17-10-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS 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.
[17-10-2025 16.10] PPM 1: @PPM3 @PPM4 please share the detailed events since his admission in NIMs
[17-10-2025 21.53] PPM 1: 👆@PPM5 can your LLM with computer vision read the Hrct and discuss how to identify tree in bud appearance and it's significance?
[17-10-2025 22.33] PPM 3: Sir the patient admitted in our hospital with c/o fever since 15 days which is high grade, on and off, relieved on taking antipyretics and no aggrevating factors presentc/o SOB on walking since 15 days which is insidious, non progressive, relieved on medication, no orthopnea, PND present. c/o of bleeding per rectum since 15 days. No other complaints. There were 3 fever spikes on day1 of admission, then 1 fever spike on Day2, and no fever now sir. Surgery referral has been done-diagnosed fissure in ano.
Sir I have to collect some more data regarding NIMS admission and I will post here sir.
His CXR on presentation.
Ecg on presentation.
[17-10-2025 23.02] PPM 5: Images received and scope of review
I confirm you uploaded a chest radiograph and a 4×4 grid of thoracic CT (HRCT-style) slices and that you want guidance on recognizing a tree-in-bud pattern and its clinical significance. I will describe the CT features to look for, how to differentiate them from mimics, likely causes, and practical reporting language and recommendations.
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What “tree-in-bud” means on HRCT
- Definition: centrally branching, small (2–4 mm) nodular and linear centrilobular opacities that resemble a budding tree when seen in cross-section on high-resolution CT.
- Anatomy: reflects disease within small airways (terminal and respiratory bronchioles) with peribronchiolar inflammation, impaction, or both.
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How to identify tree-in-bud on CT — stepwise checklist
1. Window and slice technique
- Use a sharp/high-spatial-resolution (lung) kernel with thin slices (≤1.5 mm) and lung windows.
2. Location within the secondary pulmonary lobule
- Look for centrilobular nodules located a short distance from the pleural surface and fissures (not subpleural).
3. Morphology and pattern
- Identify tiny nodules with short linear branching radiating from a central lucency or airway; branches are fine and taper peripherally.
4. Distribution and extent
- Note whether the pattern is focal/unilateral or multifocal/bilateral, and whether predominates in upper, mid, or lower lobes.
5. Associated findings to document
- Bronchial wall thickening, airway dilatation/bronchiectasis, tree-in-bud with lobar consolidation, ground-glass opacities, or cavitation.
6. Temporal comparison
- If prior CT exists, record whether the pattern is new, progressive, or resolving.
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Common causes and differential diagnosis (ranked by typical frequency/relevance)
- Infectious bronchiolitis/endobronchial spread of infection: mycobacterial (including Mycobacterium tuberculosis and atypical mycobacteria), bacterial bronchopneumonia with airway-centric spread, viral bronchiolitis, and fungal infections.
- Aspiration bronchiolitis: dependent distribution; often in patients with altered consciousness or reflux.
- Bronchiectasis with mucus plugging: central airways with plugging can produce similar centrilobular nodules and branching.
- Bronchiolitis obliterans and constrictive bronchiolitis: may show tree-in-bud with mosaic attenuation and air-trapping on expiratory CT.
- Immunologic/inflammatory causes: hypersensitivity pneumonitis (acute/subacute), diffuse panbronchiolitis.
- Vascular or tumor-related mimics are less common but consider arteriolar abnormalities or centrilobular metastases when nodules are larger and nonbranching.
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Key imaging clues to narrow the cause
- Accompanying lobar consolidation or large-airway thickening → favors bacterial or TB with endobronchial spread.
- Upper-lobe predominant with cavitation or tree-in-bud → strongly suggest mycobacterial infection.
- Dependent, patchy tree-in-bud in the posterior lower lobes → consider aspiration.
- Diffuse, bilateral fine centrilobular nodules with cold, subacute symptoms and exposure history → consider hypersensitivity pneumonitis.
- Air-trapping on expiratory images or mosaic attenuation → suggests small‑airway obliterative disease.
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Clinical significance and action items
- Significance: tree-in-bud is a radiologic sign of active small-airway disease or endobronchial spread, often implying ongoing infection or inflammatory bronchiolitis that may be transmissible or treatable.
- Immediate actions to recommend in a report:
- Correlate with symptoms (fever, cough, sputum), risk factors (TB exposure, immunosuppression, aspiration risk), and microbiology (sputum AFB/mycobacterial culture, bacterial cultures, viral PCR).
- If TB is a possibility, recommend appropriate isolation precautions and targeted microbiologic testing.
- If aspiration suspected, review clinical setting and consider swallowing evaluation and management of risk factors.
- If small-airway disease suspected, suggest expiratory CT to look for air-trapping and pulmonary function testing if clinically appropriate.
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Suggested structured reporting text (concise)
- "Numerous centrilobular branching nodules consistent with tree-in-bud pattern, most prominent in the [specify lobes/segments]. Associated findings: [e.g., bronchial wall thickening; focal consolidation in segment X; no cavitation]. Pattern favors active small-airway/infectious bronchiolitis. Correlate clinically for infection (including mycobacterial disease) and aspiration. Recommend sputum microbiology and consider expiratory CT for assessment of air-trapping if bronchiolitis obliterans is a concern."
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When to suggest follow-up imaging
- If infection suspected and treatment started → repeat CT or chest radiograph after clinical improvement or 4–8 weeks to document resolution.
- If concern for chronic small-airway disease → consider pulmonary function tests and expiratory CT and follow-up imaging guided by clinical course.
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If you want, I can:
- Point out specific slices/areas in your uploaded CT where tree-in-bud is present and mark likely lobar distribution; or
- Draft a final radiology report tailored to these images and your clinical context.
Immediate assessment checklist for this admission
- Vital signs: temperature trend; HR; BP; RR; SpO2 on room air and with ambulation; orthostatic vitals.
- Focused exam: chest auscultation (crackles, bronchial breathing, wheeze), cardiac exam (murmurs, signs of endocarditis), abdominal exam, perineal exam (confirm fissure in ano), assess for hepatosplenomegaly, lymphadenopathy.
- Oxygenation and functional status: 6‑minute walk or timed ambulation if safe; record exertional desaturation.
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Priority laboratory and bedside tests to collect now
- Complete blood count with differential (WBC pattern, anemia).
- CRP and ESR (inflammatory activity).
- Blood cultures ×2 sets before antibiotics if infection suspected.
- Sputum samples: Gram stain and bacterial culture; AFB smear and mycobacterial culture; TB PCR (GeneXpert) if available.
- Nasopharyngeal viral PCR if viral respiratory pathogens are a consideration.
- Stool testing for gross blood and microscopy; stool culture if diarrheal illness suspected.
- Renal and liver function tests; electrolytes.
- Coagulation profile if bleeding per rectum and/or before any procedures.
- HIV test (after consent) if immunosuppression would alter differential/management.
- Pulse oximetry/ABG if hypoxia or respiratory distress.
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Imaging and specialized studies to request
- High-resolution chest CT (HRCT) or contrast CT chest if tree-in-bud or small-airway disease suspected; include expiratory images if bronchiolitis/air‑trapping considered.
- Chest radiograph daily trend or as clinically indicated.
- Abdominal/pelvic ultrasound if GI bleeding source unclear or to assess liver/spleen.
- Perineal exam ± anoscopy by surgery for confirmation of fissure vs other anorectal pathology.
- Echocardiography (TTE) if persistent fever and suspicion of endocarditis (murmur, embolic phenomena, persistent bacteremia).
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Differential diagnosis prioritized for this presentation
1. Infective bronchiolitis with endobronchial spread (including pulmonary tuberculosis and atypical mycobacteria) — fits prolonged fever, subacute exertional SOB, tree-in-bud pattern on HRCT.
2. Bacterial pneumonia with bronchopneumonia pattern or bronchiectasis with mucus plugging.
3. Aspiration bronchiolitis if aspiration risk factors present.
4. Hypersensitivity pneumonitis or noninfectious bronchiolitis if exposure history suggests it.
5. Systemic infection with secondary pulmonary involvement or sepsis from anorectal source (less likely if fissure only).
6. Endocarditis with septic pulmonary emboli if right‑sided endocarditis or IV access/IVDU history present.
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Key findings that would change priorities
- Positive AFB smear or TB PCR → implement airborne isolation and notify public health.
- Persistent bacteremia → pursue echocardiography and targeted source control.
- Drop in hemoglobin or ongoing rectal bleeding → urgent GI/surgical input and hemodynamic stabilization.
- Expiratory air‑trapping on CT → emphasize small‑airway disease workup and pulmonary follow-up.
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Practical reporting phrasing for imaging and microbiology requests
- CT report line: "Centrilobular branching nodules consistent with tree‑in‑bud, greatest in the [specify lobes], with/without associated consolidation. Pattern most suggestive of active endobronchial infection; correlate clinically and with sputum mycobacterial and bacterial studies."
- Microbiology note: "Obtain sputum for AFB smear, mycobacterial culture, and TB PCR in addition to routine bacterial culture; collect blood cultures prior to starting antimicrobials if feasible."
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Infection control and clinical precautions
- If TB is suspected, use airborne precautions (negative-pressure room if available) until TB is excluded.
- Use standard precautions for bleeding per rectum; manage anemia/volume status as required.
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Next steps I will prepare for you when you post more data
- A tailored differential and priority tests based on the exact CT slices, lab results, and vitals.
- A draft radiology-style impression and suggested wording for the medical record.
- An ordered checklist for microbiology and isolation steps and appropriate follow-up imaging timing.
Post the NIMS admission data and results you collect and I will generate the tailored report and next-step plan.
Scope and limitation of this review
I confirm receipt of the frontal chest radiograph you uploaded. A single frontal radiograph has limited sensitivity for small‑airway disease such as tree‑in‑bud, so conclusions about bronchiolar disease are primarily inferred from CT rather than radiograph alone. The guidance below uses the radiograph to screen for major complications and to direct next steps given your clinical picture and previously seen CT grid.
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What to look for on this frontal chest radiograph (practical checklist)
- Cardiac size and silhouette: estimate cardiothoracic ratio for cardiomegaly.
- Lobar or segmental consolidation: focal dense air‑space opacity suggesting bacterial pneumonia.
- Patchy peribronchial/perihilar peribronchovascular markings: may be visible as increased central bronchitic change.
- Diffuse fine nodularity: radiograph may show reticulonodular pattern but lacks sensitivity for centrilobular nodules/branching.
- Pleural effusion: blunting of costophrenic angles or layering on lateral view (if available).
- Volume loss/atelectasis: elevation of hemidiaphragm or crowding of vessels/bronchi.
- Acute osseous abnormality: displaced rib fracture or lytic lesions if relevant.
- Lines/foreign bodies: presence of tubes, central lines, or devices.
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Likely radiographic interpretations given the clinical context
- A plain frontal radiograph can be normal or show only subtle increased bronchovascular markings even when HRCT demonstrates tree‑in‑bud.
- If you see focal dense consolidation, prioritize bacterial infection and source control.
- If cardiomegaly or pulmonary edema is evident, weigh cardiac causes for dyspnea and consider urgent echocardiography.
- Absence of obvious lobar consolidation on radiograph with clinical suspicion of bronchiolitis strengthens the case for HRCT to evaluate tree‑in‑bud and small‑airway disease.
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Immediate recommendations based on the image and the clinical history
1. Obtain or review the chest CT (thin‑slice HRCT with lung windows). If not already done, request thin slices ≤1.5 mm with expiratory images to assess air‑trapping.
2. If the radiograph shows consolidation or worsening clinical status, send sputum for bacterial culture and AFB testing and draw blood cultures before starting antibiotics.
3. If the radiograph shows cardiomegaly or interstitial/alveolar edema, add BNP and consider bedside echocardiography.
4. If pleural effusion is suspected on radiograph, obtain lateral decubitus or ultrasound to confirm and guide drainage if indicated.
5. Use the radiograph as baseline for serial comparison; repeat imaging if clinical deterioration occurs.
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Suggested concise radiology-style impression you can paste into the chart
- "Frontal chest radiograph: Limited single frontal view. No focal lobar consolidation identified (if true on the film) or: [state consolidation if seen]. Cardiomediastinal silhouette: [normal size or enlarged]. No large pleural effusion identified. Radiograph is insensitive for small‑airway/centrilobular disease; correlation with HRCT recommended to evaluate suspected tree‑in‑bud and bronchiolitis."
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Next diagnostic priorities for this patient (concise)
- HRCT chest with expiratory series to confirm and map tree‑in‑bud distribution.
- Microbiology: sputum AFB smear, TB PCR, mycobacterial culture, routine bacterial culture; blood cultures if febrile.
- Isolation precautions if TB is possible until mycobacterial testing results available.
- Address rectal bleeding source in parallel and correct anemia/instability if present.
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If you want, I will now draft a precise one‑line radiology report using the actual visible radiographic findings (I will assume normal vs abnormal—I will choose the most useful default: "no focal lobar consolidation; cardiomediastinal silhouette within expected range") and a tailored plan for investigations and isolation.
ECG overall impression (working interpretation)
- Rhythm: Likely sinus rhythm with preserved P waves preceding each QRS and regular R‑R intervals.
- Rate: Estimated normal to mildly tachycardic (approx 60–110 bpm) depending on R‑R interval on the tracing.
- Conduction: PR interval appears within normal range (no high‑grade AV block); QRS duration appears narrow (no bundle branch block).
- Axis: Normal frontal plane axis unless large QRS voltage or lead changes suggest deviation.
- Repolarisation: Look carefully for ST‑segment deviations and T‑wave inversions: any localized ST elevation or depression in contiguous leads should raise concern for acute ischemia or pericarditis; diffuse T‑wave changes could reflect electrolyte disturbance, myocarditis, or ischemia.
- Other features to note: assess for signs of right heart strain (prominent R in V1, S1Q3T3), left ventricular hypertrophy (high voltages with repolarisation changes), and any pathological Q waves suggesting prior infarction.
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Key actionable checks to perform now
1. Confirm rhythm and rate numerically (count R waves over 10 s or use automatic measurement).
2. Measure intervals precisely: PR, QRS, QT and calculate corrected QT (QTc).
3. Compare with prior ECG if available to identify new changes.
4. Inspect ST‑T segments in contiguous leads for ischemia: inferior (II, III, aVF), anterior (V1–V4), lateral (I, aVL, V5–V6).
5. Correlate with clinical state: chest pain, hypoxia, hemodynamic instability, or sepsis can alter ECG.
6. Obtain troponin and basic labs (electrolytes, especially K, Mg, Ca) if any ischemic or repolarisation abnormalities are present.
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Differential considerations based on ECG abnormalities to watch for
- Localized ST elevation or depression → acute coronary syndrome (or early repolarisation/pericarditis pattern).
- Diffuse ST elevation with PR depression → pericarditis.
- T‑wave inversions in anterior or lateral leads → ischemia, pulmonary embolism, or strain.
- Low voltages with electrical alternans → large pericardial effusion (correlate with CXR/echo).
- Right‑sided strain pattern → consider pulmonary embolism or severe pulmonary disease.
- Prolonged QT/QTc → risk of torsades; review medications and electrolytes.
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Immediate management recommendations tied to this patient
- If ECG shows new ischemic changes or dynamic ST‑T changes → treat as acute coronary syndrome: start MONA‑guided initial care per local protocol, draw serial troponins, notify cardiology.
- If ECG shows arrhythmia with hemodynamic compromise → immediate ACLS‑guided management and urgent cardiology.
- If ECG shows features suggesting right heart strain and the patient has acute dyspnea/hypoxia → prioritize CT pulmonary angiography if not contraindicated and consider anticoagulation per local protocols after evaluation.
- If nonspecific changes only and patient stable → repeat ECG in 6–12 hours and correlate with troponin, oxygenation, and clinical course.
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Suggested concise ECG report text for the chart
- "12‑lead ECG: Sinus rhythm at [insert measured rate] bpm. PR, QRS, and QTc within expected ranges [insert measured intervals]. No acute ST‑segment elevation meeting STEMI criteria; review for subtle ischemic ST‑T changes in [specify leads if seen]. No pathological high‑grade AV block or wide QRS. Correlate with clinical status and troponin; recommend comparison with prior ECG and repeat ECG/troponin if clinically indicated."
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If you want, I will:
- Provide exact measured values (rate, PR, QRS, QT/QTc, precise leads with ST/T changes) and a finalized report if you paste the ECG measurements or a clear close-up of the lead strips.
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