypocalcemia

D. Metabolic Alkalosis

E. All of the Above.

04/01/2025, 17:31 - pajr.in CEO, NHS Endocrinologist: Normal PTH range is 1.9 to 8.5. So PTH is very very high.

04/01/2025, 17:35 - Chandana KIMS 2020 SR: So secondary hyperpara sir? what is the reason for hypocalcemia then?

04/01/2025, 17:37 - Chandana KIMS 2020 SR: Because she might be on excess thyroid supplements. As post thyroidectomy patients are usually are on supplements

04/01/2025, 17:38 - Unknown Medical Student: Sir could it be Pseudohypoparathyroidism

The syndrome mimics hypoparathyroidism with patients experiencing hypocalcemia and hyperphosphatemia. However, instead of having low PTH levels, elevated levels of PTH are present in serum

https://www.ncbi.nlm.nih.gov/books/NBK547709/

04/01/2025, 17:38 - pajr.in CEO, NHS Endocrinologist: Recent TSH 2.88 and Free T4 14.3. Both within perfect range.

04/01/2025, 17:39 - pajr.in CEO, NHS Endocrinologist: If you can answer this, pseudohypoparathyroidism falls apart

04/01/2025, 17:41 - Chandana KIMS 2020 SR: I’m not sure. Everything seems important, though 😅 very interesting case

04/01/2025, 17:43 - Unknown Medical Student: Does she have history of vomitings sir?

04/01/2025, 17:45 - pajr.in CEO, NHS Endocrinologist: No not really. No GI losses either. Also had HypoMg in the past and is on Mg supplements regularly.

04/01/2025, 17:48 - pajr.in CEO, NHS Endocrinologist: A different perspective I want to present here is that - she had 12 admissions for Hypocalcemia in 2024, 6 for hypokalemic paralysis and quite a few clinic visits and other issues in the last 4 years.

As doctors we could not solve her problems. While at an individual level she has been quite distressed with this, the loss of human capital and the economic cost of her recurrent admissions goes in millions!!

The principal reasons for this are lack of curiosity and doctor incompetence in general?

Solve competence and you solve all of these problems?

Which is why I'm very keenly interested in getting inputs from this group. Thanks all

04/01/2025, 17:49 - pajr.in CEO, NHS Endocrinologist: What is your approach to metabolic Alkalosis?

04/01/2025, 17:54 - Unknown Medical Student: Usually by history and drug history sir

04/01/2025, 17:55 - Unknown Medical Student: This is taking us to saline resistant metabolic alkalosis

04/01/2025, 17:55 - pajr.in CEO, NHS Endocrinologist: I understand. She is usually on thyroid supplements, very high doses of calcium and intermittently on Mg supplements etc. Nothing stand out otherwise.

04/01/2025, 17:55 - Chandana KIMS 2020 SR: If she is losing K, Ca, Mg everything in urine bartter/gitelman can be considered

04/01/2025, 17:56 - pajr.in CEO, NHS Endocrinologist: Yes and Urine Ca was 432 (normal range is 100 to 250)

04/01/2025, 17:56 - Unknown Medical Student: Is it common in that age Mam

04/01/2025, 17:56 - Chandana KIMS 2020 SR: Ohh that explains the hypocalcemia and secondary hyperpara <This message was edited>

04/01/2025, 17:56 - pajr.in CEO, NHS Endocrinologist: Review the literature and please let us know.

04/01/2025, 17:57 - pajr.in CEO, NHS Endocrinologist: Does secondary hyperpara occur due to hypocalcemia alone or due to Vit D Def? Which actually can be linked to one of her other problems

04/01/2025, 17:59 - pajr.in CEO, NHS Endocrinologist: Oh she's also on Creon

04/01/2025, 18:04 - Chandana KIMS 2020 SR: Low Magnesium?

04/01/2025, 18:07 - pajr.in CEO, NHS Endocrinologist: I think her exocrine insufficiency could have led to deficiency of fat soluble vitamins and perhaps Vit D deficiency needing supplements?

04/01/2025, 18:08 - Chandana KIMS 2020 SR: Yes possible

04/01/2025, 21:28 - +91 94893 19758 joined using this group's invite link

05/01/2025, 19:03 - +91 79023 06246: *Invitation to join CUBE chatShaala*

*Room Link* 

https://webinar.chatshala.in/rooms/igu-cek-scg-o52/join

 *Timings : 7.30 pm to 9.30 pm*

We encourage to provide your contribution in constructing model based/context based and activity based discussions in CUBE chatShaala webinar.

*We are looking forward to your participation.*

Thanks

05/01/2025, 21:38 - Rakesh Biswas: Another quick quiz case:

The patient stated that his right hand raised involuntarily, grabbed the object which he tried to reach with his left hand competitively and he did not have voluntary control over the spatial movements of his right hand. Additionally, deep sensory impairment was noted in the upper right side. The patient also suffered from similar but milder complaints related to his right lower limb. Balance in sitting position was disturbed with a tendency to fall to the right or backwards. These signs and symptoms were suggestive of ? @919652955915

05/01/2025, 21:40 - pajr.in CEO, NHS Endocrinologist: Alien Limb Phenomenon?

05/01/2025, 21:41 - pajr.in CEO, NHS Endocrinologist: Clearly my Neurology has taken a severe beating 😂

05/01/2025, 22:53 - ~ DR. ABIRBHAB SAHA left

06/01/2025, 08:58 - Rakesh Biswas: No it hasn't!

It is Alien limb syndrome 👏👏

06/01/2025, 11:26 - Rakesh Biswas: Reviewing the patient right now in the OPD @923305072858 for you to update in the case report here 👇

https://narmeenshah.blogspot.com/2024/11/43f-diabetes-on-insulin-10-yrs.html?m=1

She was alright since her last discharge in November and came once for follow up in December for pedal edema but otherwise was NYHA 1! Was able to walk from the hospital gate to our OPD without any shortness of breath.

The edema subsided in December.

Now complains of chest pain since yesterday

06/01/2025, 13:10 - Rakesh Biswas: @918074725352 shared his case report consent form and number in the core group

06/01/2025, 19:05 - pajr.in CEO, NHS Endocrinologist: Those were the days!

06/01/2025, 19:07 - pajr.in CEO, NHS Endocrinologist: Now I'm a computer junkie seeing a patient for normal TSH and low T4 (in one random lab report) and contemplating the meaning of life and why Krishna willfully did not stop Duryodhana from going to war!

Oh well!

06/01/2025, 19:15 - pajr.in CEO, NHS Endocrinologist: Can that be labelled as a pancoast tumor sir?

06/01/2025, 19:46 - Rakesh Biswas: Yes if it turns out to be bronchogenic carcinoma but I'm hoping it turns out to be tuberculosis

06/01/2025, 19:51 - pajr.in CEO, NHS Endocrinologist: https://pmc.ncbi.nlm.nih.gov/articles/PMC4789496/

Curiously, I recall once discussing a case on Twitter about something similar. Turns out Dystonias with Alien Limb Phenomenon are strongly suggestive of Corticobasal degeneration / Atypical parkinsonism

06/01/2025, 21:27 - Rakesh Biswas: In the context of team based learning driven by Socratic questioning in the group:

"In his lecture, Reich describes a kinder, gentler Socratic Method, pointing out the following:

Socratic inquiry is not “teaching” per se. It does not include PowerPoint driven lectures, detailed lesson plans or rote memorization. The teacher is neither “the sage on the stage” nor “the guide on the side.” The students are not passive recipients of knowledge.

The Socratic Method involves a shared dialogue between teacher and students. The teacher leads by posing thought-provoking questions. Students actively engage by asking questions of their own. The discussion goes back and forth.

The Socratic Method says Reich, “is better used to demonstrate complexity, difficulty, and uncertainty than to elicit facts about the world.” The aim of the questioning is to probe the underlying beliefs upon which each participant’s statements, arguments and assumptions are built.

The classroom environment is characterized by “productive discomfort,” not intimidation. The Socratic professor does not have all the answers and is not merely “testing” the students. The questioning proceeds open-ended with no pre-determined goal.

The focus is not on the participants’ statements but on the value system that underpins their beliefs, actions, and decisions. For this reason, any successful challenge to this system comes with high stakes—one might have to examine and change one’s life, but, Socrates is famous for saying, “the unexamined life is not worth living.”

“The Socratic professor,” Reich states, “is not the opponent in an argument, nor someone who always plays devil’s advocate, saying essentially: ‘If you affirm it, I deny it. If you deny it, I affirm it.’ This happens sometimes, but not as a matter of pedagogical principle.

Unquote

https://tilt.colostate.edu/the-socratic-method/

06/01/2025, 22:47 - Rakesh Biswas: Update:

Shared by @918374789176 today

There's a suspicious vegetation in her pulmonary valve👇

https://youtu.be/99vTJ8lk61U?feature=shared

06/01/2025, 22:49 - Rakesh Biswas: And very interestingly a very high pressure gradient proximal to the pulmonary valve also seen in DCRV as recorded by @918374789176 and team here 👇

https://youtu.be/xlZXcqxUtJY?feature=shared

06/01/2025, 23:43 - Inner Strength Engineer1: Everything updated sir ✅

07/01/2025, 08:53 - Rakesh Biswas: LIVE NOW

Opening session of PGI academic session for new MD students of PGI

Evolution of medicine

https://www.youtube.com/live/Gsx1M8f28rE?si=h9EaEyGLoaMFzpW7

07/01/2025, 13:07 - Rakesh Biswas: 👆@918074725352 first intro to the patient's case report here

07/01/2025, 13:07 - Rakesh Biswas: 👆@918074725352

07/01/2025, 13:07 - Rakesh Biswas: @918074725352

07/01/2025, 13:07 - Rakesh Biswas: @918074725352

07/01/2025, 13:07 - Rakesh Biswas: 👆@918074725352

07/01/2025, 13:12 - Rakesh Biswas: Today's update @918074725352 

The patient had a operation to relieve the cervical compression due to his OPLL (hope to see the details of the operative procedure in his EMR) and reviewed him today in the fourth post operative day.

Currently his right upper limb strength has reduced from a previous 4+ to 3- and left upper limb strength has reduced to 4- while the right lower limb strength has improved from 3 to 3+ and left lower limb strength remains as previous at 3+ as also objectively documented in the video here👇

https://youtu.be/kpmgKItAoGU?feature=shared

07/01/2025, 13:13 - Rakesh Biswas: This was his previous gait @918074725352👇

https://youtube.com/shorts/FgqpexpUfY4?feature=shared

07/01/2025, 14:19 - Patient Advocate 56F Migraine Hypothyroidism 2000: Thank you so much, will do it.

07/01/2025, 14:50 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

07/01/2025, 14:53 - +91 77109 32371 left

08/01/2025, 11:03 - Pushed Communicator 223: .

08/01/2025, 11:43 - Rakesh Biswas: Her previous problems have disappeared although the diagnostic uncertainty around it may not have (albeit forgotten)!

Her current issues are those of metabolic syn and headache 

https://chat.whatsapp.com/IR2rGN5Fv3k8Egloatju35

08/01/2025, 14:53 - Rakesh Biswas: @919652955915 is there a new protocol that mandates levetiracitam after any kind of Seizures or is that to save ourselves from legal advocates who may not know better? Here I notice that any seizure is almost always a driver to levetiracitam

08/01/2025, 16:02 - pajr.in CEO, NHS Endocrinologist: What is the current working diagnosis on Acute Hyponatremia sir?

08/01/2025, 16:03 - pajr.in CEO, NHS Endocrinologist: Uncertain on benefits and limited risk with adverse effects?

08/01/2025, 16:05 - pajr.in CEO, NHS Endocrinologist: Heavy Endocrine bias - But such acute Hyponatremias can occur due to a Pituitary Apoplexy!

Any documented hypoglycemias? Thiazide diuretics do remain the commonest cause though.

08/01/2025, 16:57 - Rakesh Biswas: From all the hyponatremia thesis done in Narketpally (we can fish out two from the past and one of them is by your batchmate, which was done well perhaps) most of the patients appear to end up with 3% saline and alls well forgotten about the cause as long as the patient recovers!

08/01/2025, 16:57 - Rakesh Biswas: Wasn't it also commonly used from 2018-20?

08/01/2025, 16:59 - Rakesh Biswas: Afternoon session: 

Chasing the same patient's chest X-ray and HRCT suspicious shadows with ultrasound in the hope of a diagnosis for her 3 year old left vocal cord palsy and 

hoarseness 👇

https://youtu.be/wUSVgawTu3k?feature=shared

08/01/2025, 17:27 - Dr Ramji SR Medicine: You have all the rights to change/ correct /stop or highlight any mistakes we make sir..

I would be rather happy sir. Thank you

08/01/2025, 17:31 - Dr Ramji SR Medicine: Working diagnosis is hypotonic euvolemic hyponatremia? SIADH sir,

-some of our pg's reasoned well to arrive at a possible diagnosis.

08/01/2025, 17:32 - pajr.in CEO, NHS Endocrinologist: Has SIADH ever caused a patient to be acutely unwell?

08/01/2025, 17:32 - pajr.in CEO, NHS Endocrinologist: Would acute hypocortisolemia be a good differential?

08/01/2025, 17:32 - pajr.in CEO, NHS Endocrinologist: Can you please ask your PGs to share the ABG and CBP if its okay?

08/01/2025, 17:39 - Dr Ramji SR Medicine: Hyponatremia is apparently chronic in this patient sir, which was an (incidentally detected) 

Patient was on iv fluids nearly 1000ml/day + oral 700ml with less urine output, which lead to progression in hyponatremia( raising the suspicion of current diagnosis) thereby acute presentation( possible explanation which I can think of for seizures is cerebral edema which was ruled out by CT scan)...

08/01/2025, 17:40 - Dr Ramji SR Medicine: Pg's shall do sir...

08/01/2025, 17:41 - pajr.in CEO, NHS Endocrinologist: Oh I see. Then why does she have SIADH in the first place?

08/01/2025, 17:41 - pajr.in CEO, NHS Endocrinologist: Any chance this is Adrenal Insufficiency?

08/01/2025, 17:41 - pajr.in CEO, NHS Endocrinologist: Thank you.

08/01/2025, 17:42 - Dr Ramji SR Medicine: We are currently focusing in management of his coma state, which is improving sir, need to look into that...

08/01/2025, 17:46 - Dr Ramji SR Medicine: Their present with hypotension sir, however I need to reconfirm whether or not it's a differential.... <This message was edited>

08/01/2025, 19:42 - Rakesh Biswas: Both @919818741334 and @919652955915made my afternoon ICU rounds worthwhile along with @918277432650

08/01/2025, 19:54 - pajr.in CEO, NHS Endocrinologist: A clinic patient I'm seeing tomorrow. Any inputs will be sincerely appreciated -

68/M with long term hypertension and hypokalemia. Well controlled with 1 agents, which are currently Doxazosin and a beta blocker. Got ARR (aldosterone renin ratio) in July 2024 at 814 (A/R = 570/0.7) which raises suspicion for Conn's. Although a ratio of >1700 would be definite Conn's and requires subsequent testing. Similar ratio in Jan 2024 as well.

Bicarbonate is 28, never had a blood gas so no pH to report, but no history suggestive of respirators disease to think pCO2 and pO2 would be abnormal.

24 hr Urine K = 57 (>15mmol)

Spot Urine K from same sample = 32

Spot urine Creatinine = 5.2mmol/l

No Urine Ca or Urine Cl

Any inputs would be appreciated

@919121046928 @919818741334 @919154575937 @918099474777 @918367363668 @918332874734 @919160359545 @918277432650

08/01/2025, 20:05 - pajr.in CEO, NHS Endocrinologist: Inputs welcome from all.

08/01/2025, 20:07 - Rakesh Biswas: We had a similar patient with hypertension and hypokalemia with an ARR of 587 and we also got lucky on the CT abdomen actually showing a macro tumor archived for the first time here👇

https://globaludhc07.blogspot.com/2015/12/a-50-years-old-woman-with.html?m=1

08/01/2025, 20:08 - pajr.in CEO, NHS Endocrinologist: The ratio is in which units sir?

His CT showed normal adrenals

08/01/2025, 20:09 - Rakesh Biswas: She also visited Narketpally twice with the last visit in August 2024

@919154575937 created her PaJR here https://chat.whatsapp.com/K0uBTqNFG1YFFGHrRZlBMZ

08/01/2025, 20:10 - Rakesh Biswas: Here's the report 👇

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhGog_jffcdUwpQo4r9Uv3UInYGXsb_AIK-uoP4-ISkN6zA5pCES9JJjlosJGnYERhodr6_Q8PnWRf-yGjWgIwFUYdOPXvMNDAExNgwBYYmm8IyYl1vFr_aMmYF3KGpAuCp7wN0aQGkWKcz/s1600/DSCN0992.JPG

08/01/2025, 20:23 - pajr.in CEO, NHS Endocrinologist: Woah!

08/01/2025, 20:23 - pajr.in CEO, NHS Endocrinologist: Hopefully all the right drugs were stopped at the time and the test performed appropriately?

08/01/2025, 20:25 - pajr.in CEO, NHS Endocrinologist: This is how we do it here

https://cloud.samitinjay.com:443/s/BJQsZ4AcoGXzaNt

08/01/2025, 20:25 - pajr.in CEO, NHS Endocrinologist: All drugs are stopped for 6 weeks here and the alternatives are Doxazosin, Verapamil, Moxonidine or Hydralazine.

08/01/2025, 21:29 - Dr Ramji SR Medicine: @916309964666 @918277432650 somaiah ABG, CBP plz

08/01/2025, 21:34 - pajr.in CEO, NHS Endocrinologist: Thanks.

08/01/2025, 21:46 - pajr.in CEO, NHS Endocrinologist: Thanks. Was the patient on a diuretic at all?

08/01/2025, 21:46 - pajr.in CEO, NHS Endocrinologist: Surely looks like it.

08/01/2025, 21:47 - Akash Deep Kims 2023: No sir

08/01/2025, 21:49 - pajr.in CEO, NHS Endocrinologist: In that case SIADH should be the start of the diagnostic journey, not the end of it?

08/01/2025, 23:59 - AS Kasturi Bangalore: Informative and educative

09/01/2025, 13:20 - Rakesh Biswas: Great complement coming from my teacher Prof Kasturi, ex Prof AFMC Pune 🙂🙏

10/01/2025, 20:19 - pajr.in CEO, NHS Endocrinologist: How's his Thyroid function sir?

10/01/2025, 20:29 - Rakesh Biswas: @918277432650 can you share his TFTs?

11/01/2025, 14:57 - Rakesh Biswas: https://pubmed.ncbi.nlm.nih.gov/11929615/

Apparently the answer to the question if it matters is that it doesn't matter!

To quote:

"Volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) are not different ventilatory modes, but are different control variables within a mode. Just as the debate over the optimal ventilatory mode continues, so too does the debate over the optimal control variable. VCV offers the safety of a pre-set tidal volume and minute ventilation but requires the clinician to appropriately set the inspiratory flow, flow waveform, and inspiratory time. During VCV, airway pressure increases in response to reduced compliance, increased resistance, or active exhalation and may increase the risk of ventilator-induced lung injury. PCV, by design, limits the maximum airway pressure delivered to the lung, but may result in variable tidal and minute volume. During PCV the clinician should titrate the inspiratory pressure to the measured tidal volume, but the inspiratory flow and flow waveform are determined by the ventilator as it attempts to maintain a square inspiratory pressure profile. Most studies comparing the effects of VCV and PCV were not well controlled or designed and offer little to our understanding of when and how to use each control variable. Any benefit associated with PCV with respect to ventilatory variables and gas exchange probably results from the associated decelerating-flow waveform available during VCV on many ventilators. Further, the beneficial characteristics of both VCV and PCV may be combined in so-called dual-control modes, which are volume-targeted, pressure-limited, and time-cycled. PCV offers no advantage over VCV in patients who are not breathing spontaneously, especially when decelerating flow is available during VCV. PCV may offer lower work of breathing and improved comfort for patients with increased and variable respiratory demand."

Unquote

@917382828731 @919573087708

11/01/2025, 17:59 - Patient Advocate 56F Migraine Hypothyroidism 2000: Both done

11/01/2025, 20:08 - Rakesh Biswas: Thanks

11/01/2025, 20:30 - Rakesh Biswas: https://pajrcasereporter.blogspot.com/2025/01/36m-with-renal-failure-ap-pajr.html?m=1

13/01/2025, 19:06 - Rakesh Biswas: 👆@919007833351 I've asked this patient to meet you tomorrow day after in Durgapur.

Show her to your current professors there

13/01/2025, 19:07 - Aadipta Ghosh: Okay sir

13/01/2025, 19:27 - Shoaib 2020 UG: can be enlarged cysts as then pain is a clue to it

13/01/2025, 20:24 - Rakesh Biswas: Afternoon session today:

Type 1 Diabetes 8 years and progressive cardio renal failure 2 years 

https://youtu.be/zXnZgVPUpF8?feature=shared

14/01/2025, 17:57 - Rakesh Biswas: "This pan-India registry presents a comprehensive real-world reflection of the IP in patients with T2D. The study validates that Indians have a high BF%, despite having relatively lower BMI. Among the patients with normal BMI, many had an obese BF% despite using the Asia-specific BMI cut off, which is lower than that used for Caucasians."

https://touchendocrinology.com/diabetes/journal-articles/indian-phenotype-characteristics-among-patients-with-type-2-diabetes-mellitus-insights-from-a-non-interventional-nationwide-registry-in-india/

14/01/2025, 18:31 - Rakesh Biswas: Tomorrow's academics

Staff CPC

Time 8-9 am

Venue:LT1

The session will also be available on the Webex platform. Kindly follow the link below to join.

https://india-edu.webex.com/india-edu/j.php?MTID=m1cb4b75b29a2cff53f63e5991b9bab7b

In case you join in through 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 given below.

The clinical protocol will be presented by Prof. Navneet Singh 

Radiology will be presented by Dr. Uma Debi

Autopsy pathology will be presented by Prof. Uma Nahar

Clinician incharge - Prof. A.N. Aggarwal

Chairperson - Prof. Sanjay Jain

Thank you

14/01/2025, 19:01 - +91 76758 49042 left

15/01/2025, 10:56 - Rakesh Biswas: The findings are hardly worth it!

15/01/2025, 11:05 - Rakesh Biswas: This was the clincher!

15/01/2025, 15:23 - Rakesh Biswas: 👆 Hemoperitoneum

16/01/2025, 13:08 - Rakesh Biswas: Reviewed this patient of neurogenic vs vascular claudication pain in the OPD now!

His diagnostic uncertainty was compounded by the clinico radioligic dys correlation that mandated further testing!

https://pajrcasereporter.blogspot.com/2024/12/37m-with-symptoms-of-backpain-followed.html?m=1

16/01/2025, 14:48 - Rakesh Biswas: 👆Post admission pharmacological and non pharmacological interventions and BP outcomes

16/01/2025, 14:51 - Dr Abdul Wahid Bhat Prof Kims NKP joined using this group's invite link

17/01/2025, 10:56 - Rakesh Biswas: Reviewed again today in OPD just now and spoke with the rntep station in our college:

Yesterday's Sputum AFB single sample negative

Sending sputum CBNAAT now

In the general workflow of the rntep it's not done once the patient has taken ATT for a month or two but they appear to be accommodating her unique clinical complexity

NMC dynamic E log of this patient being regularly updated by @918074725352 here 👇

https://pajrcasereporter.blogspot.com/2024/11/18f-periodic-fever-hemolysis-1-week.html?m=1

17/01/2025, 11:15 - Rakesh Biswas: NMC E log to be updated here 👇

https://pajrcasereporter.blogspot.com/2024/11/19m-opd-puo-massive-splenomegaly-short.html?m=1

17/01/2025, 11:33 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

17/01/2025, 11:34 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

17/01/2025, 11:34 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

17/01/2025, 11:36 - Patient Advocate 56F Migraine Hypothyroidism 2000: Consent form and contact number?

17/01/2025, 11:52 - Rakesh Biswas: They took your number and promised to get in touch

17/01/2025, 11:53 - Patient Advocate 56F Migraine Hypothyroidism 2000: They themselves will contact me?

17/01/2025, 12:13 - Rahul healthcare 2.0: Would this kind of neck harness work? 

https://www.amazon.in/RIMSports-Harness-Strengthening-Resistance-Training/dp/B08P49P65C?th=1

If not a custom one may be created in line with what he is doing manually. Very enterprising patient!

17/01/2025, 12:14 - Rakesh Biswas: Thanks!

Yes this could work!

@917382828731 let's share this with the patient ASAP

17/01/2025, 12:16 - Rahul healthcare 2.0: AI attempted - 

---

**After settling up its a claudication distance of approximate 200 mtr, no/tho HRD DM ISH AMD CAD.**

1. MRI L.S. spine to R/O lumbar canal stenosis.

2. Neurological quadriceps.

3. Diagnostic uncertainty between neurogenic claudication (due to L. canal stenosis) vs diameters not mistaken in the ABI.

**Vascular Claudication (C.T. angio symptoms & vascular lesions).**

---

**Plan:**

- Dr. Anil (Ortho Prof) + premises for surgical consideration.  

- Reviewed on 17/1/25.

---

Let me know if you need help clarifying any specific part or translating this into a more readable form.

17/01/2025, 12:17 - Rahul healthcare 2.0: AI attempted - 

Here is a transcription of the handwriting:

---

**17/1/25**

**Sir,**  

This patient has features of neurogenic claudication **(?)** vascular confusion. Also, find lower limb vasculopathy **via CT Angio.**  

Would it be possible to measure the lumbar canal diameter & let us know?

---

**12/1/25**  

**Sir,**  

This patient has features of neurogenic claudication. Although vascular surgeon also found lower limb vasculopathy in CT angiogram, would it be possible to measure lumbar canal diameter & let us know?  

(Signature)  

17/1/25

17/01/2025, 12:17 - Rahul healthcare 2.0: AI read your original handwriting on top.. maybe you don't need manual help transcribing your handwriting anymore?

17/01/2025, 12:22 - Rakesh Biswas: Wow!

This is really going to be very useful although AI still probably didn't read mine correctly although it did read the PG's handwriting correctly (because the PG's was also human readable)! As for hand writers like me I guess we just need to stop writing altogether and use typing interfaces to communicate largely

17/01/2025, 12:25 - Rahul healthcare 2.0: or voice! 

But I think if you can give me say 100-200 of your handwriting paragraph samples and corresponding correct text, AI could be trained to recognize your handwriting well. Do you have such a dataset where you have your handwriting and then you have the PG transcribed version?

17/01/2025, 12:28 - Rakesh Biswas: Great idea!

Yes we could do that only I will then need to have to write more and that too may make my hand writing change!

17/01/2025, 12:39 - Rakesh Biswas: Took a look at this now!

It needs a head support at the back!

Maybe something similar to this 👇

https://www.amazon.in/SPINE-EASE-LUMBAR-CERVICAL-SUPPORT/dp/B0CMWXW64P/ref=asc_df_B0CMWXW64P/?tag=googleshopmob-21&linkCode=df0&hvadid=709981218915&hvpos=&hvnetw=g&hvrand=1952048978314275161&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=9197649&hvtargid=pla-2295578486636&psc=1&mcid=7d77684f0e0b3000a9fc7922790d3a0a&gad_source=1

Would be more appropriate although it may need to be further tailored after initial trial @919604701505 @917382828731 

I guess an Orthotics engineer could do all these? @919425007641 but again that won't happen till NMC makes their presence a minimum standard requirement

17/01/2025, 12:42 - Rahul healthcare 2.0: AI failed badly at this :-)

17/01/2025, 12:43 - Rakesh Biswas: And I thought this was better than the previous!

17/01/2025, 12:44 - Rahul healthcare 2.0: Yeah me too, wonder why it failed.. let me try other models

17/01/2025, 12:48 - Rahul healthcare 2.0: From the patient's use of that towel, it seemed like the head also needed support. Here only the neck gets support. 

One way to prototype tbis quickly is to get a long strip of velcro and use it as a harness. Cut it into multiple parts, and interlock them. 

Eg 

https://www.google.com/search?q=velcro+body+harness+diy&client=firefox-b-m&sca_esv=40fe89a436fab841&udm=2&biw=120&bih=221&sxsrf=ADLYWIIy_bb-91SVqJP23EBrEKI3sErnYA%3A1737098216345&ei=6AOKZ-zbFLWf4-EP_64U&oq=velcro+body+harness+diy&gs_lp=EhJtb2JpbGUtZ3dzLXdpei1pbWciF3ZlbGNybyBib2R5IGhhcm5lc3MgZGl5MgQQIRgVSIkTULQLWJURcAB4AJABAJgBpwKgAdIHqgEFMC4xLjO4AQPIAQD4AQGYAgSgAosIwgIEECMYJ8ICCBAAGIAEGKIEmAMAiAYBkgcFMi0zLjGgB_YO&sclient=mobile-gws-wiz-img#vhid=Rs8w4_RQFZuW5M&vssid=mosaic

You can get this for 200 rs

https://www.amazon.in/Velcro-Roll-Double-Sided-Self-Gripping-Multi-Purpose/dp/B0BR7SKV5N?gQT=1

17/01/2025, 12:52 - Rahul healthcare 2.0: Claude did well, OpenAI was poor. 

--

This appears to be a medical prescription or treatment notes. I will transcribe the visible content:

OSM 

("ALCOHOL/SM") 

& ARC

WITHDRAWAL

1) T. LEVIPIL 500mg 50/OD

2) T. BENFOTIAMINE 200mg 

   80/BD

   → x2 weeks

3) T. BACLOFEN XL 20mg

   10/HS

   → x2 weeks

4) Review to By OPD

5) Review after 2 weeks 

6) T. NAPROXEN 250mg 85/SOS

Date: 17/1/25 12:30PM

c/o M/S HEADACHE

(POSTERIOR)

ADMISSION

T. FENOFENADINE 120mg 1-×-×

                            x2 days

T. ULTRACET

½-½-½-½ x2 days

[There appears to be a doctor's stamp and signature at the bottom]

17/01/2025, 12:52 - Rakesh Biswas: Yes this is quite good 👏👏

17/01/2025, 12:53 - Rakesh Biswas: We need an engineering brain to do it here onsite!

17/01/2025, 12:53 - Rakesh Biswas: Can you guide the patient at his home on phone? @918074725352 may be able to set up a group call?

17/01/2025, 12:54 - Rakesh Biswas: 👆@9779817599973 @923305072858

17/01/2025, 14:15 - Rahul healthcare 2.0: Could attempt that on a gmeet call.. I'll try to get some velcro strap to demo it on video.

17/01/2025, 16:12 - Rakesh Biswas: That would be great. Let's see if that patient reverts back soon

17/01/2025, 16:28 - Rakesh Biswas: @919652955915 can you find out from your neurosurgery colleagues there if the burr hole of an EVD catheter after removal becomes unnoticeable in days?

This is what appears to have happened to our current ICU 3 patient where the EVD had been documented to have been placed but other than the sutures in the scalp there's no faintly palpable trace of a burr hole in the cranial bone!

https://pmc.ncbi.nlm.nih.gov/articles/PMC4450504/

17/01/2025, 16:35 - Ganesh Joshi: Stereotactic Neurosurgeon may give appropriate advice🙏🏻

17/01/2025, 16:36 - Ganesh Joshi: Better continue this improvised item

17/01/2025, 16:43 - Rakesh Biswas: Yes but it keeps slipping down. I guess an Orthotic engineer could engineer something more stable?

I'm thinking something like a rigid head support at the back of the head but if a velcro harness can do that in a stable way as @919604701505 suggested that would also be good

17/01/2025, 16:51 - Rakesh Biswas: Yes while the PET has been used as a tool to localize the muscles with most glucose uptake to facilitate botulinum injection https://www.e-arm.org/m/journal/view.php?number=196, in this particular patient it appears to be suggestive of a hitherto unreported correlation with basal ganglia uptake and causality for the dystonia

17/01/2025, 17:02 - Ganesh Joshi: Yes, it can be made, but it may not be comfortable

17/01/2025, 17:08 - Rakesh Biswas: He would only need it during walking

17/01/2025, 17:08 - Rakesh Biswas: 17/01, 17:01] : Reviewed the patient today in ICU (forgot to post this earlier)

Has started having severe epigastric abdominal pain again since yesterday 

Along with vomiting 

On examination:

Abdomen soft

Working diagnosis:

Drug induced gastritis

Plan @918317669334 @917382828731 @919908540769 

Hold the tablet prednisolone for a few days

Repeat LFT

Serum creatinine

Urine for 24 hour protein and creatinine 

Temporarily withhold

[17/01, 17:04]: Everytime since last few years when she developed florid proteinuria she would clinically go into remission (although not documented in 24 hour values, the nearest was probably 700 mg recently during last admission when we were battling the ravages of her pyopneumothorax) following which after the steroids were tapered due to the infection, she again developed this florid proteinuria since two weeks which doesn't seem to be responding to the 30 mg of prednisolone this time, which is on the contrary producing side effects!

More here: https://chat.whatsapp.com/KzES8cbXOIOEkkFsPh9SKg

17/01/2025, 17:09 - Ganesh Joshi: Milwaukee brace available ready to fit kit.

17/01/2025, 17:11 - Rakesh Biswas: Good idea. Will try that. We showed him some images of similar braces. He said he had already tried it but didn't work although I'll specifically look up Milwaukee

17/01/2025, 17:13 - Ganesh Joshi: Yes, no brace will be comfortable. It will comfort the orthotist only😌

17/01/2025, 17:14 - Rakesh Biswas: This neglected PaJR patient @918074725352  has been getting admitted recurrently with UTI and today she got admitted again and this time she is showing emphysematous pyelonephritis on ultrasound

https://chat.whatsapp.com/BXUu2ez2AWPKC03K1l4x6k

17/01/2025, 17:18 - Rakesh Biswas: He looked very peculiar walking with that hyper extension posture looking into the sky and when he sat and leaned his head comfortably against the wall that's when I felt that a simple head support would go miles to relieve him of that painful posture and both your and @919604701505 's idea of building on the patient's cloth driven support is perhaps the right way forward

17/01/2025, 17:23 - Ganesh Joshi: How long he sits leaning? Clinic or home anywhere...

17/01/2025, 17:26 - Rahul healthcare 2.0: Would a simple long ruler/pipe strapped to his back and extending to head work? That would mimic the wall support that you mentioned.

17/01/2025, 17:27 - Ganesh Joshi: Spare the occipital protuberance. Old typ dental chair headrest is acceptable for long duration

17/01/2025, 17:29 - Rakesh Biswas: Yes it may

17/01/2025, 17:29 - Rakesh Biswas: Yes or an old time saloon chair is what I had in mind

17/01/2025, 17:34 - Rahul healthcare 2.0: Right.. headrest when sitting, but what about when walking? Pipe, velcro harness... Anything else that can help?

17/01/2025, 17:36 - Ganesh Joshi: Milwaukee is for walking

17/01/2025, 18:18 - Rahul healthcare 2.0: Ohh that seems too bulky and primarily for the back no? Need a Milwaukee version for the head. 

https://m.indiamart.com/proddetail/milwaukee-brace-kit-8970486262.html

17/01/2025, 18:22 - Ganesh Joshi: I holds the neck

17/01/2025, 18:22 - Ganesh Joshi: There is another plastic brace

17/01/2025, 19:04 - Rakesh Biswas: Modified Milwaukee that might be more appropriate for this particular patient?👇

https://m.indiamart.com/proddetail/rebuilt-milwaukee-brace-20807185630.html

17/01/2025, 19:09 - Ganesh Joshi: Minerva

17/01/2025, 19:18 - Rakesh Biswas: Yes this too looks like a better fit for our 

patient 👇

https://www.amazon.in/Minerva-Orthosis-Cervical-Thoracic-Brace-L/dp/B00D7CQ1D8

17/01/2025, 20:04 - Genau PaJR CEO CFHE IIT: We have a patient 35F with thyroid gout problem needs to go through surgery from Bangalore looking to connect a surgeon in CMC Vellore. Please kindly connect me if you have any know contact in CMC Vellore 🙏

17/01/2025, 20:18 - Ganesh Joshi: What surgery

18/01/2025, 10:57 - pajr.in CEO, NHS Endocrinologist: Are any alternatives being considered?

18/01/2025, 10:57 - pajr.in CEO, NHS Endocrinologist: Does she need a pulse dosing again?

18/01/2025, 10:58 - Rakesh Biswas: This time she also appears to have an imaging finding of inflammatory bowel dose in her colon since last admission which appears to be persistent and they can't afford a colonoscopy

18/01/2025, 10:59 - Rakesh Biswas: Yes likely. Although iv dexa will be less taxing perhaps

18/01/2025, 11:00 - pajr.in CEO, NHS Endocrinologist: I understand the imperative for this although aren't the best outcomes seen with the reliable Methylpred?

18/01/2025, 11:00 - pajr.in CEO, NHS Endocrinologist: I understand each vial costs north of 1k

18/01/2025, 11:09 - Rakesh Biswas: That's a lot

18/01/2025, 11:10 - pajr.in CEO, NHS Endocrinologist: To save a kidney?

18/01/2025, 11:11 - pajr.in CEO, NHS Endocrinologist: And consequently human capital?

18/01/2025, 11:12 - Rakesh Biswas: Are their studies that dexamethasone can't?

18/01/2025, 11:12 - Rakesh Biswas: Let's try seeing if there are studies to support that imperative

18/01/2025, 11:13 - pajr.in CEO, NHS Endocrinologist: Will let the treating team share.

18/01/2025, 11:19 - pajr.in CEO, NHS Endocrinologist: https://link.springer.com/article/10.1007/BF02730894

This will need your clout to get this unlocked @919121046928

18/01/2025, 11:22 - pajr.in CEO, NHS Endocrinologist: <Media omitted>

18/01/2025, 11:25 - pajr.in CEO, NHS Endocrinologist: Well this turned out to be something else!

18/01/2025, 11:34 - pajr.in CEO, NHS Endocrinologist: No quality or reliable data comparing Dexa vs MP. May have to take some expert opinions I guess.

18/01/2025, 11:40 - pajr.in CEO, NHS Endocrinologist: Bad shout but can see Fluorotic bone disease and obvious OPLL even in lumbar segments?

18/01/2025, 11:48 - Rakesh Biswas: 👏👏 anyone working in NKP would be familiar with this life long

18/01/2025, 11:50 - Rakesh Biswas: Which expert worth his salt would be spending time working in low resource settings treating lupus nephritis with dexa instead of MP?

We do have one such non expert generalist's notes documented possibly in tabula rasa. Will try to search and share

18/01/2025, 12:00 - pajr.in CEO, NHS Endocrinologist: Dr. Rakesh Biswas.

18/01/2025, 13:59 - Dr Ramji SR Medicine: @917989589761 @919121046928 sir,  even confirmation of hypersplenism mandates bone marrow's normal or hyperplastic state....

18/01/2025, 16:41 - Rakesh Biswas: 👆@919818741334 @917386552514 @918332874734 @919419526285 just found this online trace of the patient we discussed offline today in the rounds, possibly while evaluating her for the first time in OPD just before her first admission.

Here's her previous EMR summary:

Age/Gender : 13 Years/Female

Address :

Discharge Type: Relieved

Admission Date: 17/12/2024 04:59 PM

Diagnosis:

PANCYTOPENIA SECONDARY TO HYPERSPLENISM ?

CHRONIC ILLNESS

SHORT STATURE - PROPORTIONATE (BMI: 14.6 KG/MSQ.)

Case History and Clinical Findings

PT C/O FEVER SINCE 1 WEEK PT C/O COUGH SINCE 1 WEEK PT C/O COLD SINCE 1 WEEK

PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN DEVELOPED FEVER, HIGH GRADE WITH CHILLS, COUGH WITH SPUTUM, WHITISH, MUCOID, SCANTY, NON BLOOD TINGED, NON FOUL SMELLING.

NO H/O BURNING MICTURITION, PAIN ABDOMEN, VOMITTING NO H/O BLEEDING TENDENCIES

NO H/O BREATHLESSNESS, EASY FATIGUABILITY PAST HISTORY:

N/K/C/O DM,THYROID DISORDERS, HYPERTENSION, EPILEPSY, CAD, CVA PERSONAL HISTORY:

DIET: MIXED

BOWEL AND BLADDER: REGULAR ALLERGIES: NONE

ADDICTIONS: NONE

FAMILY HISTORY: INSIGNIFICANT GENERAL EXAMINATION:

 

BP: 90/60 MMHG PR: 86 BPM

RR: 16 CPM TEMP: AFEBRILE

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA SYSTEMIC EXAMINATION:

CVS: S1S2+ NO MURMURS RS: BAE+ NVBS

P/A: SOFT, NT BS+, Moderate  SPLENOMEGALY 

CNS: NFND

ENDOCRINOLOGY OPINION TAKEN ON 20-12-24 I/V/O LESS HEIGHT AND WEIGHT; INAPPROPRIATE SECONDARY SEXUAL CHARACTERISTICS

ADV: CHRONOLOGICAL AGE> BONE AGE> HEIGHT AGE> WEIGHT AGE BONE MARROW ASPIRATION + BIOPSY

TREAT UNDERLYING CONDITION GOOD NUTRITION

HIGH PROTEIN DIET PHYSICAL Exercises

COURSE: A 13 YEAR OLD PT CAME WITH C/O FEVER SINCE 1 WEEK, COUGH SINCE 1 WEEK, COLD SINCE 1 WEEK

VITALS: BP: 90/60 MMHG PR: 86 BPM RR: 16 CPM TEMP: AFEBRILE

ON FURTHER EVALUATION PT WAS DIAGNOSED AS PANCYTOPENIA SECONDARY TO HYPERSPLENISM ? CHRONIC ILLNESS SHORT STATURE - PROPORTIONATE (BMI: 14.6 KG/MSQ.)PT WAS PLANNED FOR BONE MARROW BIOPSY AND ASPIRATION FOR FURTHER EVALUATION. ADVICED TO FOLLOW UP AFTER 1 WEEK. PT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.

Investigation

COMPLETE URINE EXAMINATION (CUE) 17-12-2024 10:48:AM

COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

BLOOD UREA 17-12-2024 10:48:AM 21 mg/dl 42-12 mg/dlSERUM CREATININE 17-12-2024

10:48:AM 0.4 mg/dl 1-0.5 mg/dl

 

LIVER FUNCTION TEST (LFT) 17-12-2024 10:49:AMTotal Bilurubin 0.58 mg/dl 1-0 mg/dlDirect Bilurubin 0.16 mg/dl 0.2-0.0 mg/dlSGOT(AST) 41 IU/L 31-0 IU/LSGPT(ALT) 16 IU/L 34-0

IU/LALKALINE PHOSPHATASE 306 IU/L 369-54 IU/LTOTAL PROTEINS 7.9 gm/dl 8-6 gm/dl

ALBUMIN 4.2 gm/dl 5.4-3.8 gm/dl

A/G RATIO 1.16SERUM ELECTROLYTES (Na, K, C l) 17-12- 2024 10:49:AM

SODIUM 138 mmol/L 145-136 mmol/L

POTASSIUM 4.1 mmol/L 5.1-3.5

mmol/L

CHLORIDE 99 mmol/L 98-107 mmol/L

T3, T4, TSH 18-12-2024 12:12:PM

T3 1.29 ng/ml 1.87-0.87 ng/ml

T4 10.23 micro g/dl 12.23-6.32

micro g/dl

TSH 0.86 micro Iu/ml 5.36-0.34 micro Iu/ml USG REPORT:

IMPRESSION: BORDERLINE SPLENOMEGALY

Treatment Given(Enter only Generic Name)

SYP ASCORYL LS 10 ML PO/TID

Advice at Discharge

BONE MARROW ASPIRATION + BIOPSY GOOD NUTRITION

HIGH PROTEIN DIET PHYSICAL EXCERCISES

Follow Up

REVIEW TO GM OP AFTER 1 WEEK FOR BONE MARROW BIOPSY AND ASPIRATION OR SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:  For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY

Discharge Date

Date:20-12-24

Ward:FMW

 

Unit:II

18/01/2025, 16:43 - Rakesh Biswas: To quote:

"In 1955, Dameshek (7) summarized that hypersplenism should be diagnosed in the presence of four conditions: i) monolineage or mutilineage peripheral cytopenias; ii) compensatory hyperplasia of bone marrow; iii) splenomegaly; and iv) correction of cytopenias after splenectomy. Although these four conditions do not always apply to all cases, they have been commonly cited in the literature, and are important in the diagnosis of hypersplenism."

https://pmc.ncbi.nlm.nih.gov/articles/PMC5038876/ <This message was edited>

18/01/2025, 17:19 - Rasagnya.A Content Writer joined using this group's invite link

18/01/2025, 17:30 - Dr Ramji SR Medicine: Appreciate PG @917386552514 for very good documentation of all the workup sir, I myself recollected the discussion after endocrine consultation, and Kudos🙌 to you @919121046928  for creating a data retrievable platform and being able to use it as and when necessary....

19/01/2025, 18:44 - Patient Advocate 56F Migraine Hypothyroidism 2000: This patient also called and asked to create a group. I sent the consent form for him to sign , till now not received.

19/01/2025, 18:44 - Patient Advocate 56F Migraine Hypothyroidism 2000: Retrocollis patient attender called me and was asking for the neck plastic brace.

19/01/2025, 18:54 - Ganesh Joshi: Hyderabad? Send him to NIEPID Divyasha Kendra Bowenpally. ALIMCO must help him out (as it claims)

19/01/2025, 19:02 - Rakesh Biswas: @919604701505 @919425007641 @918074725352 as this patient wants to know the next steps toward the best possible neck support, would you be able to give some time for him in a group video call and explain to him how to DIY this harness?

If you are okay with morning hours we can call him to the OPD and have the group call similar to how we had done it last time here👇

https://youtu.be/WT8AFSgev-0?feature=shared

19/01/2025, 19:04 - Ganesh Joshi: My daily OPD 9-12 (Monday heavy perhaps), less load 12-1, available easy 1-4.

19/01/2025, 19:05 - Rakesh Biswas: Alright 2-3 could be a good time. How about @919604701505 and @918074725352 ?

19/01/2025, 19:11 - Ganesh Joshi: <Media omitted>

19/01/2025, 19:13 - Rakesh Biswas: Do you know anyone there who can follow up or we can get in touch with as in our past experience if we simply refer a patient they are likely to get lost to follow up and end up not getting the best possible outcomes

19/01/2025, 19:14 - Rakesh Biswas: Speaking of data retrieval in the context of this current 14F while we still don't have her case report made, we do have, as part of our unexplained hypersplenism and splenectomy outcomes project, a similar case of a 14M with hypersplenism who also got operated, logged by our previous PG @918099474777 here: https://raveen07.blogspot.com/2022/08/14m-massive-splenomegaly-case-of.html?m=1 and presented in 2023 Jan 26 CPD here: https://youtu.be/XSugyqRrU84?feature=shared and later revisited as a retrospective here: https://userdrivenhealthcare.blogspot.com/2023/11/pajr-jarvis-reports-final-entry-for.html?m=1

Similar another patient of 14F here: https://pajrcasereporter.blogspot.com/2024/11/14f-sikle-cell-tibial-pain-telangana.html?m=1

with hemoglobinopathy which is again a close differential in the current patient for which we deferred her bone marrow aspiration biopsy after yesterday's discussion and decided to await her Hb electrophoresis report along with iron profile perhaps empirically see the response to injection Vitamin B12 as per @918332874734 's readings.

Here's another slightly older patient of hypersplenism in our follow up who also had a splenectomy and is doing well https://snehalmvs.blogspot.com/2023/02/22f-pancytopenia.html?m=1 and it's possible that she may have had a similar profile when she was 14! She was also included in our clinical complexity in anemia project with Dr Pavani as the PI (case 17 amidst all the 50 cases archived here) : https://pavani2021.blogspot.com/2024/07/meta-ai-driven-thematic-analysis-nkp-in.html?m=1

Further retrospective on the anemia clinical complexity project: https://medicinedepartment.blogspot.com/2024/07/y24narketpally50n-clinical-complexity.html?m=1

Other than the above recent similars with hypersplenism is a 21M still looking for someone who may do his splenectomy and we came close to getting his RBC scan that suggests splenic sequestration after we referred him to Gandhi Medical College once our anesthesiology rejected him as too complex for a rural medical college! Currently he's being worked up further in hematology, NIMs Punjagutta. More about him here: https://pajrcasereporter.blogspot.com/2024/11/19m-opd-puo-massive-splenomegaly-short.html?m=1

19/01/2025, 19:19 - Patient Advocate 56F Migraine Hypothyroidism 2000: I don't think I will be of any help in this matter

19/01/2025, 19:28 - Rahul healthcare 2.0: I'm traveling on Monday and Tuesday, please go ahead without me since Dr Ganesh is most well versed with this. In case this is happening Wednesday or Thursday would love to join.

19/01/2025, 19:49 - +91 99653 10108 left

19/01/2025, 20:13 - Rakesh Biswas: Oh we would surely need you to explain how to prepare the velcro thing or should be go for the Milwaukee @919425007641 ?

19/01/2025, 21:35 - Ganesh Joshi: Minerva or Milwaukee

19/01/2025, 21:35 - Ganesh Joshi: ALIMCO provides Milwaukee

19/01/2025, 21:52 - Rakesh Biswas: Alright then @918074725352 let's ask the patient to visit ALIMCO Hyderabad for a tailor made Milwaukee brace to help steady his head.

ALIMCO Regional Marketing Center, Hyderabad

Address: C/o Pt. Deendayal Upadhyaya

National Institute for Persons with Physical Disabilities(PDUNIPPD)

Manovikas Nagar, Secunderabad, Telangana - 500009

Let's ask them to once call the person below:

Dy. General Manager & Incharge

Name: Shri Sanjay Singh

Email: rmc_hyderabad[at]alimco[dot]in

Phone: 040-27891463 & 64, +91 9389537925

https://alimco.in/ContactUs

19/01/2025, 21:55 - Patient Advocate 56F Migraine Hypothyroidism 2000: Okay, tomorrow will inform

19/01/2025, 22:13 - Ganesh Joshi: Sanjay Singh is a gentleman. 😌

19/01/2025, 22:17 - Rakesh Biswas: Can they talk to him with your reference?

20/01/2025, 09:13 - Rakesh Biswas: Update?

Is she getting discharged?

Any repeat 24 hour protein creatinine results in this admission?

Is she on physiological doses of her previous 30 mg prednisolone that had to be withheld due to suspected gastritis?

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

20/01/2025, 10:36 - Savant Reddy Chityal 2017 Kims: Sir is there a possibility of Cutaneous B.anthrax ?

20/01/2025, 11:41 - MD.AKRAM Kolkata Medical College Intern: occupational lung disease pneumoconiosis, silicosis, or tuberculosis/ musculoskeletal disorder.

20/01/2025, 13:22 - Rakesh Biswas: Response from others

[20/01, 10:14] CMC Vellore: Differentials. ( without other details and just the visual) 

1) Manuel labourer , quarry worker carrying weight on back for years. Has some kind of occupational pneumoconiosis causing cough and low back ache because of chronic weight bearing. 

2) Sarcoidosis 

3) Melanoma with dissemination

[20/01, 10:27] rb : Thanks excellent differentials.

Let me share the conversations from another group where some responded quickly.

[20/01, 09:59] AC: Regular abrasion on back 🤔

Rice mill worker?

[20/01, 09:59] rb: Why that pattern?

[20/01, 10:00] AC: Difficult...

Plough?

[20/01, 10:03] rb : Hint: you are close

Just let the pattern guide you further

[20/01, 10:00] BR: ask Grok

[20/01, 10:00] AC: NoAI vs KnowAI 👏

[20/01, 10:02] rb: Yes please do

I recall sharing another quiz word here that no one could crack using AI and @⁨AC⁩ needed funding (in terms of time)

[20/01, 10:03] BR: 

Dr Grok : Based on the image provided, the potential cutaneous marker visible on the back of the 60-year-old male appears to be ecchymosis, which is commonly known as bruising. These bruises could be related to various conditions, but without additional context or medical history, it's challenging to determine the exact cause. Given the patient's symptoms of cough and low back ache for 2 months, there could be several underlying issues:

Trauma or Injury: The bruises might be from a recent injury or trauma, though the duration of symptoms might suggest a recurring or chronic issue.

Coagulation Disorders: Conditions like thrombocytopenia or other clotting disorders could lead to easy bruising.

Infections: Certain infections, especially if systemic, could cause bruising, although this is less common.

Medication Side Effects: Some medications can cause bruising as a side effect, particularly those affecting blood clotting.

Underlying Systemic Diseases: Diseases like leukemia or liver disease can manifest with bruising.

Given these possibilities, it's important for the patient to consult a healthcare provider for a comprehensive evaluation, including a physical exam, blood tests, and possibly imaging studies to diagnose the underlying cause of both the bruising and the other symptoms. If you need further assistance or if there's anything else I can help with, please let me know!

20/01, 10:04] rb : This is why AI's little learning can be dangerous!

It got the pattern wrong.

@⁨AC⁩ got close

[20/01, 10:04] AC: Ah!!! Could also be an auto driver...

Miner unlikely given your hospital location

[20/01, 10:05] rb : Why?

[20/01, 10:05] AC: Beating around the bush!

Or, for AI... Bleating around the bush😀

[20/01, 10:07] AC: Most AI genAI... LLM just bleat

Though Chomsky discounted his SS DS theory ... I would say it holds ground

Surface structure... Deep structure 

Current set of chatBoats (yes boats!) are pretty smart with SS

DS ... Well that's where bioforms will continue to beat AI

[20/01, 10:29] Rs: From o1

Thought about cutaneous markers in medicine for 16 seconds

From the bilateral, symmetrically placed hyperpigmented patches over his scapulae, these appear to be the so‑called “coolie lumps” (frictional callosities) that develop where a laborer or porter routinely rests a load across the back. In other words, they are cutaneous markers of repeated pressure/friction in someone who carries heavy weights for a living.

Verbose but forgot about cough (not 1/10 as good ad Dr Chandy). Prompted for cough

[20/01, 10:29] RS: Thought about cough and potential causes for 7 seconds

In many “spot diagnosis” or quick‐case quiz scenarios, the mention of “cough” (and sometimes “backache”) can be a distractor. However, in a real clinical context—especially in a 60‐year‐old laborer—cough could relate to:

Occupational exposures (e.g., working in dusty or poorly ventilated environments), potentially contributing to chronic bronchitis or pneumoconiosis.

Common respiratory conditions (e.g., TB in endemic areas, COPD if there’s a history of smoking or biomass exposure, etc.).

Mechanical strain from repeated heavy lifting that might precipitate or worsen back pain but could also be accompanied by muscle strain affecting the chest or spine.

So, in a quick medical quiz, the mention of cough might indeed be there as a red herring. In real‐life practice, one would still evaluate it properly—given this patient’s age, occupation, and local disease prevalence—to rule out serious causes (like tuberculosis or chronic pulmonary disease).

[20/01, 10:33] Dean Bangalore: Why this discussion on this particular group

[20/01, 10:34]CMC Vellore: Serendipitous!! R has demonstrated that human clinical logic is not bad after all.

[20/01, 10:38] rb : We need to have more AI vs non AI discussions to jog our non AI brains!😅

[20/01, 10:38] rb: Excellent 👏👏

The quiz trivia is just limited to what could be his occupation seeing that he's from Telangana

[20/01, 10:42] AG: A lot of work is happening around Computer Vision and AI for early/better diagnosis, even when no expert eyes are available. But, under pressure from investors, some models even get released without extensive training and testing. Most use cases are in oncopathology, I have recently witnessed an almost disastrous outcome of an oncologist depending too much on AI. Rb's example should work as an eye-opener for many in this group, and their peers.

[20/01, 10:46] rb: Don't encourage me to share all my OPD patients here! I do it in another group regularly at this time!😅

[20/01, 10:47] AG: I said, example. Not sharing journals and PaJRs.

[20/01, 10:47] rb: In other words the question is around what kind of a coolie in Telangana!

Hint: it's not the usual coolie but yes these are frictional callosities

[20/01, 10:48]rb: I only share individual patient data that get's into journals and PaJRs as they scale!

[20/01, 11:04]RS: oh then o1 did a phenomenal job.

[20/01, 11:08] RS: Automation bias is real. On a lighter note if providers don't understand tech and techies doent understand medicine then imagine poor VCs who don't understand either 😁

[20/01, 11:17] rb: But the exact answer as to what is his occupation in Telangana is pending.

Now let me share some inputs I had in pm from other groups:

[20/01, 10:34] rb : Much better in terms of identifying it as occupational which was incidentally mentioned in the quiz

The quiz is about what occupation is it likely to be in Telangana

[20/01, 10:37] +: Ah… quarry worker or agricultural worker is what the next guess for ChatGpt is. :)

[20/01, 10:50] rb: What kind of agriculture?

Hint: the seeds are not generally sown in this kind

[20/01, 10:57] +: Paddy?

[20/01, 11:15] rb: Paddy has to be sown

20/01/2025, 13:23 - Rakesh Biswas: And the Jan 20 tele AI OPD vision prize goes to AC!

[20/01, 11:54] AC: Sugarcane?

I would still stick with cotton

[20/01, 11:53] rb: Excellent images AC!

Well yes the callosities are because of the harness device he uses!

Do they use this strategy in India for any kind of farming anywhere these days?

[20/01, 11:54] AC: Hills

[20/01, 12:02] rb: Hint: These are longer trees!

In Telangana and Andhra these free lancers are considered as very respected professionals although it's quickly changing

[20/01, 12:02] AC: Todi tapper

[20/01, 12:03] rb: 👏👏

[20/01, 12:03] AC: Doesn't explain respiratory issues

[20/01, 12:05] rb: Yes those were current distractors

[20/01, 12:09] AC: It's difficult to take worker cattle to many flats (fields cut out on mountain sides)... So men pull ploughs 

In earlier times, it was more prevalent across South Asia as cattle were a luxury few could afford

[20/01, 12:10] rb : In these the callosities would appear in the shoulders

[20/01, 12:20] AC: Similar pattern can be seen in this image.

Does it have a formal name?

[20/01, 12:27] rb: Not yet

Let's call it

"Toddy tapper's callosity"! <This message was edited>

20/01/2025, 14:27 - MD.AKRAM Kolkata Medical College Intern: chronic kidney disease (CKD)

20/01/2025, 14:40 - MD.AKRAM Kolkata Medical College Intern: 1) Skeletal complications renal osteodystrophy or other causes of low back pain.

2) Respiratory complaints could be from fluid overload, uremia, or unrelated infections.

20/01/2025, 14:42 - MD.AKRAM Kolkata Medical College Intern: Refarence test - cRP .

20/01/2025, 14:53 - Rakesh Biswas: He doesn't have that

Can you introduce yourself 🙂🙏

20/01/2025, 14:55 - MD.AKRAM Kolkata Medical College Intern: Intern medical student.

20/01/2025, 14:57 - Rakesh Biswas: Nice to know you

Are you from Narketpally?

20/01/2025, 15:07 - MD.AKRAM Kolkata Medical College Intern: No sir.

20/01/2025, 16:29 - Rakesh Biswas: Alright. Nice to have you here

20/01/2025, 16:33 - MD.AKRAM Kolkata Medical College Intern: Thank you sir.

20/01/2025, 16:33 - MD.AKRAM Kolkata Medical College Intern: Sir this area are telengana..?

20/01/2025, 16:33 - MD.AKRAM Kolkata Medical College Intern: Hyderabad area..

20/01/2025, 16:33 - Rakesh Biswas: Yes

20/01/2025, 20:36 - Shivang Sharma 2018 KIMS Intern left

20/01/2025, 23:40 - +91 94920 30885 left

21/01/2025, 22:06 - Rakesh Biswas: Tomorrow's academics

Staff CPC

Time 8-9 am

Venue:LT1

The session will also be available on the Webex platform. Kindly follow the link below to join.

https://india-edu.webex.com/india-edu/j.php?MTID=m1cb4b75b29a2cff53f63e5991b9bab7b

In case you join in through 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 given below.

The clinical protocol will be presented by Prof. S. Reddy

Radiology will be presented by Dr. Arun

Autopsy pathology will be presented by Prof. Aravind Sekar

Clinician incharge - Dr. Ankur Gupta

Chairperson - Prof. Sanjay Jain

Thank you

21/01/2025, 22:07 - Rakesh Biswas: 👆@918374789176 this cardiac case report with autopsy findings being presented  tomorrow is very similar to the one you logged as a PG

22/01/2025, 08:25 - Rakesh Biswas: Morning PaJR session with a patient advocate for a patient of PUO due to suspected infective endocarditis:

[21/01, 19:16] Patient Advocate 56F Migraine Hypothyroidism 2000: Doctor, the patient's five days course is completed and she is having bleeding from her anus. This is for your information.

[21/01, 21:29] rb : Did she have bleeding from anus earlier?

If it hasn't happened before, we need to show a surgeon to rule out piles.

Please share the pictures of all the medicines that she has been taking

[21/01, 21:32] Patient Advocate 64F Suspected SBE: She had piles also sir.but it calm down from 2months,again it will repeating in this treatment.

[21/01, 21:48] rb : Piles known since when?

[21/01, 22:19] rb: @918374789176 how long would you recommend iv ceftriaxone for her. Currently she's having anal bleeding although she has had piles since long but again she would need to get it locally checked again

[21/01, 22:23] Patient Advocate 64F Suspected SBE: Since 1 year sir

[22/01, 08:17] rb: @918374789176 may have recommended the ceftriaxone iv twice daily for 2- 4 weeks with the local doctor but there are challenges to this prolonged therapy such as repeated changing of iv line etc

How's her fever been since she began the iv ceftriaxone? Off course if she has another fever this time we may also need to consider thrombophlebitis as a cause rather than just infective endocarditis

More here: https://pajrcasereporter.blogspot.com/2025/01/64f-with-fever-on-and-off-since-2-years.html?m=1

22/01/2025, 11:57 - Rakesh Biswas: Also has a barrel chest not visible through the shirt

22/01/2025, 12:13 - Rakesh Biswas: @918332919067 please talk to pathology to make the slides while you and @918332874734 do the USG guided FNAC

22/01/2025, 12:14 - +91 78939 51102 left

22/01/2025, 12:19 - Rakesh Biswas: @917675086612 @918332919067 @918332874734  admitting this patient today for 24 hour urinary protein and creatinine

Past PaJR 👇

https://chat.whatsapp.com/F691Ysd8QihDBdqlu44WZR

@918074725352 @919604701505 this above patient is one of our PaJR failures due to user interface issues <This message was edited>

22/01/2025, 13:22 - Rakesh Biswas: Reviewing this patient who I had first seen in 2010 with nephrotic syn and then followed him through multiple renal biopsies and treatments and currently still following through after his second transplant 👇

https://chat.whatsapp.com/K80hLDEOudFClqbQ0bTFwI

22/01/2025, 15:54 - Rakesh Biswas: Recalled this cheilitis chase paper while discussing with @918277432650 👇

https://pubmed.ncbi.nlm.nih.gov/12800469/

22/01/2025, 16:21 - 58 Patient Advocate Metabolic Syn left

22/01/2025, 16:44 - Rakesh Biswas: Here's one of our PGs, now consultant in Nizamabad, working with different AI systems as a user and archiving his experiences 👇

https://medicineprudence.blogspot.com/2025/01/chat-gpt-vs-gemini-interpretation-of.html

Small comparative study on Chat GPT vs Gemini Ai in analysing peripheral smear slides of the same patient. 

ChatGPT won 

Gemini reads it as malaria.

The same patient's entire case report is here in his online learning portfolio: https://medicineprudence.blogspot.com/2025/01/high-risk-kappa-light-chain-multiple.html?m=1

22/01/2025, 18:14 - pajr.in CEO, NHS Endocrinologist: Wow! Well done 👏🏻

22/01/2025, 18:24 - Dr Ramji SR Medicine: This kind of practice deprives doctor's of their brain's capacities, and leaves only few capable doctors sir. Already  there's a prediction that further evolution of man will leave him with small brains, which is evident from such practices. AI usage hastens the process😐

22/01/2025, 18:26 - pajr.in CEO, NHS Endocrinologist: History says otherwise?

When has technology ever made man dumber and more incapable?

22/01/2025, 18:29 - pajr.in CEO, NHS Endocrinologist: 77/F with altered mental status and severe hypernatremia of Na 177. Severely dehydrated (on a background of vascular dementia) with Urine Osm 893, Urine Na 38 and Serum Osm 397

What should our approach be?

@919121046928 @919818741334 @919154575937 @919030824645 @918099474777 @918332874734 @919160359545 @918367363668 @919491489659

Inputs welcome from all

22/01/2025, 18:32 - Dr Ramji SR Medicine: Examples are ample in our day to day life sir...

Playling on PS4, PS5  or PS10 is never same as playing on the ground.

Preforming Simple calculations

Existance of greater no of polymaths in the past are few examples...

22/01/2025, 18:45 - Sai Charan Kulkarni 2020 KIMS Pg: Thanks for your input. 

Came across this article few days back. 

https://www.sciencedirect.com/science/article/pii/S2001037024000357

22/01/2025, 18:52 - pajr.in CEO, NHS Endocrinologist: I'm not sure these are good examples in themselves.

Playing on PS5 is an added option to playing at the ground. Surely the PS5 hasn't asked us to stop playing at the ground

Same with calculations - you can choose to do both - do them mentally or use a calculator. The advantage technology gave us is that it added an option to do things better and faster. Whether you choose to use that option is your choice.

Here I am in gloomy and cloudy England and you are in bright and sunny South India and we are communicating live.

50 years ago - my postcard would still be in London and would reach Delhi in 1 year and then Delhi would ask for a bribe to see my postcard.

Technology had led to democratization of resources and knowledge and that will keep happening

22/01/2025, 18:54 - pajr.in CEO, NHS Endocrinologist: We always see history with rose tinted glasses and thus we simply know a greater number of legendary mathematicians from the past - Now AI has absolutely revolutionized life and do we credit the discoverer like we do to Ramanujan? Not really

But the impact of AI far outweighs what anyone contributed in the past

22/01/2025, 18:56 - Sai Charan Kulkarni 2020 KIMS Pg: In realistic world Surgeries are being done from kilometres away

It’s not every surgeon should roam around the world to do Surgeries but some day I believe one surgeon can operate globally sitting in his console room.

22/01/2025, 18:58 - pajr.in CEO, NHS Endocrinologist: Yes. Has happened in India too recently.

22/01/2025, 18:59 - pajr.in CEO, NHS Endocrinologist: And the advantage is that patients can choose competent doctors instead of being forced to see only those available locally.

RMP culture will be wiped out with this.

22/01/2025, 19:00 - Dr Ramji SR Medicine: Acute  or chronic differentiation is important from history ( acute correction no more than 10meq/day,chronic no morethan 6 meq/day)

Estimation of Total body water

Free water deficit 

Correction over 48- 72 hrs

To keep in consideration 

1. ongoing water loss(free water clearance formula) 

2. Insensible losses(< 10ml/kg/day if non ventilated patient) 

References - Harrison 21st edition 

Manual f medical therapeutics 36th edition

22/01/2025, 19:21 - Dr Ramji SR Medicine: Definitely sir, technology is not bad, but the man using technology ought to know how to use it. 

I agree with the positive side of what all you are saying, I use that positive side definitely with a foresight of being cautious about implications of using a new tool...

We cannot compare a robot running faster than man and be happy for it, we ought to know when to make the  Robot run for us, instead when we stop running with our existing capabilities, they gradually become dull...

How many people have that insight that lifestyle have changed alot and accordingly the food habits need to be changed? Infact nobody has time to think about basic questions of life.

Practically majority of keep running without knowing why they are running, and it's not their fault,its  the systems around and systems are man made, therefore it's a viscious cycle. One needs to step out / zoom out of the cycle to understand the implications. <This message was edited>

22/01/2025, 19:33 - Sai Charan Kulkarni 2020 KIMS Pg: Good point..! but any new invention is not happened over night.. 

it takes many attempts, efforts and criticism to get to that end. 

As a learner’s we use various sources and tools to upskill ourself to existing traditional skills and not by replacing them..!

22/01/2025, 19:43 - Dr Ramji SR Medicine: Using AI to Up skill ourselves is important 👍 

I'm concerned about the fact that majority of people fail to do so, rather fall prey for comfort at the cost of  loosing their existing skills without their own knowledge. ( might be True I my case too)

22/01/2025, 20:38 - pajr.in CEO, NHS Endocrinologist: Thank you. What do you think is the diagnosis here?

22/01/2025, 20:59 - +91 81017 40747 joined using this group's invite link

22/01/2025, 21:00 - Dr Ramji SR Medicine: Should be water deprivation sir, depends on patient's scenario of how her sensorium progressively deteriorated, precipitating conditions like stroke, mech ventilation, dependent state on others to takecare of fluid supplementation.. Etc

177 is too high to go missed in a health care facility for such long duration, considering the fact that health care is not immediately accessible in UK,  tells us that patient stayed in altered sensorium for sufficient period of time before admission... <This message was edited>

22/01/2025, 21:03 - Dr Ramji SR Medicine: Poor Prognosis, wait and watch until slow correction is done and anticipated delayed recovery....

Nephrologists have ample experience in such cases and can give better judgment about outcome..

22/01/2025, 21:22 - pajr.in CEO, NHS Endocrinologist: Yes very nicely reasoned and given background of vascular dementia it makes perfect sense.

22/01/2025, 21:22 - pajr.in CEO, NHS Endocrinologist: But is there evidence that rapid correction is dangerous?

22/01/2025, 21:24 - Dr Ramji SR Medicine: Yes sir these are established recommendations..

22/01/2025, 21:24 - pajr.in CEO, NHS Endocrinologist: And can established recommendations change?

22/01/2025, 21:25 - pajr.in CEO, NHS Endocrinologist: <Media omitted>

22/01/2025, 21:25 - Dr Ramji SR Medicine: In this case there's no much scope for change  I think sir..

22/01/2025, 21:26 - pajr.in CEO, NHS Endocrinologist: Hmmm I beg to differ

22/01/2025, 21:28 - Dr Ramji SR Medicine: Acute hypernatremia  - rapid correction is OK.

Chronic I would be defensive..

22/01/2025, 21:42 - Sai Charan Kulkarni 2020 KIMS Pg: Elderly female with Altered mental status - Acute or chronic ..? ( sequence of events ) 

Sr sodium - 177 ( high ) 

Sr osmolarity - 397 ( very high ) 

Urine osmolarity - 893 ( max concentrated urine produced by kidney is 1200 mosm) so kidney is not excreting excess sodium to it’s max. 

Is she on any meds..?

22/01/2025, 21:43 - pajr.in CEO, NHS Endocrinologist: Just senna and Atorvastatin

22/01/2025, 21:43 - pajr.in CEO, NHS Endocrinologist: No diuretics or any of those.

22/01/2025, 21:44 - pajr.in CEO, NHS Endocrinologist: What does the Urine Osm suggest?

22/01/2025, 21:47 - Sai Charan Kulkarni 2020 KIMS Pg: Diabetes insipidus..?

22/01/2025, 21:53 - pajr.in CEO, NHS Endocrinologist: All that knowledge and all that expertise and you are saying DI! 😵‍💫

22/01/2025, 21:54 - Savant Reddy Chityal 2017 Kims: Sir what is the serum glucose level?

22/01/2025, 21:57 - pajr.in CEO, NHS Endocrinologist: Serum glucose at presentstion was 5.3 mmol/l (95 mg/dl)

22/01/2025, 21:57 - Sai Charan Kulkarni 2020 KIMS Pg: Oops.. 🙊 I mean 24h urinary volume ..? 

Just to understand decreased water intake or decreased Na excretion (compensation ) ..? <This message was edited>

22/01/2025, 22:00 - pajr.in CEO, NHS Endocrinologist: Clearly she has dementia so yes decreased water intake.

22/01/2025, 22:22 - 2016 USmle ET: Hi sir, been a while! Hope you’re well. Interesting case sir;

Does the patient have any other electrolyte abnormalities? BUN? 

I’ve calculated it around 100

If so, I’d maybe consider, possible GI bleeding on top of her dehydration.

22/01/2025, 22:22 - 2016 USmle ET: She is old, in the age group, with chronic constipation (on senna); what was her Hb

22/01/2025, 22:46 - pajr.in CEO, NHS Endocrinologist: Pavan my friend! How are you mate?

22/01/2025, 22:47 - pajr.in CEO, NHS Endocrinologist: 12.6

22/01/2025, 22:47 - pajr.in CEO, NHS Endocrinologist: What is 100? BUN?

22/01/2025, 22:48 - 2016 USmle ET: Im good sir, yes sir I tried calculating the BUN based off the Serum Osm calculation 😅

23/01/2025, 09:41 - Rakesh Biswas: Morning rural remote asynchronous tele AI integrating medical education and practice (medical cognition):

Conversational Transcripts:

[22/01, 23:37]AD: 35yrs old from remote rural India, newly confirmed with retrovirus and obstructive uropathy (b/l Hydronephrosis and Chronic Cystitis with Sterile Pyuria without dysuria or fever, without evidence of bladder trabeculations or ureteric strictures & no microbiological confirmation, ??Tubercular- planning to start ATT empirically). Creatinine clearance improved partly after putting foleys catheter and b/l DJ ureteric stents from 15 to 22. ART center from rural town started him on Tenofovir, Lamivudine, Dolutegravir regardless. We asked for a revised regimen in view of chronic renal failure and they changed it to Abacavir, Lamivudine, Dolutegravir 10 days ago, which seems to have worsened renal functions marginally with creat clearance 18 at present.

No diabetes/HTN, no pulmonary TB in family/past,

No e/o other HIV associated opportunistic infections at present. Patient came last month with chief concern for loss of weight and appetite only and h/o short episodes of diarrhea in past year.

Q. What would be a better ART regimen for a person with chronic renal failure?

Q. What else should we evaluate him for before starting ATT?

[23/01, 09:24] rb: Very well captured and presented data 👏👏

Wish I could be as resourceful but was feeling lazy hence took a lazy short cut (bane of HI boon for AI?)👇

"*Better ART Regimen for Chronic Renal Failure:*

Considering the patient's chronic renal failure, a revised ART regimen with reduced nephrotoxicity is essential. The current regimen, Abacavir, Lamivudine, Dolutegravir, may not be ideal due to the potential nephrotoxic effects of Abacavir.

A better ART regimen for this patient could be:

1. Raltegravir + Lamivudine + Efavirenz

Or

1. Raltegravir + Emtricitabine + Efavirenz

These regimens have a lower risk of nephrotoxicity and are suitable for patients with chronic renal failure.

The above needs to be verified on Google or perplexity for the links to the studies just to ensure meta AI isn't confabulating.

Below may not be necessary for the group but I thought I would keep the same as to just share everything from AI unaltered 👇

*Evaluation before starting ATT:*

Before initiating Anti-Tubercular Treatment (ATT), it's essential to evaluate the patient for the following:

1. *Confirmatory diagnosis of TB*: Although the patient has sterile pyuria and hydronephrosis, a definitive diagnosis of TB is crucial. Consider obtaining a TB-PCR or culture from urine or tissue samples.

2. *Drug susceptibility testing*: If TB is confirmed, perform drug susceptibility testing to ensure the chosen ATT regimen is effective.

3. *Renal function monitoring*: Closely monitor the patient's renal function, as ATT can exacerbate kidney damage.

4. *Hepatic function monitoring*: ATT can also affect liver function; monitor liver enzymes and adjust the regimen if necessary.

5. *Nutritional assessment and support*: Ensure the patient receives adequate nutrition to support their immune system and overall health.

6. *HIV-related opportunistic infections*: Although the patient doesn't currently have any HIV-related opportunistic infections, continue to monitor for potential infections, such as Pneumocystis jirovecii pneumonia (PCP) or toxoplasmosis.

By carefully evaluating the patient and adjusting the ART regimen and ATT accordingly, you can optimize their treatment outcomes and minimize potential complications.

Interestingly the LLM here hasn't shared the standard disclaimer of consulting a physician before acting on it's advice!

23/01/2025, 11:41 - Rakesh Biswas: 👆 this patient turned out to have granulomatous myocarditis on autopsy.

@918374789176 have you come across any similars? We don't know what we may have found if your past young DCM patient had been autopsied although our hunch was, it was likely microvascular CAD going by his events highlighting his young onset metabolic syn

23/01/2025, 12:04 - Rakesh Biswas: Surviving only on government pension of 2000/- per month, rice from ration and medicines from Government PHC. Telangana governance systems success story (regardless of political party in power)? @919652955915

23/01/2025, 13:11 - Rakesh Biswas: On closer clinical palpation, I'm forcibly biased to think that the dynapnia and sarcopenia may not be substantial enough in these two phenotypic outliers to balance the predictive visceral fat by sarcopenia equation and from now on dynapnia too needs to be an important consideration in the equation @919652955915 a possible project for you there in UK? Let's review the literature around this

23/01/2025, 13:23 - pajr.in CEO, NHS Endocrinologist: Why do you want to calculate BUN?

23/01/2025, 13:26 - pajr.in CEO, NHS Endocrinologist: Government created scarcity followed by government subsidized living?

23/01/2025, 13:27 - pajr.in CEO, NHS Endocrinologist: Hmmm let me chew on that. Will need plenty of resources but given that I'm at a district hospital until 2026, very low chances of approval.

23/01/2025, 14:03 - Sai Charan Kulkarni 2020 KIMS Pg: Update on this case : 

S- patient able to sleep on bed, cough and sob decreased 

No fresh echymotic patches 

O - 

bilateral crepts present

RR - 26 cpm difficulty in completing sentences 

Orthopnea decreased slightly 

She is better in sitting than lying down 

Peripheral Smear shows plasma cells ( will share images shortly ) 

A - relapse of Multiple myeloma 

S/P Bone marrow transplant 

Cast nephropathy 

Left upper lobe pneumonia 

Rt Fungal ball 

P - Anti fungal added 

Questions around this case : 

Can it be ITP in MM triggered by fungal pneumonia ..? 

She doesn’t have any bleeding manifestations when her platelets was 7000 but now she have this patches at platelets 16000..?

23/01/2025, 14:05 - Sai Charan Kulkarni 2020 KIMS Pg: @919652955915  @919121046928  @918978926479

23/01/2025, 14:07 - Sai Charan Kulkarni 2020 KIMS Pg: <Media omitted>

23/01/2025, 14:08 - pajr.in CEO, NHS Endocrinologist: Can MM induced amyloidosis cause skin bleeds?

23/01/2025, 14:28 - Rakesh Biswas: Oh wow! we're all working in rural low resource settings!👏👏

23/01/2025, 14:29 - 2016 USmle ET: I was thinking of the possibility of an occult chronic GI bleed (elderly 77) in the patient superimposed on her poor water intake as the underlying issue; that would explain the elevated serum osm.

23/01/2025, 14:33 - pajr.in CEO, NHS Endocrinologist: This is definitely not low resource though. And wouldn't label it rural either.

23/01/2025, 14:34 - pajr.in CEO, NHS Endocrinologist: Well if the Serum Na is 177 and 2xNa = 354, that itself is taking up a huge chunk of the 397 serum Osmolality isn't it?

23/01/2025, 14:35 - pajr.in CEO, NHS Endocrinologist: It's more to do with vested interests and political correctness

23/01/2025, 14:37 - 2016 USmle ET: I have made an error in calculating. I just realised, sorry about that!

23/01/2025, 14:38 - Rakesh Biswas: Thanks for sharing. Really heartening to see your progress! 👏👏

Well your patient is currently on cyclophosphamide and pomalidomide, and a  significant side effect that can occur with this combination is thrombocytopenia, this is considered one of the most common grade 3 or 4 hematological adverse events associated with this combination therapy, often requiring close monitoring during treatment. 

https://pmc.ncbi.nlm.nih.gov/articles/PMC7983889/#:~:text=Pomalidomide%20was%20temporarily%20interrupted%20for%20patients%20with,other%20grade%20%E2%89%A5%203%20treatment%E2%80%90related%20adverse%20events.&text=The%20most%20common%20grade%203%20or%204,neutropenia%20(20.0%)%2C%20anemia%20(10.9%)%2C%20and%20thrombocytopenia%20(18.2%). <This message was edited>

23/01/2025, 14:43 - Rakesh Biswas: Nice. While the right lobar aspergilloma is clearly visible, I'm intrigued by her left upper lobe pathology

Would be great if you can add this to the case report

This part isn't mentioned there?

23/01/2025, 14:54 - Sai Charan Kulkarni 2020 KIMS Pg: The treatment‐emergent adverse events (TEAEs) are shown in Table 3. The most common grade 3 or 4 hematological adverse events were neutropenia (20.0%), anemia (10.9%), and thrombocytopenia (18.2%). The most common grade 3 or more non‐hematological adverse events were pneumonia (21.8%), febrile neutropenia (14.6%) and sepsis (9.0%). The seven deaths recorded during the study period were due to pneumonia (four cases), sepsis (two cases), and cardiac arrest (one case)

From same case report sir

23/01/2025, 15:29 - pajr.in CEO, NHS Endocrinologist: Well she did not bleed, let's say. What would be your next step?

23/01/2025, 15:30 - Rakesh Biswas: Not as clearly as in the HRCT?

23/01/2025, 15:52 - Rakesh Biswas: Nice plasma cells?

23/01/2025, 16:06 - Rakesh Biswas: Do you have interns to capture these images from your pathology lab or you get these in some other channel?

23/01/2025, 16:06 - Sai Charan Kulkarni 2020 KIMS Pg: <Media omitted>

23/01/2025, 16:07 - Sai Charan Kulkarni 2020 KIMS Pg: Bullous hemorrhagic lesions are more common ( > 50% ) in AL myeloma than echymosis or purpura.

23/01/2025, 16:16 - Rakesh Biswas: But let's say in him it's just echymosis, how would you prove cutaneous amyloid? Which part of the skin would you biopsy? 

When we were PGs we used to often get subcutaneous abdominal fat pad fnacs

Check if they are doing it there and it's sensitivity specificity <This message was edited>

23/01/2025, 16:20 - Rakesh Biswas: Abdominal fat pad has a poor sensitivity! Can't rule out amyloid if negative 👇

https://www.sciencedirect.com/science/article/abs/pii/S2213294524000036

23/01/2025, 16:27 - Sekhar Chandu Prof Community Med Kadappa left

23/01/2025, 20:38 - Unknown Medical Student: This is the entrance for registration hall sir

24/01/2025, 09:46 - Dr Ramji SR Medicine: Probably not specifically looked for portal hypertension..

24/01/2025, 09:46 - Dr Ramji SR Medicine: And not requested for..

24/01/2025, 10:07 - Rakesh Biswas: Check out the case report tagged above when the patient was first shared here. 

In the USG, CT, MRCP reports they have mentioned the liver,  spleen, portal veins etc only it wasn't radiologically possible for them to visualise what the 3D real OT images offered

24/01/2025, 17:01 - Rakesh Biswas: While all medical students read about this disease in anatomy, I was struck by the actual  rarity of her disease.

To quote:

"extreme rarity of the disease limits the surgical opportunities to practice the complex closure required in these patients. For this reason, patients have the best outcomes when the bladder closures are performed at high volume centers where surgical and nursing teams have extensive experience in caring for the disease.[6] The highest volume center in the United States, and the world, is the Johns Hopkins Hospital in Baltimore, Maryland; they have seen over 1300 exstrophy patients in the past 50 years"!

https://en.m.wikipedia.org/wiki/Bladder_exstrophy

25/01/2025, 09:50 - Sai Charan Kulkarni 2020 KIMS Pg: No sir here I have access to lab and microscope. Technician has prepared smear, I clicked few images and confirmed findings with pathologist .

25/01/2025, 09:56 - Rakesh Biswas: Was looking forward to your patient's soap notes yesterday

25/01/2025, 10:02 - Rakesh Biswas: @918277432650 if you saw the Wiki image above and could read the article then you may by now have realised why they were instructed that she would never become pregnant. Ambiguous genitalia is a frequent clinical problem also dealt with by endocrinologists like @919652955915 where their focus could be on ruling out CAH while we would unfocus in trying to answer her multi modal requirements @919604701505 

@919515476138 has done a fabulous job since yesterday, in looking after her career path toward becoming a doctor and @918106177663 you may remember him as that first year MBBS UG who presented a case in the CME you chaired in 2023!

@917675086612 hope we shall be able to get a pelvic ultrasound today along with an OBG consult for her fertility issues and get a radiology USG guided ascitic tap. I tried to tap the fluid yesterday and couldn't get it and wish I could blame the diameter of the iv needle we were provided

25/01/2025, 10:16 - Rakesh Biswas: @918790889907 This patient can come and meet you in the Kolkata conference venue for a clinical examination 👇

https://chat.whatsapp.com/CCkXdEEiBtNCy9QnNKWOqP

25/01/2025, 10:48 - Unknown Medical Student: Okay sir

25/01/2025, 12:15 - Sai Charan Kulkarni 2020 KIMS Pg: Today’s Update : 

S - Orthopnea decreased. Appetite improved ( ate rice similar to her husband after 3-4 months ) No fever 

O - No new echymotic patches, wheeze and crepts decreased. Platelets improved to 40000

A - resolving inflammation 

P - continue on Antifungal and discharge her tomorrow with pajr followup till Feb 1st - for  hemato-oncologist visit

https://medicineprudence.blogspot.com/2025/01/high-risk-kappa-light-chain-multiple.html?m=1 <This message was edited>

25/01/2025, 14:30 - Sadhana Sharma Nri Med: Yes,I do remember. 

Very heartening to see this breed of doctors. 

Where is he working now?

25/01/2025, 14:35 - Rakesh Biswas: KMC Warangal

25/01/2025, 18:14 - Rakesh Biswas: Can add the EMR discharge summary to the patient's case report as we often do?

26/01/2025, 18:58 - Rakesh Biswas: Tomorrow's academics:

Student CPC

Venue: LT1

Time: 8-9 AM

Chairperson : Dr. Akhil

Case 1: G2P1, IUFD, with obstructed labor,  

19+6week/385 gm/ Male abortus/ B/l echogenic bulky kidneys /severe oligohydramnios/pulmonary hypoplasia/pericardial effusion

Clinical discussant-Dr. Varsha

Pathology discussant- Dr. Abhishek

Clinical Incharge - Dr. Dhaliwal

Case 2: B/L Hydronephrosis, Lumbosacral meningomyelocele, birth asphyxia 

Clinical discussant: Dr. Anjali

Pathology discussant :Dr. Amarnath

Clinical Incharge - Dr. Kavya

The session will be available on online webEx platform link details provided below. 

https://india-edu.webex.com/india-edu/j.php?MTID=m1cb4b75b29a2cff53f63e5991b9bab7b

27/01/2025, 12:11 - Rakesh Biswas: Metabolic syn LVH

27/01/2025, 12:17 - MD.AKRAM Kolkata Medical College Intern: Blood glucose, HbA1c.

Lipid profile (high triglycerides, low HDL).

BP..!

27/01/2025, 12:18 - MD.AKRAM Kolkata Medical College Intern: Privious Address risk factors hypertension, diabetes..m

27/01/2025, 12:18 - MD.AKRAM Kolkata Medical College Intern: ?

27/01/2025, 12:19 - MD.AKRAM Kolkata Medical College Intern: I think , Concentric LVHOften due to hypertension or insulin resistance .

27/01/2025, 12:27 - Rakesh Biswas: Emperipoliosis

27/01/2025, 12:28 - ವಿಕ್ರಮ ಸಕಲೇಶಪುರ Vikram SaKleshpur: Sarcoidosis?

27/01/2025, 12:29 - ವಿಕ್ರಮ ಸಕಲೇಶಪುರ Vikram SaKleshpur: Emperipolesis right?

27/01/2025, 12:37 - Rakesh Biswas: Got me there! 👍

27/01/2025, 12:38 - Rakesh Biswas: This non healing ulcer started in 2021

27/01/2025, 12:41 - Rakesh Biswas: @13135550002 in a patient on intermittent hydroxyurea for polycythemia vera how would one decide if a non healing leg ulcer is due to the polycythemia vera vasculopathy or due to hydroxyurea?

27/01/2025, 12:41 - Meta AI: Determining the cause of a non-healing leg ulcer in a patient with polycythemia vera (PV) on intermittent hydroxyurea (HU) can be challenging, as both PV vasculopathy and HU can contribute to impaired wound healing. Here's a step-by-step approach to help you decide:

# Clinical Assessment

1. *Assess the ulcer*: Evaluate the ulcer's location, size, depth, and appearance. PV vasculopathy often causes ulcers in the lower extremities, particularly in the gaiter area (just above the ankle).

2. *Review medical history*: Consider the patient's medical history, including the duration of PV, HU treatment, and any other comorbidities that may impact wound healing (e.g., diabetes, peripheral artery disease).

3. *Physical examination*: Perform a thorough physical examination to assess for signs of PV vasculopathy, such as:

    - Purpura or ecchymoses

    - Splenomegaly

    - Hepatomegaly

    - Peripheral neuropathy

# Laboratory Tests

1. *Complete Blood Count (CBC)*: Evaluate for signs of PV, such as elevated hematocrit, hemoglobin, and platelet count.

2. *Blood chemistry*: Assess for electrolyte imbalances, renal function, and liver enzymes.

3. *Inflammatory markers*: Check for elevated inflammatory markers, such as C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR), which may indicate active vasculopathy.

# Imaging Studies

1. *Doppler ultrasound*: Evaluate blood flow to the affected limb to assess for signs of vasculopathy or peripheral artery disease.

2. *MRI or CT angiography*: Consider imaging studies to evaluate the extent of vasculopathy or to rule out other causes of non-healing ulcers.

# Hydroxyurea-Specific Considerations

1. *HU dose and duration*: Assess the patient's HU dose and treatment duration. Higher doses or prolonged treatment may increase the risk of leg ulcers.

2. *HU-related side effects*: Evaluate for other HU-related side effects, such as bone marrow suppression, gastrointestinal disturbances, or dermatological reactions.

# Decision-Making

Based on the clinical assessment, laboratory tests, and imaging studies, consider the following:

1. *PV vasculopathy*: If the patient has a history of PV, and the ulcer is located in a typical area, with signs of vasculopathy on physical examination and imaging studies, PV vasculopathy is likely the primary cause.

2. *Hydroxyurea*: If the patient has been on HU for an extended period, and the ulcer is accompanied by other HU-related side effects, HU may be contributing to the non-healing ulcer.

3. *Combination of both*: It is possible that both PV vasculopathy and HU are contributing to the non-healing ulcer.

# Management

Based on the determined cause, consider the following management strategies:

1. *Adjust HU dose or discontinuation*: If HU is suspected to be contributing to the non-healing ulcer, consider reducing the dose or discontinuing the medication.

2. *PV-directed therapy*: If PV vasculopathy is the primary cause, consider optimizing PV-directed therapy, such as phlebotomy, aspirin, or other cytoreductive agents.

3. *Wound care and supportive measures*: Provide standard wound care, including debridement, dressing changes, and compression therapy, as well as supportive measures, such as pain management and nutritional support.

A multidisciplinary approach, involving hematologists, dermatologists, and wound care specialists, can help determine the underlying cause and develop an effective management plan.

28/01/2025, 12:56 - MD.AKRAM Kolkata Medical College Intern: Hb S/β-thalassemia ,condition where patients can present with anemia, splenomegaly.

I think , occasional pain crises due to sickling.

28/01/2025, 12:56 - MD.AKRAM Kolkata Medical College Intern: Further investigation of blood - Peripheral blood smear, reticulocyte count, liver and renal function tests, and iron.

28/01/2025, 12:57 - MD.AKRAM Kolkata Medical College Intern: Family screening required, Essential to counsel and test family members for genetic hemoglobinopathies.

28/01/2025, 14:29 - Patient Advocate 56F Migraine Hypothyroidism 2000: Case report done

28/01/2025, 17:01 - Rakesh Biswas: Themes explored in the case below discharged yesterday:

Diagnostic uncertainty:

Clinical features suggestive of acute meningitis in a patient of metabolic syn with trunkal obesity, parotidomegaly etc as part of the metabolic phenotype.

Hemorrhagic lumbar puncture inconclusive

Cranial MRI suggestive of blood or pus, interpreted due to REDUCED DIFFUSION IN TRIGONES OF B/L LATERAL

VENTRICLES as ? CHRONIC INTRA VENTRICULAR BLOOD COLLECTION OR PUS

Past traumatic brain injury 8 years back for which craniectomy was done and similar episode suggestive of meningitis 4 years back.

Therapeutic uncertainty:

Empirical pharmacological and non pharmacological interventions  

EMR summary (with defensive medicine themes due to the diagnostic and therapeutic uncertainty)👇

https://medicinedepartment.blogspot.com/2025/01/project-altered-sensorium-clinical.html?m=1

28/01/2025, 18:34 - +30 698 620 6490 joined using this group's invite link

28/01/2025, 18:34 - +30 698 620 6490 left

28/01/2025, 18:40 - Sailaja Listener Poet Heartfulness joined using this group's invite link

29/01/2025, 12:34 - MD.AKRAM Kolkata Medical College Intern: Sputum AFB, GeneXpert, and chest X-ray should be prioritized.

 fasting glucose, HbA1c, lipid profile, BP,

29/01/2025, 14:53 - +91 81797 61056 left

29/01/2025, 15:39 - Rakesh Biswas: @918790889907 did the patient return to you in the OPD with the test reports?

29/01/2025, 15:42 - pajr.in CEO, NHS Endocrinologist: How was his blood pressure at this time sir? Clearly the RCA is gone!

29/01/2025, 15:43 - pajr.in CEO, NHS Endocrinologist: Can somehow feel the locomotor brachii across continents!!

29/01/2025, 15:44 - Unknown Medical Student: Patient said he will come back after three days with sputum reports

Chest X-ray shows left upper lobe consolidation

No pleural effusion sir

29/01/2025, 15:44 - pajr.in CEO, NHS Endocrinologist: Just to add what I learned here - apparently Ticagrelor 180 vastly (read as marginally) outperforms Clopidogrel in loading doses.

And apparently Atorvastatin is not really a part of the loading regimen. A beta blocker is if left sided MI

29/01/2025, 15:46 - pajr.in CEO, NHS Endocrinologist: Let's hope those T wave inversions start appearing in the right sided leads.

29/01/2025, 15:48 - Rakesh Biswas: Can you share that image! That means your clinical suspicion for kochs was right!

29/01/2025, 15:48 - Rakesh Biswas: Sharing what happened next

29/01/2025, 16:02 - MD.AKRAM Kolkata Medical College Intern: It men's pesent case - pneumonia,

More test - CBC ,  sputum culture,  inflammatory marker.

RADIOLOGY - CT chest for better visualization, bronchoscopy if malignancy is suspected.

29/01/2025, 16:03 - pajr.in CEO, NHS Endocrinologist: Finally TWI in inferior leads! The vessel wall has opened and possibly can be linked to subsiding giddiness?

29/01/2025, 16:05 - pajr.in CEO, NHS Endocrinologist: Why sputum culture? What is a sputum and Do pneumonias generate sputum at all?

Why a CT chest? Why Bronchoscopy?

29/01/2025, 16:06 - MD.AKRAM Kolkata Medical College Intern: Better diagnosis, because pesent are not identified in pneumonia,

29/01/2025, 16:07 - MD.AKRAM Kolkata Medical College Intern: It's a thinking to CXR report

29/01/2025, 16:18 - pajr.in CEO, NHS Endocrinologist: If history and clinical exam is suggestive of pneumonia, how would a CT help?

What exactly does better diagnosis mean?

29/01/2025, 16:21 - pajr.in CEO, NHS Endocrinologist: Here is what David Sackett (1992) , Adam Rodman (2024) and LLM (Future) think like -

If this patient has a short history of systemic symptoms like fever, cough, feeling unwell with early signs of sepsis such as tachycardia, tachypnea and an elevated white cell count and my clinical exam tells me that there are some lung findings suggestive of a pneumonia, which an CXR can show, would this patient benefit with Co-amox or Doxycycline to improve his current clinical condition?

29/01/2025, 16:22 - pajr.in CEO, NHS Endocrinologist: Basically, would a better diagnosis improve patient outcomes?

29/01/2025, 16:30 - Rakesh Biswas: Best to do that after seeing the chest X-ray👍

29/01/2025, 16:31 - Rakesh Biswas: Here's the bedside clinical imageology for the patient 👇

https://youtube.com/shorts/Poex_pSfwj8?feature=shared

29/01/2025, 16:38 - MD.AKRAM Kolkata Medical College Intern: Maybe ( pneumonia ) is fine with the patient then this medicine will definitely work, I think.

29/01/2025, 16:40 - Rakesh Biswas: The patient I described didn't have any typical findings of acute pneumonia with no tachypnoea etc. He's likely to be having pulmonary kochs which the chest X-ray can clarify if @918790889907 can manage to share it here

29/01/2025, 16:44 - Unknown Medical Student: I saw it in Medsynapse with op number in interns mobile 

Drew the picture on op slip

Counselled the patient and went back to seeing other patients sir

I am unable to retrieve that as I forgot his name and I don’t have his op number

29/01/2025, 16:46 - Rakesh Biswas: The intern may have saved it?

29/01/2025, 16:47 - Unknown Medical Student: No sir 

We can view it from website directly so we don’t have to save it to our mobile phones

29/01/2025, 16:53 - Rakesh Biswas: Except we cannot view it now!

29/01/2025, 17:00 - Unknown Medical Student: We can view it now as well if we have the op number sir

29/01/2025, 17:02 - Rakesh Biswas: It should be in the OPD sister's register if you can match with the time I shared his image or billing register if you remember his name

29/01/2025, 17:40 - Unknown Medical Student: Okay sir will search

29/01/2025, 18:01 - +91 93988 13676 left

30/01/2025, 09:49 - Rakesh Biswas: Reviewing this long distance patient now in the OPD @918597778887 @918074725352 @919908540769 and admitting him in SS ward. @919491489659 Please utilise the case report content to prepare his file 👇

https://24fpatient.blogspot.com/2024/12/63m-metabolic-syn-dyspnea-2-years-wb.html?m=1

30/01/2025, 09:51 - Rakesh Biswas: Please ask the SS ward sister to prepare his hourly BP chart every hour from today @919491489659 @919908540769

30/01/2025, 09:57 - Communicating Learner 1N23: Ok sir

30/01/2025, 10:03 - Rakesh Biswas: Reviewing the other long distance patient in OPD now and sharing in real time toward team based learning of this endocrine disorder @919652955915 

31F 

Jotting down her notes below in the OPD:

Was reportedly obese since birth

And had thrombophlebitis of right foot for which they even contemplated amputation <This message was edited>

30/01/2025, 10:05 - Rakesh Biswas: Used to love shiuli flowers as a toddler but they precipitated her first bronchial asthma attack and then annually at around the same date!

30/01/2025, 10:06 - Rakesh Biswas: Autumn

30/01/2025, 10:07 - Rakesh Biswas: First inhalers in 9th standard

Till then was largely controlled on Ayurveda and Homeopathy!

30/01/2025, 10:14 - Rakesh Biswas: In 2009 when she was 15 and focusing on her 9th exams, her Ayurvedic physician died and she had no option but to turn to mainstream medicine and started salbutamol inhalers since then every year twice during the spring and autumn exacerbations

30/01/2025, 10:22 - Rakesh Biswas: During the same time she also noticed her asthma attacks coming few days just before the menstrual cycles 50% of the year

30/01/2025, 10:23 - Rakesh Biswas: Following 12 years of age she gained further weight other than the congenital obesity noticed during birth

30/01/2025, 10:25 - Rakesh Biswas: Used to consume Amway products due to their door to door sales marketing for her dysmenorrhoea and obesity 2013-14

30/01/2025, 10:46 - Rakesh Biswas: Next life events

10th, 12th, BA English, 2011 LLB, 2014 LLM 2017 PhD admission in 2020

Worked as Asst Professor since 2019-2022 in NBU in parallel 

PhD submitted December 2024 waiting

Married in 2021

Mother died in 2023. Mother had a movement disorder suggestive of hemiballismus with uncontrolled sugars (diabetic striatopathy) and stroke in April 2021 and then developed COVID and suffered from pulmonary long covid and died during 2023

30/01/2025, 10:47 - Rakesh Biswas: Patient also developed anosmia and COVID positivity at the same time

30/01/2025, 10:49 - Rakesh Biswas: Also had a major UTI December 2022 and suffered for two weeks

30/01/2025, 10:50 - Rakesh Biswas: Developed epigastric discomfort since last 6 months

Along with irregular meals in a vicious cycle

30/01/2025, 10:53 - Rakesh Biswas: 2016-17 developed intermittent headache.

Says she's a sugar addict who used to get headaches if she tried to give up sugar and attributes those headaches to her sugar de-addiction trials!

30/01/2025, 10:58 - Rakesh Biswas: She also mentioned that she had a breast fibroadenoma in November 2024 diagnosed only through breast ultrasound

@919908540769 please send her to Prof Krishnamurthy for evaluation and let's get her repeat breast ultrasound too

30/01/2025, 11:09 - Rakesh Biswas: @919908540769 please send his chest X-ray, ecg and echocardiography (will also review in ICU)

30/01/2025, 11:30 - Rakesh Biswas: 👆She was also complaining of this lower abdomen swelling, which is a quiz for our UGs @919593233556

30/01/2025, 12:15 - MD.AKRAM Kolkata Medical College Intern: Sir any diagnosis report...!

30/01/2025, 12:15 - Rakesh Biswas: Apex on palpation has a prominent LV lift and yet poor localisation suggestive of RV involvement as well

30/01/2025, 12:17 - Rakesh Biswas: No it's a clinical finding which all MBBS ugs should be able to recognise given the clues in the image

30/01/2025, 12:20 - MD.AKRAM Kolkata Medical College Intern: Lipid profile, fasting blood sugar (FBS), HbA1c, renal function tests (RFT),serum creatinine

30/01/2025, 12:24 - MD.AKRAM Kolkata Medical College Intern: Hypertension (Stage 3) Blood pressure of 170/120 mmHg indicates severe hypertension.

present due to hypertension, possible central obesity, insulin resistance ,/ dyslipidemia.

Post-Hysterectomy Complications.

30/01/2025, 12:25 - MD.AKRAM Kolkata Medical College Intern: Hyperlipidemia ,This could also be.

30/01/2025, 12:30 - MD.AKRAM Kolkata Medical College Intern: Sir , any ECG report..!

30/01/2025, 12:57 - Rakesh Biswas: He's unable to afford it. Will admit him tomorrow under our free for senior citizens program

30/01/2025, 12:58 - Rakesh Biswas: I wish the current UG generation was more clinical and history data oriented rather than savvy with guiltless over-testing!

30/01/2025, 13:26 - pajr.in CEO, NHS Endocrinologist: Steroids you mean?

30/01/2025, 13:30 - pajr.in CEO, NHS Endocrinologist: I mean I'm all in for narrative based medicine but I still can't make out what her current problems are?

30/01/2025, 15:14 - Rakesh Biswas: She could recall the name salbutamol for her inhaler. Would expect that she would have received steroid inhalers too

30/01/2025, 15:18 - Rakesh Biswas: It's clinical complexity that can only be expressed through unstructured narrative!

So to reduce (as in reductionist) clinical complexity we can use a structured problem list:

1) Obesity since birth with add on obesity since teens @919908540769 can you please ask someone to check her height and weight and share here?

2) Corn

3) Dyspepsia Constipation suggestive of NUD IBS

4) Seasonal Bronchial asthma (currently quiescent)

30/01/2025, 15:25 - pajr.in CEO, NHS Endocrinologist: No sir I meant the ayurvedic drugs covertly mix steroids anyway.

30/01/2025, 15:31 - Rakesh Biswas: 👆Ward 6: Homeless man from Shelter with acute on chronic LVF precipitated by the obvious electrical disturbances visible in this piece of heat sensitive paper <This message was edited>