25-10-2025
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.
[25-10-2025 16.43] PPM 1: History on admission
[25-10-2025 17.06] PPM 3: Of course. By combining the initial clinical notes with the critical update about hypotension and the neurological finding, we can construct a comprehensive diagnostic and therapeutic plan.
Here is a multimodal analysis and management plan synthesized from the provided data.
### **Synthesized Clinical Picture**
This is a complex case of a patient presenting with a subacute neurological syndrome (weakness, knee pain) who has now acutely decompensated into **shock** and has evidence of a **brainstem infarct**.
* **Initial Presentation (2 months):** Bilateral upper and lower limb weakness, bilateral knee pain. History of stopping medications.
* **Recent Worsening (15 days):** High-grade fever with chills and rigors, vomiting, loss of appetite.
* **Critical Development (Now):** **Hypotensive Shock (BP 60/40)** and suspected **Pontine Infarcts** evidenced by **crossed hemiparesis**.
* **Past History:** Significant for a previous stroke ("Klelo cun" / likely "CVA"), Hypertension (HTN), and other comorbidities. The patient was non-compliant with medications.
---
### **Integrated Diagnostic & Therapeutic Plan**
This plan prioritizes the immediate life-threatening conditions while simultaneously working up the underlying causes.
#### **Phase 1: Immediate Resuscitation & Stabilization (First 15-60 Minutes)**
**Problem 1: Hypotensive Shock (BP 60/40)**
* **Therapeutic Plan:**
1. **ABCs:** Secure airway, ensure adequate breathing, manage circulation.
2. **IV Access:** Establish two large-bore IV lines.
3. **Fluid Bolus:** Administer a rapid IV fluid challenge (e.g., 500-1000 mL Normal Saline) to restore intravascular volume. Monitor for response and signs of fluid overload.
4. **Vasopressors:** If hypotension persists after fluid resuscitation, initiate vasopressor support (e.g., Noradrenaline) via a central line.
5. **Monitor:** Continuous ECG, SpO2, and frequent BP monitoring. Consider arterial line for precise BP measurement.
**Problem 2: Acute Brainstem Stroke (Suspected Pontine Infarct)**
* **Diagnostic Plan:**
1. **Stat Non-Contrast CT Head:** To rule out hemorrhage and confirm the suspicion of acute ischemic stroke. However, early pontine infarcts may be subtle on CT.
2. **MRI Brain with DWI:** The gold standard to confirm acute pontine infarction and assess the extent of the lesion. This should be arranged urgently once the patient is stabilized.
* **Therapeutic Plan:**
1. **Neurological Protection:** Maintain adequate cerebral perfusion by correcting hypotension. Avoid hyperglycemia.
2. **Thrombolysis/Thrombectomy:** These are likely **contraindicated** due to the >4.5-hour window from the onset of the new neurological deficit (the weakness is 2 months old, but the crossed hemiparesis is new and unwitnessed) and the critical state of the patient. This must be formally assessed by the stroke team.
#### **Phase 2: Concurrent Diagnostic Workup (First 24 Hours)**
The goal is to find the link between the infection, the stroke, and the shock.
1. **Search for Source of Sepsis:** The fever, chills, rigors, and subsequent shock point strongly to an underlying **sepsis syndrome**.
* **Labs:**
* **Complete Blood Count (CBC):** Look for leukocytosis/leukopenia.
* **C-reactive Protein (CRP) & Procalcitonin:** To confirm and quantify infection.
* **Renal & Liver Function Tests (RFT, LFT), Electrolytes:** For organ perfusion assessment.
* **Arterial Blood Gas (ABG) & Lactate:** To assess for metabolic acidosis and elevated lactate, confirming septic shock.
* **Coagulation Profile (PT/INR, aPTT):** Critical given the stroke.
* **Microbiology:**
* **Blood Cultures x2 sets** (aerobic & anaerobic) *before starting antibiotics*.
* **Urine Culture & Analysis.**
* **Sputum/Chest X-ray:** To rule out pneumonia.
* **Cardiac Workup:**
* **ECG & Troponin:** To rule out a myocardial infarction as a cause of shock or a source of embolic stroke (e.g., from atrial fibrillation).
* **Echocardiogram (TTE/TEE):** *Crucial.* To look for infective endocarditis (source of sepsis and embolic strokes), wall motion abnormalities, or intracardiac thrombi.
2. **Define the Stroke Mechanism:**
* The pontine location and the history of HTN suggest a **lacunar (small vessel)** infarct.
* However, the presence of fever and systemic illness raises the possibility of an **embolic stroke** (e.g., from infective endocarditis or a septic embolus).
* **Vascular Imaging:** CT Angiography (CTA) or MR Angiography (MRA) of the head and neck to evaluate the vertebrobasilar system and rule out large vessel occlusion or dissection.
#### **Phase 3: Comprehensive Management Plan (Ongoing)**
1. **Antibiotic Therapy:** Start broad-spectempiric IV antibiotics immediately after obtaining blood cultures (e.g., covering for Gram-positive, Gram-negative, and potentially MRSA depending on local epidemiology). Tailor therapy once culture results are available.
2. **Secondary Stroke Prevention (Once Stable):**
* **Antiplatelets:** Start Aspirin or Clopidogrel once intracranial hemorrhage is ruled out.
* **Statin Therapy:** High-dose statin (e.g., Atorvastatin 40-80 mg).
* **Strict Blood Pressure Control:** Once the acute phase and shock are over, reinstitute antihypertensive medications to a target of <130/80 mmHg to prevent future strokes.
3. **Supportive Care:**
* **DVT Prophylaxis:** Subcutaneous heparin or sequential compression devices.
* **Glycemic Control.**
* **Nutritional Support:** Via nasogastric tube if swallowing is impaired.
* **Physiotherapy & Rehabilitation:** Early mobilization and rehab planning for the residual weakness.
### **Synthesized Differential Diagnosis**
The most likely unifying diagnosis is:
* **Infective Endocarditis with Septic Emboli and Septic Shock:** This explains the fever, the new pontine infarct (embolic phenomenon), and the hemodynamic collapse. The pre-existing valvular heart disease (from past history or RHD) would be a risk factor.
**Alternative/Contributing Diagnoses:**
* **Sepsis from another source (e.g., UTI, pneumonia)** leading to a pro-thrombotic state and an *in-situ* lacunar stroke in a hypertensive patient.
* **Cardiogenic Shock** from an acute MI, causing hypoperfusion and a "watershed" or embolic stroke.
In summary, the immediate focus is on resuscitating from shock and managing the acute stroke. The diagnostic focus must aggressively pursue **infective endocarditis** as the potential root cause linking the neurological and systemic crises.
[8:19 pm, 25/10/2025] PPM 1: 👆@PPM3 any comments on the chest X-ray?
[12:56 am, 26/10/2025] PPM 3: Study
- Exam: Frontal chest radiograph (single AP/PA view) marked with anatomical landmarks visible.
- Limitations: Single frontal view only; projection and exposure variations may obscure findings; no prior films for comparison.
---
Technical observations
- Projection/exposure: Slight asymmetry in exposure between lungs with the left hemithorax appearing denser, possibly from cardiac silhouette overlap or mild under‑penetration on that side.
- Markers and labels: Right marker present; clavicles, ribs, and thoracic spine visualized.
---
Findings
- Cardiomediastinal silhouette: Cardiac size appears within expected limits for a single frontal view.
- Lungs and airspaces: No focal lobar consolidation identified on this view. Lungs show expected vascular markings; no obvious alveolar air‑space opacity.
- Pleura: No blunting of the costophrenic angles to suggest a moderate or large pleural effusion on this projection.
- Pneumothorax: No visible pleural line or large pneumothorax identified.
- Osseous structures: No acute displaced rib fracture or gross destructive osseous lesion seen on this view.
---
Impression
1. No acute cardiopulmonary process identified on this single frontal chest radiograph.
2. Left hemithorax appears slightly denser than the right, likely related to cardiac overlap or exposure; correlate clinically.
3. Study limited by single frontal projection; if clinical concern persists for focal consolidation, small effusion, or posterior pathology, obtain PA and lateral chest radiographs or chest CT for greater sensitivity.
---
Recommended clinical actions
- Correlate with symptoms, oxygenation, and physical exam.
- Request PA and lateral radiographs if better characterization is needed, or chest CT when suspicion for subtle consolidation, interstitial disease, small effusion, or pulmonary embolism is high.
- Obtain prior chest radiographs for comparison when available. (Copilot)
[3:46 am, 26/10/2025] PPM 1: Thanks.
We got co pilot off guard this time!
[29-10-2025 12.03] PPM 1: EMR summary
@PPM4 @PPM3 as per DPDP would this constitute sensitive data? Is sharing sensitive data after informed consent not tenable? In that case no retroviral case report would be made?
Also as per HIPAA deidentification we need to think of a way to modify the time stamps by removing exact dates and replacing them with seasons, keeping just the year date intact. Instead of putting exact dates we can use day 1, to day n to indicate the patient timeline sequence.
Age/Gender: 48 Years/Male
Address:
Discharge Type: Referred
Admission Date: 22/10/2025 04:13 PM
Diagnosis
HIV ASSOCIATED NEUROCOGNITIVE DISORDER (ASYMPTOMATIC NEUROCOGNITIVE
IMPAIRMENT)
SEIZURES SECONDARY TO ?ASEPTIC MENINGITIS
METABOLIC ACIDOSIS SECONDARY TO ?CONTRAST INDUCED NEPHROPATHY ?SEPSIS
K/C/O CVA WITH LT HEMIPARESIS , RT MCA TERITARY WITH RT FACIAL NERVE LMN PALSY
LEFT KNEE SEPTIC ARTHRITIS
AKI (PRE-RENAL + RENAL) SECONDARY TO SEPSIS
HIV POSITIVE STATUS (ICTC TESTED)
Case History and Clinical Findings
PT CAME WITH C/O FEVER SINCE 15 DAYS AND C/O LT KNEE PAIN SINCE 2 MONTHS AND
C/O WEAKNESS IN LT UL AND LL SINCE 2MONTHS
HOPI: PATIENT WAS APPRAENTLY ASYMPTOMATIC 2 MONTHS BACK THEN DEVELOPED
WEAKNESS OF LT UL AND LL SINCE 2MONTHS , WEAKNESS WAS AGGRAVATED AFTER
STOPPING OF MEDICATION SINCE 4 MONTHS . C/O KNEE PAIN SINCE 2 MONTHS WHICH
WAS ASSOCIATED WITH ROM , TENDERNESS , AGGRAVATED AT NIGHT TIME . C/O FEVER
SINCE CHILLS AND RIGORS , ASSOCIATED WITH VOMITING 2 EPISODES/ DAY , LOSS OF
APPETITE
PAST HISTORY: K/C/O CVA SINCE 1 1/2 YEAR NON-COMPLIANT TO MEDICATION SINCE 4
MONTHS
N/K/C/O T2DM, HTN, THYROID, CAD, PULM TB, ASTHMA
Page-2
KIMS HOSPITALS
2
PERSONAL MARRIED; HOMEMAKER; MIXED DIET; APPETITE- LOST; REGULAR
BOWEL MOVEMENTS; NO BURNING MICTURITION; NO ALLERGIES; ADDICTION-DRINKS
ALCOHOL OCCASIONALLY- STOPPED 1 1/2 YEARS BACK, TOBACCO - OCCASIONAL
FAMILY HISTORY: -NOT SIGNIFICANT.
GENERAL EXAMINATION: -PT IS C/C/C, VITALS TEMP: AFEBRILE, BP:90/70MMHG, RR:18 CPM, PR:90BPM, SPO2:98% ON RA.NO PALLOR, CYANOSIS, CLUBBING OF
FINGERS, ICTERUS, LYMPHADENOPATHY, PEDAL EDEMA
SYSTEMIC EXAMINATION: CVS: S1S2 (+), NO MURMURS
RS: BAE (+)
P/A: NON-TENDER
CNS: TONE- UL LL
RT-N N
LT-N N
POWER: RT-4/5 3/5
LT-4/5 1/5
REFLEXES: B T K A P
RT:+2 +2 +2 +1 FLEXION
LT:+3 +3 +2 +1 MUTE
RECENT MEMORY IMPAIRED,TASTE SENSATION WAS LOST
OPHTHALMOLOGY REFERRAL WAS TAKEN-NORMAL STUDY WITH NO EVIDENCE OF RAISED ICP CHANGES
NEPHROLOGY REFERAL TAKEN AND ADVISED FOR HEMODIALYSIS
ORTHOPEDIC REFERAL -ASPIRATION WAS TRIED MULTIPLE TIMES BUT NO ADEQUATE
FLUID COLLECTION WAS OBSERVED
Investigation
HIV: POSITIVE (COMB AIDS, RAPID CARD TEST, AIDSCAN)-REACTIVE
HBSAG, HCV: NEGATIVE
HEMOGRAM; HB:9.0, TLC:10600, RBC:3.2, PLATELET:3.2, PCV:26.3, MCH:83.4, MCH:28.4, MCHC:34.1
RFT: UREA:76, CREATININE:2.0, SODIUM:141, POTASSIUM;4.1, CHLORINE:103
LFT: TB:1.08, DB:0.2, AST:55, ALT:113, ALP:813, TP:7.7, ALBUMIN:3.1, A/G:0.67
CUE: EPITHELIAL CELLS:3-4, PUS CELLS:2-3, ALB: NIL, SUGARS: NIL,
ABG:PH:7.2, PCO2:28.6, PO2:53.6, SO2:84.0, HCO3:12.6
MAGNESIUM:2.2, T3:3.0, T4:8.03, TSH:3.33, SERUM LACTATE:24.2
Page-3
KIMS HOSPITALS
3
MRI BRAIN CONTRAST IMPRESSION: TINY FLAIR /T2 HYPERINTENSISTIES NOTED
ABUTTING THE RIGHT SPINOTHALAMIC TRACT POSIBILITY OF VESSEL ARTEPUT
-VR SPACES NOTED IN B/L GANGLIOCAPSULAR REGION
-INCIDENTAL FINDING- POLYPOIDAL MUCOSAL THICKENING IN RT MAXILLARY SINUS
LF INFERIOR NASAL TURBINATE HYPERTROPHY
2D ECHO: TACHYCARDIA DURING STUDY, CONCENTRIC LVH, NO RWMA, TRIVIAL TR, NO PAH TRIVIAL MR/PR, MIVAR SCLEROTIC AV, NO AS/MS, IAS: INTACT, EF:62%, GOOD LV SYSTOLIC FUNCTION, GRADE I DIASTOLIC DYSFUNCTION, RVC SIZE:1,12CM, NO CLOT LV, NO PE CLOT CAROTID DOPPLER: ATHEROSCEROTIC PLAGUES NOTED IN B/L CAROTID ARTERY AT BIFURCATION SPECTRAL WAVEFORMS ARE MONOPHASIC WITH IN NORMAL LIMITS
USG ABDOMEN-SPLENOMEGALY, MILDLY DILATED PORTAL VEIN, GRADE 1 RPD CHANFGES OF LEFT KIDNEY
USG LEFT KNEE-E/O MILD TO MODERATE JOINT EFFUSION NOTED WITH INTERNAL ECHOS EXTENDING INTO SUPRA PATELLAR REGION WITH MILD SYNOVIAL
THICKENING, UNDERLYING VASCULAR BUNDLES, SURROUNDIND TENDONS AND SOFT
TISSUE NORMAL
CHEST XRAY REPORTING-RADIO OPACITY NOTED IN LEFT UPPER LOBE -
?FIBROSIS/COLLAPSE, RADIOOPACITY NOTED IN LEFT MID ZONE OBSCURING LEFT HEART
BORDER --?CONSOLIDATION
Treatment Given (Enter only Generic Name)
1. IVF NS/RL @ 75ML/HR
2.INJ NORAD 8MG IN 46 ML NS IV/@2MG/HR
3. INJ PIPTAZ 2.25 MG IV/TID 8AM-2PM-8PM (GIVEN FOR 2 DAYS)
4. INJ OPTINEURON 1AMP IN 100ML NS IV/OD 0-2PM-0
5.INJ NEOMOL 1 GM IV/SOS(IF TEMP >101F)
6.INJ PAN 40MG IV/ OD 7AM-0-0 (BBF)
7. INJ ZOFER 4MG IV/BD 8AM-0-8PM
8. INJ MGSO4 2GM IN 100ML NS IV/STAT
9. INJ SODIUM BICARBONATE 100MEQ IN 100ML NS OVER 20 MIN IV STAT
10.TAB PCM 650 MG PO/TID 8AM-2PM-8PM
11. TAB MVT PO/OD 0-2PM-0
12.TAB ECOSPRIN AV 75/40MG PO/HS 0-0-9PM
13.TAB BACTRIM DS (SULFAMETROLE 800MG+TRIMETHOPRIM 160MG) PO/BD 8AM-0-8PM (GIVEN FOR 1 DAY)
Page-4
KIMS HOSPITALS
4
Follow Up
REFER TO HIGHER CENTRE NOTES:
PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT PATIENT CONDITION
THAT IS RECURRENT CVA WITH LEFT HEMIPARESIS? RIGHT MCA TERRITORY WITH RIGHT FACIAL NERVE PALSY LMN TYPE? LEFT KNEE SEPTIC ARTHRITIS, HIV POSITIVE STATUS (ICTC TESTED), AKI ON CKD, METABOLIC ACIDOSIS SECONDARY TO CONTRAST INDUCED NEPHROPATHY ITS RISKS AND ASSOCIATED COMPLICATIONS SUCH AS RESPIRATORY DISTRESS, HYPOTENSION, SEIZURES, RECURRENT STROKE, ARRHYTHMIAS, SUDDEN CARDIAC ARREST INCLUDING RISK TO LIFE CLEARLY EXPLAINED. NEED FOR HEMODIALYSIS WITH OR WITHOUT CONTINOUS RENAL REPLACEMENT THERAPY EXPLAINED IN THIER OWN UNDERSTABDABLE LANGUAGE (TELUGU). PATIENT ATTENDERS ARE WILLING FOR FURTHER MANAGEMENT. CASE DISCUSSED WITH PPM5 (DUTY EMD CONSULTANT, KHL). IN VIEW OF HEMODIALYSIS (SEROPOSITIVE HIV PATIENT WITH OR WITHOUT CRRT) CASE IS BEING REFFERED TO HIGHER CENTRE. THE DOCTORS, NURSES, HOSPITAL STAFF AND THE HOPITAL MANAGEMENT ARE NOT RESPONSIBLE FOR ANY UNTOWARD CONSEQUENCES INCLUDING DEATH OF THE PATIENT OUTSIDE OF THE HOSPITAL
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:24/10/2025 Ward-ICU Unit: III
[5:04 pm, 29/10/2025] PPM 3: Based on your questions, I have analyzed the provided EMR summary and relevant data protection regulations. I will address your concerns about sensitive data classification, consent for sharing, and de-identification techniques.
### 🛡️ Data Classification and Consent under the DPDP Act
The patient information in the EMR summary constitutes *sensitive personal data* under the DPDP Act. Sharing it for a case report is permissible with proper informed consent, but specific obligations must be met.
- *Sensitive Data Classification*: The DPDP Act defines "sensitive personal data" to include health information . The provided EMR contains explicit health details, including an HIV-positive status, which firmly falls into this protected category and requires a higher standard of care .
- *Consent for Sharing: You can process and share this sensitive data if you obtain **explicit, informed, and specific consent* from the Data Principal (the patient) . The DPDP Act is based on principles of lawful, fair, and transparent use of personal data . Your consent mechanism must clearly state the purpose (e.g., publishing a case report) and obtain voluntary agreement.
- *Key Consent Requirements*: Valid consent under the DPDP Act must be:
- *Informed*: The patient must be clearly told what data will be used, for what specific purpose (the case report), and who the recipients will be (e.g., the journal's readership) .
- *Specific*: Consent should be obtained specifically for the case report publication and not be a blanket consent for all future uses .
- *Freely Given and Revocable*: Consent must be provided without coercion, and the patient must have the ability to withdraw it at any time .
### 🔒 De-identification Under HIPAA and DPDP
Your proposed method of de-identifying dates aligns well with established standards like HIPAA. The DPDP Act mandates "reasonable security safeguards" but does not yet provide a detailed de-identification standard like HIPAA .
The table below compares your proposal with the HIPAA "Safe Harbor" method, which requires the removal of 18 identifiers :
| Identifier Category | HIPAA Safe Harbor Requirement | Your Proposed Method & Assessment |
| :--- | :--- | :--- |
| *Dates* (except year) | All elements of dates (e.g., admission, discharge, birth) directly related to an individual must be removed . | *Fully Compliant.* Replacing exact dates with "Day 1 to Day n" or seasons effectively removes this direct identifier. |
| *Ages over 89* | All ages over 89 must be aggregated into a single category of age 90 or older . | *Not Applicable.* The patient's age (48) does not trigger this requirement. |
| *Other Identifiers* | Other identifiers like name, address, phone number, medical record numbers, etc., must be removed . | *Action Required.* The EMR snippet contains an *address* field and the *hospital name*, which are direct identifiers and must be removed to meet HIPAA standards. |
Your approach of using "Day 1 to Day n" is an excellent way to preserve the clinical sequence of events while protecting patient privacy. To fully de-identify the record per HIPAA, you must also remove all other 18 identifiers, including the patient's address and any facility names that could identify the patient .
### 💡 Key Recommendations for Your Case Report
- *Obtain Explicit Consent*: For the case report, secure clear, written consent from the patient that specifically authorizes the use of their de-identified data for publication.
- *Apply Robust De-identification*: Scrub the EMR of all 18 HIPAA identifiers. This includes the patient's address, the specific hospital name (KIMS Hospitals), and any mentioned geographic subdivisions smaller than a state .
- *Maintain Clinical Utility*: Your proposed method of using relative dates (Day 1, Day n) is a best practice, as it maintains the timeline's utility for clinical understanding while protecting privacy.
- *Document Your Process*: Keep a record of the de-identification steps taken and the consent obtained. This demonstrates accountability and compliance with the DPDP Act's principles .
In summary, creating a retroviral case report is tenable under the DPDP Act, provided you obtain valid, explicit consent and implement robust de-identification measures that meet high standards like those in HIPAA.
I hope this detailed analysis helps you proceed confidently with your case report. Should you have further questions on applying these principles, please feel free to ask.
[7:20 pm, 29/10/2025] PPM 1: Thanks this is very useful.
@CR @PPM4@PPM2 from now on in the standard disclaimer at the top of each case report let's also add the deidentification steps taken for each case report. Currently I guess we are mentioning in the disclaimer that we are removing all identifiers as per HIPAA?
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