THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[29-09-2025 12.20] PPM 1: Admitting this patient from the OPD now
[29-09-2025 12.27] PPM 3: Oh Great to see it happening. Welcome Director, AYUSH (Clinic), NCT Government of Delhi.
[29-09-2025 12.29] PPM 1: Yes with us it happens every day all the time
[29-09-2025 12.31] PPM 3: Welcome Founder, Integrative Chrono-bio-medicine Association
[29-09-2025 12.35] PPM 4: Link to detailed history and so far treatment given?
[29-09-2025 12.39] PPM 1: Welcome everyone as we take you on a trip through our 24x7 passion of trying to improve patient illness outcomes through team based learning outcomes driven by technology
Here's the video of the diaphragmatic movement of this 58F patient of right sided diaphragmatic palsy , we admitted from our OPD just now and who is currently having shortness of breath possibly due to acute left ventricular failure other than her diaphragmatic palsy
Note how the left shadow of her abdomen is moving more than the right shadow of her abdomen 👇
[29-09-2025 12.41] PPM 4: Great to see such kind of documentation and encouragement for doing so.🙏🏻
[29-09-2025 12.42] PPM 3: Please provide the Online link, shown here
29-09-2025 12.43] PPM 1: Yes I'm not sure if anyone has captured this sign in video before although I recall reading it from very very old textbooks!
Now with the advent of bedside ultrasound I would myself prefer to put and check it out with the ultrasound probe rather than depend on light and shadow but it was good to have this documentation opportunity due to our low resource OPD
You mean this link?👇
[29-09-2025 12.51] PPM 4: Yes indeed Sir
Do provide the follow-up of this case once you do with USG part was this clinical observation have lots to offer in next kind of profoundly abdominal examination in our routine checkup.
[29-09-2025 12.52] PPM 1: All our patient follow ups are provided in the PaJR group for the patient such as the one here.
Hopefully we'll be able to keep following her up through this group
[29-09-2025 14.40] PPM 5: Lateral view of chest x ray
[29-09-2025 16.12] PPM 1: The outside x-ray right dome of diaphragm appears to be higher.
[29-09-2025 16.14] PPM 4: Are they both taken on the same day or in the Right posture?
[29-09-2025 16.14] PPM 1: Good point. History recorded by @ PPM6
[29-09-2025 16.23] PPM 1: She appears to be having a thyroid swelling since 10 years that was operated this August 2025 and the history in the attached summary doesn't tell us why that 10 year swelling worsened but on examination there were cervical lymph nodes that were excised as also seen in the current clinical examination images attached.
@PPM7 @PPM8 please share her ECG done today
[29-09-2025 16.38] PPM 1: Received 100 m Ci orally on 22/9/25
Her radiation exposure level on 22/9/25 is 2.2 mrad/hour at 1 meter distance.
@Meta AI@PPM9 will this affect the caregivers @PPM10 @PPM6 @PPM8 currently taking care of her? Please substantiate your inputs with perplexity styled references.
[29-09-2025 16.38] Meta AI: To assess the potential impact on caregivers, let's break down the radiation exposure information provided.
## Radiation Exposure Level
The patient's radiation exposure level is 2.2 mrad/hour at a 1-meter distance. To put this into perspective, the average yearly radiation dose per person in the US is approximately 620 mrem, which translates to about 0.07 mrem/hour (assuming 8,760 hours/year). The patient's caregivers would be exposed to a relatively higher dose, but still within potentially safe limits, depending on the duration of exposure.
## Calculating Exposure for Caregivers
Let's assume a caregiver spends 8 hours a day with the patient. The exposure would be:
2.2 mrad/hour * 8 hours = 17.6 mrad/day
## Comparing to Standard Limits
Occupational exposure limits vary, but for radiation workers, the limit is typically 5 rem (5,000 mrem) per year. For caregivers in this scenario, assuming continuous exposure at the calculated rate:
17.6 mrad/day * 365 days ≈ 6.42 rad/year (or 6,420 mrem/year)
This is above the general public's annual limit but below occupational limits for radiation workers. However, caregivers are not typically classified as radiation workers, so precautions should be taken.
## Precautions for Caregivers
Given the potential exposure, caregivers should consider the following precautions¹ ²:
- *Minimize exposure time*: Limit time spent near the patient to reduce overall exposure.
- *Maximize distance*: Increase distance from the patient, as radiation exposure decreases with distance.
- *Use shielding*: Utilize shielding materials, like lead aprons, to reduce radiation exposure.
## Conversion and Calculation Tools
For further calculations and conversions, consider using online tools like³ ⁴:
- Radiation Dose Rate Converter (RP Alba)
- Rad Pro Calculator (free online radiological units conversions)
## Conclusion
While the radiation exposure level may pose some risk to caregivers, implementing precautions can minimize exposure. Consult with radiation safety experts to determine the best course of action for specific situations.
Admission Date: 19/07/2025 10:13 AM
Diagnosis
FOLLICULAR NEOPLASM OF THYROID
Case History and Clinical Findings
PATIENT C/O SWELLING INFRONT OF NECK SINCE 10 YEARS
HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 YEARS BACK THEN SHE DEVELOPED
SWELLING INFRONT AND RIGHT LATERAL PART OF NECK WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSED TO THE PRESENT SIZE. SWELLING IS ASSOCIATED WITH PAIN WHICH IS DULL ACHING TYPE OF PAIN CONTINUOUS WITH NO AGGRAVATING AND RELIEVING FACTORS
H/O FEVER WHICH IS INTERMITTENT IN NATURE
H/O BREATHLESSNESS WHICH IS INTERMITTENT
H/O LOSS OF SLEEP, LOSS OF APPETITE, HEAT INTOLERANCE, WEAKNESS, EXCESSIVE
SWEATING
H/O DYSPHAGIA, HOARSENESS
NO H/O OTHER SWELLINGS
PAST HISTORY
K/C/O DM SINC E7 YEARS ON TAB GLIMI M2
K/C/O HTN SINCE 1 YEAR ON TAB TELMISARTAN 40 MG
N/K/C/O CVA,CAD,TB,EPILEPSY,ASTHMA
SURGICAL HISTORY
H/O TUBECTOMY 32 YEARS AGO
PERSONAL HISTORY
Page-2
KIMS HOSPITALS
MARRIED, WORKER, LOSS OF APPETITE, MIXED DIET, REGULAR BOWEL AND BLADDER
MOVEMENTS, NO KNOWN ALLERGIES AND ADDICTIONS.
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL PHYSICAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING OF FINGERS, GENERALISED
LYMPHADENOPATHY, EDEMA OF FEET
BP:120/80MMHG
PR: 92 BPM
RR: 16 CPM
TEMP: AFEBRILE
SP02: 99 %
GRBS: 104 mg%
SYSTEMIC EXAMINATION:
CVS: S1,S2+
RS: BAE+
CNS:NFND
P/A:SOFT , BS+
LOCAL EXAMINATION
INSPECTION
SOLITARY OVOID SHAPED SWELLING OF SIZE 2X2CM PRESENT IN FRONT OF NECK MORE TOWARDS RIGHT SIDE EXTENDING SUPERIORLY UPTO THYROID NOTCH INFERIORLY UPTO SUPRASTERNAL NOTCH AND LATERALLY ON RIGHT SIDE UPTO 8CM FROM MIDLINE SURFACE OF SWELLING APPEARS TO BE SMOOTH
SWELLING MOVES WITH DEGLUTITION
LOWER BORDER OF SWELLING IS VISIBLE
SKIN OVER THE SWELLING IS NORMAL
NO VISIBLE PULSATIONS, SCARS, SINUSES
PALPATION
NO LOCAL RISE OF TEMPERATURE, NO TENDERNESS
ALL INSPECTORY FINDINGS ARE CONFIRMED WITH RESPECT TI SITE SIZE, SHAPE
SURFACE OF THE SWELLING IS SMOOTH
CONSISTENCY OF SWELLING IS FIRM
MARGINS OF SWEELING ARE REGULAR
Page-3
KIMS HOSPITALS
TRACHEA IS SLIGHTLY DEIATED TO LEFT
PERCUSSION
DULL ON PERCUSSION
AUSCULATION
NO BRUIT
LYMPH NODE EXAMINATION
INSPECTION
SOLITARY OVAL SHAPED SWELLING OF SIZE 4X3CM PRESENT OVER THE RIGHT LATERAL ASPECT OF NECK EXTENDING 2CM AWAY FROMTHE THYROID GLAND LATERALLY AND 3CM FROM CLAVICLE,5CM AWAY FROM MASTOID PROCESS
SURFACE OF SWELLING APPEARS TO BE SMOOTH
TORTICOLLIS TO RIGHT SIDE IS PRESENT
NO SCARS, SINUSES
PALPATION
NO LOCAL RISE OF TEMPERATURE, TENDERNESS IS PRESENT
ALL INSPECTORY FINDINGS ARE CONFIRMED WITH RESPECT TO SITE SIZE,SHAPE AND
EXTENT
SURFACE OF THE SWELLING IS SMOOTH
CONSISTENCY OF SWELLING IS HARD
FLACTUATION -PRESENT
NO MOBILITY
Investigation
POST PRANDIAL BLOOD SUGAR 19-07-2025 157MG/DL
RFT 19-07-2025 UREA 20 mg/dl 50-17 mg/dl CREATININE 0.7 mg/dl 1.2-0.6 mg/dl URIC ACID 4.2
mmol/L 6-2.6 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dl PHOSPHOROUS 4.0 mg/dl 4.5-2.5
mg/dl SODIUM 139 mmol/L 145-136 mmol/LPOTASSIUM 4.3 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99mmol/L 98-107 mmol/LLIVER FUNCTION TEST (LFT) 19-07-2025 10:33:AM Total Bilurubin 0.81mg/dl 1-0 mg/dl Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl SGOT(AST) 31 IU/L 31-0 IU/LSGPT(ALT) 29 IU/L 34-0 IU/LALKALINE PHOSPHATASE 140 IU/L 128-56 IU/LTOTAL PROTEINS 6.9 gm/dl 8.3-6.4gm/dl ALBUMIN 4.48 gm/dl 4.6-3.2 gm/dl A/G RATIO 1.85
THYROID PROFILE 19-07-2025 T3 1.08 ng/ml 1.87-0.87 ng/mlT4 12.17 micro g/dl 12.23-6.32 micro
g/dl TSH 0.58 micro-Iu/ml 5.36-0.34 micro-Iu/ml HEPATITIS- B SURFACE ANTIGEN (HBSAg) RAPID
TEST 19-07-2025 Negative
Page-4
KIMS HOSPITALS
ANTI HCV ANTIBODIES (Rapid Test) RAPID 19-07-2025 10:33:AM Non Reactive COMPLETE
BLOOD PICTURE (CBP) 19-07-2025 10:34:AM HAEMOGLOBIN 11.0 gm/dl 15.0-12.0 gm/dl TOTAL COUNT 8500 cells/cumm 10000-4000 cells/cumm NEUTROPHILS 60 % 80-40 %LYMPHOCYTES 30% 40-20 %EOSINOPHILS 04 % 6-1 %MONOCYTES 06 % 10-2 %BASOPHILS 00 % 2-0
%PLATELET COUNT 4.0SMEAR Normocytic normochromic blood picture
COMPLETE URINE EXAMINATION (CUE) 19-07-2025 10:34:AM COLOUR Pale
yellow APPEARANCE Clear REACTION Acidic SP. GRAVITY 1.010ALBUMIN +SUGAR Nil BILE
SALTS Nil BILE PIGMENTS Nil PUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
USG OF NECK DONE ON 17/07/25
IMPRESSION
NECROTIC LYMPHNODES (AT THE SITE OF SWELLING)
TIRADS III LESION AT THE JUNCTION OF RIGHT LOBE AND ISTHMUS OF THYROID
TIRADS II LESION IN LEFT LOBE OF THROID
FNAC-IMPRESSION :
FEARURES ARE SUGGESTIVE OF FOLLICULAR NEOPLASM WITH FEW SUSPICIOUS FOCI
ADVICED EXCISION BIOPSY FOR CONFORMATION
X RAYS DONE:
X RAY NECK-AP, LATERAL VIEW
X RAY LUMBAR SPINE-AP, LATERAL VIEW
X RAY SKULL-AP, LATERAL VIEW
Treatment Given (Enter only Generic Name)
NORMAL DIET
1.TAB PAN 40 MG PO/OD BEFORE BREAKFAST
2.TAB.PCM 650MG PO/BD
3.TAB.GLIMI M2 PO/BD
4.TAB.TELMA 40MG PO/OD
5.TAB.MVT PO/OD
6.TAB.VIT C PO/OD
7.SYP ASCORYL-D 15ML /TID
8.MONITOR VITALS AND INFORM SOS
Advice at Discharge
SOFT DIET
Page-5
KIMS HOSPITALS
TAB.PAN 40 MG PO/OD
TAB.MVT PO/OD
TAB.VIT C PO/OD
REFER TO ONCOSURGEON I/V/O FOLLICULAR NEOPLASM
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/Attendant Declaration: - The medicines prescribed
and the advice regarding preventive aspects of care, when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:24/07/25
Ward: FEMALE SURGICAL WARD
Unit: IV
[29-09-2025 16.49] PPM 1: Thanks
Left axis with poor r wave progression suggesting CAD left ventricular failure high on the cards
Please share the video of her laryngoscopy
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