55F Back Pain 6 years Telangana PaJR

                               

06-08-2024

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.

In this case our patient is a 55 yr old female suffering with backache and pain in the legs. She shared that she has back pain while getting up from the bed. Sometimes feels pain in the shoulder and neck region. She also experienced pain while folding legs.

9 yrs back the patient had fallen while coming out of the washroom after a head bath and again fell down from the horse during her visit to Srinagar 5 yrs ago. She is also suffering with corns in her feet.

 [8/7, 10:06 AM] PaJR Coordinator: Please kindly start posting current symptoms

[8/7, 10:06 AM] PaJR Moderator: Describe how she feels in the morning immediately after getting up from bed 

Please kindly describe her daily routine from getting up in the morning hour by hour

[8/7, 10:06 AM] PaJR Coordinator: Since when?

[8/7, 10:06 AM] Patient Advocate: For last seven years

[8/7, 10:06 AM] PaJR Coordinator: Can you share her hourly daily routine before seven years when she was presumably living a normal life?

Let me share some examples in links below to demonstrate the structure of information, slotted into hourly slots we would need to proceed further in our evaluation 👇

Example 1 normalcy illustrated in another patient:

6.30 am: woke up and got prepared for morning Walk 

7.30 am: came home and went to bath 

8.00 am: students came of class 9 & class 7 and studied, drank cow milk with Proteinex 

9.15 am: had lunch with rice, dal, mixed sabji and omelette curry 

9.30 am: Did some household work 

10.00 am: Went to school 

2.00 pm: Returned home and slept 

3.30 pm: Ate ruti , 1spoon jaggery with milk and slept again

5.00 pm: Woke up, students came and studied 

7.30 pm: Went for tuition to teach, drank milk tea without sugar and 2 biscuits 

8.45 pm: Went for rehearsal of drama.

10.00 pm: Came home and had dinner, rice, fish, dal, sabji 

10.15 pm: Did some work 

11.30 pm: Slept

Another backache patient's hourly activities:

8.00 AM - Wakeup time

8-8.30 AM - Freshup

9.00 AM - breakfast (2 idly + 2 vada + chutney) + one cup tea

9.30 - 1 PM - Client work on system

2 PM- Lunch (chicken biryani approximately 300 grams)

2.45-4.30 PM - Sleeping

4.45-5.30 PM - Went out on a casual walk of approximately 1.5 km

5.45 PM - 2 muffins + one cup coffee

6. PM- 9 PM - System work

9.20 PM - Dinner (chicken biryani approximately 200 gm)

Note- The pain she had in the lower back on the left side area seems to have returned and is bothering in the same way like it did a week ago. Experiencing pain / discomfort in that area on deep breath and also when stretching body.

https://userdrivenhealthcare.blogspot.com/2024/02/pajr-telugu-guidelines-for-sharing.html?m=1

[8/7, 10:06 AM] Patient Advocate: Daily routine 

7:30 Am wake-up light exercise 

8:00 drinking water 2 glass

8:00 eat dry fruits walnut 4 or almonds 6 or sunflower seeds and pumpkin seeds occasionally 

9:00 drinking tea or coffee 

10:00 preparing breakfast for 30 mins standing in kitchen 

10:30 to 11:00 breakfast idly 3 or dosa 2 or pesarattu1

12:30 to 13:00 drinking of water 1.5 glass

13:00 Cooking of lunch for an hour standing in kitchen 

14:00 to 14:30 Lunch rice with dal/ veg. curry 

or egg weekly or chicken occasionally 

16:00 to 17:30 relaxing / sleeping 

18:00 Drinking water 2 glass

 Eating snacks sometimes 

18:00 watching TV or drying of clothes on terrace by climbing steps

20:30 light dinner 

21:00 watching TV or domestic work

22:30 sleeping 

(before 23:00)

[8/7, 10:06 AM] Patient Advocate: This is recent routine

[8/7, 10:06 AM] PaJR Coordinator: Was this yesterday's routine or is this an average routine of last 7 years?

[8/7, 10:06 AM] PaJR Coordinator: If yesterdays then please tell us in which of these hourly slots, did she experience pain

[8/7, 10:06 AM] Patient Advocate: She feels pain complete day it is high during standing for one hour or more and during forward bending, walking, sittings and standing

[8/7, 10:06 AM] PaJR Coordinator: If recent then please tell us in which of these hourly slots, did she experience pain

[8/7, 10:06 AM] Patient Advocate: Pain is high while lifting heavy items

[8/7, 10:06 AM] PaJR Coordinator: Yesterday in which hours did the pain become high and how long was it high?

[8/7, 10:06 AM] PAJR moderator: So is the pain not fluctuating but remaining constant every day?

[8/7, 10:06 AM] Patient Advocate: Unable to discriminate the pain as you asked

[8/7, 10:07 AM] PaJR Coordinator: We need to see her recent X-ray of lumbo sacral spine lateral view and AP view along with sacroiliac joints.

If it's done already, please share here if possible

[8/7, 10:07 AM] PaJR Coordinator: Had to delete the documents to protect the patient's privacy

Please remove all identifiers before sharing anything online

[8/7, 10:07 AM] patient advocate: Ok sir

She has been taking Telmisartan & Chlorthalidone 40+12.5mg one tablet in the morning for BP (for information)

[8/7, 10:07 AM] PaJR Coordinator: We need to see the x-ray films and not just the reports

Also please share the x-ray of her sacroiliac joints if available

[8/7, 10:07 AM] PaJR Coordinator: Medication was not given prior to X Ray

[8/7, 10:07 AM] Patient Advocate: Report of this X Ray ls not available, only print outs was seen by Dr.

[8/7, 10:07 AM] PaJR Coordinator: Wondering what those white fluffy opacities are in the pelvis! Let's hope they are artifacts but it will be very difficult to believe that till we can repeat and confirm that they were indeed artifacts!

Only the radiologist who supervised the x-ray at that time can confirm or we may need to repeat

[8/7, 10:07 AM] Patient Advocate: Thank you very much sir

[8/7, 10:07 AM] PaJR Coordinator: Please share the report of this x-ray! Was any medication given prior to this procedure? Medication such as barium sulfate?

[8/7, 10:07 AM] Patient Advocate: Please suggest type of tests or X Ray required for investigation and confirmation of artifacts

[8/7, 10:07 AM] Patient Advocate: Can you please guide X Ray operator on phone for better results

[8/7, 10:07 AM] PaJR Coordinator: Ok sir

[8/7, 10:07 AM] PaJR Coordinator: 👆Ask your local radiologist to repeat the x-ray in this view

[8/7, 10:07 AM] PaJR Coordinator: Report being sent

[8/7, 10:07 AM] PaJR Coordinator: The name that is visible on the x-ray, is it of the doctor or the patient?

[8/7, 10:07 AM] PaJR Coordinator: Appears to be a paraspinal muscular pain

Can you test her trunkal muscle flexion as instructed in this video linked below and take a deidentified video of the patient's trunkal muscle test and share it in your own link here?

Standard trunkal/back muscle power testing👇

https://youtu.be/H3AxTxLP7zE?feature=shared

[8/7, 10:07 AM] Patient Advocate: Good Idea but the patient needs to cover the entire face and head for deidentification perhaps

[8/7, 10:07 AM] PaJR Coordinator: Excellent work @⁨Pajr_member⁩ 👏👏

@⁨PaJR Coordinator⁩ @pajr_member please hire him as our trainee volunteer if he agrees. 

He has the potential to be a great patient advocate to many more patients one day.

The videos and the event timeline that you finally shared for us has made it so much easier to nail the diagnosis for her backache!

It's likely to be due to lumbosacral strain, which is often exacerbated with injury and muscle weakness along with spondylotic changes.

So to reverse her current issues we need to work on her back muscle strengthening as well as prevent further back injury.

Wish her videos could be shared widely if not for our patient deidentification clause as the videos are showing her face although again if the patient provides signed informed consent we can prepare the case report accordingly.

@⁨pajr_trainee⁩ is our top case reporter who is also likely to embark on a PhD in "user driven healthcare" soon. It's a name we have given to this entire process. Can check her work in her learning portfolio here:

https://24fpatientblog.blogspot.com/?m=1 and if you agree she can guide you as to how to prepare your patient's case report.

Hope to see your patient improving her muscle function with guided physiotherapy and a good end point will be when she's able to reach Grade 5 (more here: https://www.physio-pedia.com/Manual_Muscle_Testing:_Trunk_Flexion?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal)

and lose her pain too!

[8/7, 10:07 AM] Patient Advocate: Sir 

Trunkal muscle test carried and found that she unable to perform great3 test

However she could lift her head as in great2 test

[8/7, 10:07 AM] PaJR Coordinator: Ok

[8/7, 10:07 AM] Patient Advocate: Drinking 2 glass of water

[8/7, 10:07 AM] Patient Advocate: 600ml water

[8/7, 10:07 AM] PaJR Coordinator: 👍

[8/7, 10:07 AM] Patient Advocate: Drinking coffee

[8/7, 10:07 AM] PaJR Coordinator: Would be nice if you could provide informed consent to @⁨PaJR Coordinator⁩ @⁨Pajr_trainee⁩ through this form which you can download and sign from here: https://medicinedepartment.blogspot.com/2020/05/informed-patient-consent-and.html?m=1 so that she can prepare her case report. Please check the other case reports in her portfolio

[8/7, 10:07 AM] PaJR Coordinator: పండ్లు మరియు కూరగాయల కంటే చాలా ఎక్కువ తృణధాన్యాలు ఉన్నట్లు కనిపిస్తుంది.

సలాడ్లు ఎక్కువగా వేసి తృణధాన్యాలు తగ్గించవచ్చా?

Plēṭ‌lō paṇḍlu mariyu kūragāyala kaṇṭē cālā ekkuva tr̥ṇadhān'yālu unnaṭlu kanipistundi.

Salāḍlu ekkuvagā vēsi tr̥ṇadhān'yālu taggin̄cavaccā?

The plate appears to contain a lot more cereals than fruits and vegetables.

Can we add more salads and reduce the cereals?

మన శరీర బరువు పెరగకుండా మరియు మన పొట్ట పొడవు 80 సెం.మీ కంటే తక్కువగా ఉండేలా మన ఆహారం ఉండాలి. ఏమి తినకూడదు? చక్కెర మరియు పిండితో కూడిన ఆహారం పూర్తిగా నిలిపివేయబడింది. బిస్కెట్లు మరియు బ్రెడ్ పిండితో తయారు చేస్తారు, కాబట్టి బిస్కెట్లు మరియు బ్రెడ్ తినడం మానేయండి. నెలకు 500 గ్రాముల కంటే ఎక్కువ నూనె వినియోగించరాదు. ఏమి తినాలి ఫుడ్ ప్లేట్‌లో 40% వివిధ ఆకుపచ్చ కూరగాయలు మరియు 10% వివిధ రంగుల పండ్లు. మిగిలిన సగంలో బియ్యం, గోధుమలు మొదలైన తెల్లటి గింజలు మరియు దుంపలు (బంగాళదుంపలు) ఉంటాయి.

Our diet should be such that our body weight does not increase and our stomach length is less than 80 cm. What not to eat? Sugary and starchy food is completely stopped. Taya with biscuits and bread flour (translated by Google)

Mana śarīra baruvu peragakuṇḍā mariyu mana poṭṭa poḍavu 80 seṁ.Mī kaṇṭē takkuvagā uṇḍēlā mana āhāraṁ uṇḍāli. Ēmi tinakūḍadu? Cakkera mariyu piṇḍitō kūḍina āhāraṁ pūrtigā nilipivēyabaḍindi. Biskeṭlu mariyu breḍ piṇḍitō tayāru cēstāru, kābaṭṭi biskeṭlu mariyu breḍ tinaḍaṁ mānēyaṇḍi. Nelaku 500 grāmula kaṇṭē ekkuva nūne viniyōgin̄carādu. Ēmi tināli phuḍ plēṭ‌lō 40% vividha ākupacca kūragāyalu mariyu 10% vividha raṅgula paṇḍlu. Migilina saganlō biyyaṁ, gōdhumalu modalaina tellaṭi gin̄jalu mariyu dumpalu (baṅgāḷadumpalu) uṇṭāyi.

https://medicinedepartment.blogspot.com/2023/10/healthy-harvard-plate-in-telugu.html?m=1

మీరు మీ రోగి యొక్క రోజువారీ గంట కార్యకలాపాలను దిగువ స్లాట్ చేయబడిన పద్ధతిలో పంచుకోగలరా? 👇

నవీకరించబడింది 

Can you share your patient's daily hourly activities in the manner slotted below? 👇

Updated

8.30 AM - మేల్కొనే సమయం

Time to wake up

8.30-9 AM - ఫ్రెషప్

Freshup

9.30 AM - అల్పాహారం (6 వడ + చట్నీ)+ ఒక కప్పు కాఫీ

Breakfast (6 vada + chutney) + a cup of coffee

10 AM - 1 PM - క్లయింట్ కాల్స్

Client call

1.45 PM- మధ్యాహ్న భోజనం (3 కప్పుల అన్నం + చికెన్ కర్రీ సుమారు 300gm)

Lunch (3 cups of rice + chicken curry approx 300gm)

2.15-5.30 PM - క్లయింట్ పని కొనసాగుతుంది

Client work continues

6 PM - 2 మఫిన్లు + ఒక కప్పు టీ

2 muffins + a cup of tea

6. PM- 9PM- సిస్టమ్‌లో క్లయింట్ పని

Client work in the system

9.30 PM - రాత్రి భోజనం (2 కప్పుల అన్నం + చికెన్ కర్రీ సుమారు 200gm)

Dinner (2 cups of rice + chicken curry approx 200gm)

గమనిక- దిగువ ఎడమవైపు నొప్పి రోజంతా ముఖ్యమైనది. అతను తరచుగా విరామాలలో వేడి నీటి సంచితో స్థానిక హీట్ అప్లికేషన్ చేయడానికి ప్రయత్నించాడు. ఈ రోజు ఉదయం నిద్ర లేవగానే కొంచెం బెటర్ అని చెప్పాడు, బహుశా నిన్న హీట్ అప్లికేషన్ వల్ల కావచ్చు.

Note- Lower left side pain is significant throughout the day. He tried local heat application with a hot water bag at frequent intervals. He said he was a little better when he woke up this morning, maybe yesterday 

https://userdrivenhealthcare.blogspot.com/2024/02/pajr-telugu-guidelines-for-sharing.html?m=1

[8/7, 10:07 AM] patient advocate: Drinking 2 glass of water

[8/7, 10:07 AM] patient advocate: Had tee after eating walnuts

[8/7, 10:07 AM] PaJR Coordinator: Get review of X ray report w.r.t. SI joints and L5-S1

[8/7, 10:07 AM] PaJR moderator: @⁨PaJR Coordinator⁩ We couldn't get to collate the entire previous transcripts here (which may contain the review of the investigation desired by @⁨PPM3) into a case report by @⁨RS2⁩ as informed consent from the patient is pending?

[8/7, 10:07 AM] PaJR moderator: Consent was forwarded to pajr_coordinator, he said he will share mail id for sending again, wating for mail id please

[8/7, 10:07 AM] Patient Advocate: Sir, 

signed copy of consent and Authorization letter mailed for information

[8/7, 10:07 AM] Patient Advocate: Shall I share in the group

[8/7, 10:07 AM] PaJR Coordinator: 👆 Please share her hourly routine as previously shared on 13/7/24

[8/7, 10:07 AM] Pajr_moderator: Personally sent to me by @⁨PaJR Coordinator⁩

[8/7, 10:07 AM] PaJR Coordinator: Near Vizag

[8/7, 10:07 AM] PaJR Coordinator:

 Conversations with patients, health professionals and meta-AI to understand pharmacological efficacy in backache 

https://userdrivenhealthcare.blogspot.com/2024/08/udlco-meta-ai-driven-ebm-support-to.html?m=1

[8/7, 10:07 AM] Patient Advocate:  Drinking 500ml water and 300ml lemon honey water

[8/7, 10:07 AM] Patient Advocate: Drank 1.5 glass of water

[8/7, 10:07 AM] patient advocate: Rajma and tomato curry

[8/7, 10:07 AM] patient advocate: With curry leaves powder

[8/7, 10:07 AM] patient advocate: Drinking 2 glass of water and eating dates, kismis

[8/7, 10:07 AM] patient advocate: 👆

[8/7, 10:07 AM] patient advocate: Daily routine 

7:30 Am wake-up light exercise 

8:00 drinking water 2 glass

8:00 eat dry fruits walnut 4 or almonds 6 or sunflower seeds and pumpkin seeds occasionally 

9:00 drinking tea or coffee 

10:00 preparing breakfast for 30 mins standing in kitchen 

10:30 to 11:00 breakfast idly 3or dosa2 or pesarattu1or upma

12:30 to 13:00 drinking of water 1.5 glass

13:00 cooking of lunch for an Hour standing in kitchen 

14:00 to 14:30 Lunch rice with dal/ veg. curry 

or egg weekly or chicken occasionally 

15:00 to 16:00 cleaning and arranging in kitchen 

16:00 to 17:30 relaxing / sleeping 

18:00 drinking water 2 glass

 Eating snacks sometimes 

18:00 watching TV or drying of clothes on terrace by climbing steps weekly twice

20:30 light dinner

[8/7, 10:07 AM] patient advocate: 21:00 watching TV or domestic work

22:30 sleeping 

( before 23:00)

[8/7, 10:07 AM] patient advocate: Review morning stiffness and pain. Relief with hot water bath

[8/7, 10:07 AM] PaJR Coordinator: Thanks!

Please share at which hourly slots did your patient experience back pain and how long did that last yesterday?

[8/7, 10:07 AM] patient advocate: She feels pain throughout the day. However pain is slightly high during wake-up from bed and standing for longtime.

[8/7, 10:07 AM] PaJR Coordinator: Far away perhaps🫥

[8/7, 10:07 AM] patient advocate: Yes

[8/7, 10:07 AM] PaJR Coordinator: We are nearer but even we haven't met her!

[8/7, 10:07 AM] Patient Advocate: With Nuvvula karam podi

[8/7, 10:07 AM] PaJR moderator: 👆In this daily routine how much is her daily walking distance?

[8/7, 10:07 AM] Patient Advocate: 👆@⁨PaJR Coordinator⁩

[8/7, 10:07 AM] PaJR member: Please send me the previous information of this group

MMT grade 3

                                                                  MMT grade 2

[7/17, 6:15 PM] patient advocate: Videos with mask for privacy

[7/17, 6:19 PM] patient advocate: Sir 

Please check videos with mask and delete earlier videos as required

[7/17, 8:25 PM] PaJR PHR Moderator: Good Idea but the patient needs to cover the entire face and head for deidentification perhaps

[8/2, 11:59 AM] PPM 3: Get review of X ray report w.r.t. SI joints and L5-S1

[8/2, 12:27 PM] PaJR PHR Moderator: @⁨PaJR Coordinator⁩ We couldn't get to collate the entire previous transcripts here (which may contain the review of the investigation desired by @⁨PPM3) into a case report by @⁨Patient Advocate⁩ as informed consent from the patient is pending?

[8/2, 12:37 PM] PA: Consent was forwarded to coordinator, he said he will share mail id for sending again, wating for mail id please

[8/2, 12:40 PM] Patient Advocate: Shall I share in the group

[8/2, 12:56 PM] PaJR PHR Moderator: Thanks! Please DM it to the case reporter @⁨Patient Advocate

[8/12, 12.56 pm] PPM 1: The case reporter needs to ensure that the informed consent is signed by each of their logged patients and emailed to this address: informedconsentpajr@gmail.com asap and ensure that s/he gets a reply to that email 

The signed informed consent needs to be emailed along with the patient's signature, their name and complete contact details along with signature and contact details of witness along with the case report and PaJR link in that email else the people who are archiving this data will not be able to correlate who's it is.

Please find more details about the PaJR workflow here 👇

https://userdrivenhealthcare.blogspot.com/2023/12/pajr-checklist-for-inpatient-interns-in.html?m=1

[8/2, 1:24 PM] patient advocate: Sir, signed copy of consent and Authorization letter mailed for information

[8/2, 2:04 PM] patient advocate: Near Vizag

[8/2, 2:05 PM] patient advocate: Get his direct opinion

[8/2, 2:05 PM] patient advocate: Personally sent to me by @⁨PaJR Coordinator⁩

[8/2, 8:15 PM] PaJR PHR Moderator: 👆 Please share her hourly routine as previously shared on 13/7/24

[8/3, 8:21 AM] patient advocate: Drinking 500ml water and 300ml lemon honey water

[8/3, 8:38 AM] PaJR PHR Moderator: Conversations with patients, health professionals and meta-AI to understand pharmacological efficacy in backache 

https://userdrivenhealthcare.blogspot.com/2024/08/udlco-meta-ai-driven-ebm-support-to.html?m=1

[8/3, 12:59 PM] patient's advocate: With curry leaves powder

[8/3, 1:00 PM] patient advocate: Drank 1.5 glass of water

[8/3, 3:14 PM] patient advocate: Rajma and tomato curry

[8/3, 6:12 PM] +patient advocate: Drinking 2 glass of water and eating dates, kismis

[8/4, 9:30 AM] PaJR PHR Moderator: 👍

[8/6, 12:13 PM] PaJR PHR Moderator: 👆In this daily routine how much is her daily walking distance?

[8/6, 8:53 PM] Patient Advocate: Please send me the previous information of this group

[8/6, 8:58 PM] PaJR PHR Moderator: 👆@⁨PaJR Coordinator⁩

[8/7, 10:03 AM] PaJR Coordinator: Ok sir sending

[8/7, 10:45 AM] Patient Advocate: Got it

[8/10, 10:49 AM] patient advocate: Drinking 2 glass of water at 8:30am

[8/10, 10:50 AM] patient advocate: Breakfast with coconut chutney

[8/10, 2:10 PM] patient advocate: Lunch rice with dal, french beans curry and carrot pickle

[8/10, 2:10 PM] patient advocate: Lunch rice with dal, french beans curry and carrot pickle

[8/11, 10:37 AM] patient advocate: Drinking 2 glass of water at 8:30am

[8/12, 8:21 AM] patient advocate: Drinking 300 ml warm water with lemon and honey

[8/12, 8:42 AM] patient advocate: Drinking 500ml water

[8/12, 9:16 AM] patient advocate: Drinking coffee

[8/12, 11:45 AM] patient advocate: Eating apple as breakfast

[8/12, 2:11 PM] patient advocate: Lunch with rice, dal and bottle gourd, carrot pickle

[8/13, 9:15 AM] patient advocate: Drinking 300 ml warm water with lemon and honey at 8:30am

[8/13, 10:47 AM] PA: Idly with ground nut and roasted bengal gram chutney

[8/13, 2:26 PM] patient advocate: Lunch with capsicum and potato curry

[8/13, 2:30 PM] PaJR PHR Moderator: 👍

[8/14, 8:23 AM] patient advocate: Drinking 500ml water

[8/14, 8:29 AM] PaJR PHR Moderator: 👍

[8/14, 8:40 AM] patient advocate: Eating dry fruit

[8/14, 9:06 AM] patient advocate: Still she feels back pain

[8/14, 9:06 AM] patient advocate: Still she feels back pain

[8/14, 10:49 AM] patient advocate: Mark the severity of pain here as on date. This will be used in future.

[8/14, 10:49 AM] patient advocate: Does pain wake up from sleep?

[8/14, 11:03 AM] patient advocate: Breakfast dosa with chutney

[8/14, 2:52 PM] patient advocate Lunch, Rice with tomato and egg curry

[8/15, 11:04 AM] patient advocate: Breakfast poha and cashews upma

[8/15, 2:17 PM] patient advocate: Lunch, rice with dal and tomato curry

[8/15, 5:06 PM] patient advocate: Ok sir

[8/17, 9:19 AM] patient Advocate: Drinking 300 ml warm water with lemon and honey at 8:30am

[8/17, 9:19 AM] patient advocate: Drinking 500ml water

[8/17, 11:26 AM] patient advocate: Breakfast Vada with chutney

[8/19, 9:28 AM] patient advocate: Drinking 600ml water at 8:40

[8/19, 9:29 AM] PA: Eating pumpkin and sunflower seeds

[8/19, 10.55 AM] PA: Breakfast 2 banana

[8/19, 2:19 PM] patient advocate: Lunch, rice with boiled chana, bachali Kura pappu

[8/19, 2:20 PM] patient advocate: Curd with carrot, keera salad

                                        

[8/19, 8:50 PM] patient advocate: Dinner

[8/19, 9:48 PM] PaJR Coordinator: Really nice

[8/20, 8:27 AM] patient advocate: Drinking 200 ml warm water with lemon and honey

[8/20, 8:41 AM] patient advocate: Eating dry fruits

[8/20, 8:43 AM] PaJR PHR Moderator: 👍

[8/20, 10:58 AM] patient advocate: Breakfast

[8/20, 2:14 PM] patient advocate: Lunch

[8/20, 2:16 PM] PaJR PHR Moderator: Daily 1 egg per person not 2

[8/20, 2:51 PM] patient advocate: Carrot, keera salad with curd

[8/20, 4:41 PM] patient advocate: Sir, can we take 2 eggs per day and three days in a week

[8/20, 6:38 PM] PaJR PHR Moderator: Alright

[8/20, 8:41 PM] patient advocate: Light dinner

[8/20, 8:42 PM] patient advocate: With curry leaves powder and toor dal powder

[8/21, 10:27 AM] patient advocate: Drinking 600ml water at 8:40

[8/21, 11:15 AM] patient advocate: Breakfast, upma with carrot and groundnut

[8/21, 2:34 PM] patient advocate: Lunch, rice with egg curry

[8/21, 10:04 PM] patient advocate: No dinner today

[8/22, 8:29 AM] patient advocate: Drinking 300 ml warm water with lemon and honey

[8/22, 8:30 AM] patient advocate: Eating dry fruits

[8/22, 11:01 AM] patient advocate: Breakfast, fermented curd rice with chana

[8/22, 2:41 PM] PaJR PHR Moderator: Daily activities?

[8/22, 5:18 PM] PaJR Coordinator: What were the daily activities

[8/22, 5:30 PM] patient advocate: Same routine

[8/23, 9:52 AM] patient advocate: Drinking warm water with honey at 8:40 am

[8/23, 9:52 AM] patient advocate: Eating dry fruits

[8/23, 9:53 AM] patient advocate: Had Cup of tea

[8/23, 10:00 AM] PaJR PHR Moderator: And other hourly physical activities?

[8/23, 10:37 AM] patient advocate: Breakfast, Dosa with chutney

[8/23, 2:32 PM] patient advocate: Lunch, Rice with dal palak tomato coriander, chana with carrot, keera curd salad

[8/23, 8:59 PM] +patient advocate: Light dinner with rice and palak, tomato dal

[8/24, 8:45 AM] PaJR Coordinator: How is patient how is patient pain Today

[8/24, 10:18 AM] patient advocate: Drinking warm water 500ml at 8:20am

[8/24, 10:19 AM] patient advocate: Eating dry fruits

[8/24, 11:07 AM] patient advocate: Breakfast, Poha with cashew nut upma

[8/24, 2:10 PM] patient advocate: Lunch, Rice with coccinia curry and groundnut 

Curd with carrot keera salad

[8/24, 8:56 PM] patient advocate: Dinner, sweet corn

[8/24, 9:52 PM] PaJR PHR Moderator: It's a cereal and every healthy plate needs it's cereals to be balanced with fruits, vegetables (half of the plate)and pulses (1/4th)

https://nutritionsource.hsph.harvard.edu/healthy-eating-plate/

[8/25, 9:49 AM] patient advocate: Drinking 600 ml water

[8/25, 9:49 AM] patient advocate: Drinking 600 ml water

[8/25, 9:49] patient advocate: Eating dry fruits

[8/25, 10:32 AM] PaJR PHR Moderator: Water intake and it's volume needs to be driven by thirst

[8/25, 10:55 AM] patient advocate: Breakfast, carrot and groundnut upma

[8/26, 8:38 AM] patient advocate: Drinking 300 ml warm water with lemon and honey

[8/26, 9:01 AM] patient advocate: Drinking 600 ml water

[8/26, 9:01 AM] patient advocate: Eating dry fruits

[8/26, 11:05 AM] patient advocate: Breakfast, dosa with coconut chutney

[8/26, 2:27 PM] patient advocate: Lunch, Rice with cabbage moong dal curry and coconut chutney and curd

[8/26, 8:40 PM] patient advocate: Light dinner

[9:54 AM] patient advocate: Drinking of 300ml warm water

[8/27, 9:55 AM] patient advocate: Eating dry fruits

[8/27, 10:51 AM] patient advocate: Breakfast, pesarattu

[8/27, 2:21 PM] patient advocate: Lunch, Ragi sankati with potato, green peas curry and carrot curd salad

[8/28, 8:51 AM] patient advocate:Drinking 300 ml warm water with lemon and honey

[8/28, 8:51 AM] patient advocate: Drinking 600 ml water

[8/28, 8:52 AM] patient advocate: Eating pumpkin and sunflower seeds

[8/28, 11:20 AM] patient advocate: Breakfast, Samia upma with carrot and cashew nuts

[8/28, 2:33 PM] patient advocate: Lunch, Rice with chana dal, omlette and carrot, cucumber curd salad

[8/28, 8:38 PM] PA: Dinner, cucumber chana dal with curry leaves Powder

[8/29, 10:56 AM] patient advocate: Breakfast, Idly with ground nut chutney

[8/29, 2:31 PM] patient advocate: Lunch, Coconut Rice with beans potato chana and curd.

[8/30, 2:35 PM] patient advocate: Drinking 300 ml warm water with lemon and honey at 8:40am

[8/30, 2:36 PM] patient advocate: Drinking 600 ml water at 8:50am

[8/30, 2:37 PM] patient advocate: Eating dry fruits at 9:00am

[8/30, 2:37 PM] +patient advocate: Breakfast, Idly with ground nut chutney at 10:40am

[8/30, 2:40 PM] patient advocate' Lunch, Rice with moongdal curry boiled egg , groundnut 

And carrot curd salad

[8/30, 10:43 PM] PaJR PHR Moderator: 👍

[8/31, 10:44 AM] patient advocate Drinking 600 ml water at 8:50am

[8/31, 10:45 AM] patient advocate: Eating pumpkin seeds and sunflower seeds at 9:00am

[8/31, 12:06 PM] patient advocate: Breakfast, 2 banana

[8/31, 2:08 PM] patient advocate: Lunch, Rice chapathi with Rajma tomato curry and carrot curd salad

[9/1, 2:46 PM] patient advocate: Drinking 600 ml water at 8:50am

[9/1, 2:50 PM] patient advocate: Lunch with curd

[9/2, 2:26 PM] patient advocate: Lunch, Rice Babbarlu, dal with Ponnaganti tomato Kura cucumber, carrot salad

[9/2, 2:40 PM] PaJR PHR Moderator: Very nice

[9/2, 7:24 PM] patient advocate: Thank you sir

[9/3, 9:21 AM] patient advocate: Eating dry fruits at 9:00am

[9/4, 2:15 PM] patient advocate: Sir, her cold under control, however she got throat pain and lost smell sense.

Kindly suggest treatment

[9/4, 2:21 PM] patient advocate: She is suffering from cough with out phlegm

[9/4, 2:24 PM] patient advocate: Lunch, Rice with egg curry

[9/4, 4:57 PM] patient advocate:Wheezing sound observed from throat

[9/4, 7:27 PM] PaJR PHR Moderator: Cab take paracetamol for the throat pain

Others will subside on their own

[9/4, 7:59 PM] +patient advocate: Thank you sir

[9/5, 8:40 AM] patient advocate: Drinking 600 ml water

[9/5, 8:41 AM] patient advocate: Eating dry fruits

[9/5, 1:30 PM] patient advocate: Sir Can we have curd while suffering from cold

[9/5, 2:17 PM] patient advocate: Lunch, Rice with cabbage chana dal and boiled green moong

[9/5, 2:19 PM] PaJR PHR Moderator: Can be taken in moderation

[9/5, 2:40 PM] patient advocate: Thank you so much sir

[9/5, 8:20 PM] patient advocate: Dinner

[9/6, 6:05 PM] patient advocate: Sir

She is suffering from coughing and wheezing sound from throat

[9/6, 6:10 PM] patient advocate: She was using aerocort inhaler earlier in situations like this, she got asthma

[9/6, 6:10 PM] patient advocate: Request for treatment

[9/6, 6:29 PM] patient advocate: She is using inhaler, still wheezing continuing

[9/6, 6:29 PM] PaJR PHR Moderator: Aerocort is not a rational combination in the step wise management of Asthma. 

I shall try to explain her necessary treatment in a simple language but please let me know since when she has been found to be having this intermittent coughing and wheeze? When it begins how long does it last?

[9/6, 6:36 PM] patient advocate: She was suffering from last 4 days initially it was cold then developed to coughing, you adviced cetrizine and paracetamol

[9/6, 6:37 PM] patient advocate: The cold was controlled then coughing and wheezing developed 

 I can here her wheezing

[9/6, 7:45 PM] PaJR PHR Moderator: How many years has this been noticed?

How many times in a year she gets these symptoms?

[9/6, 7:49 PM] patient advocate: She was suffering from asthma from childhood

It was cured at the age of about 20 years

[9/6, 7:51 PM] patient advocate: She suffers from cold and then it developed to asthma due to climatic changes

[9/6, 7:52 PM] PaJR PHR Moderator: From the age of 20 years to her current 55 years, is this the first episode of her cough and wheeze?

[9/6, 7:52 PM] patient advocate: Asthma remains for about a week. She recovers after treatment

[9/6, 7:53 PM] patient advocate: She gets effected once or twice in a year

[9/6, 7:54 PM] patient advocate: Asthma is effective followed by cold

[9/6, 7:55 PM] PaJR PHR Moderator: So from age of 20 years till now 55 years she has had asthma episodes 35-70 times?

[9/6, 7:57 PM] patient advocate: Not sure sir

[9/6, 8:30 PM] PaJR PHR Moderator: Let us know her respiratory rate. @⁨PaJR Coordinator⁩ can help you to check out YouTube videos showing how to check her respiratory rate.

Can discuss with your local doctor to obtain

Asthalin (salbutamol rotacap) 200 mcg to be taken with a rotahaler three times a day for wheezing for 2 days 

Budecort rotacap 200mcg twice a day for 2 days 

Just sharing this technical reference for others here: https://www.nature.com/articles/s41533-023-00330-1/figures/5

There appears to be strong traction for track 1 in the figure these days but we would prefer track 1

[9/6, 8:31 PM] PaJR PHR Moderator: @⁨Pajr_trainee⁩ Would be good to update this new issue with the conversations above into her case report

[9/6, 9:28 PM] patient advocate: Sir I measured respiratory rate manually is 25 per minute.

Measurement is done by placing stethoscope at throat to listen inhale/exhale and counted rate for one minute

[9/6, 10:03 PM] PaJR PHR Moderator: Let us know how it is after the medicine

[9/6, 11:53 PM] Pajr trainee: I'll update it

[9/8, 11:39 AM] PA: Drinking 600 ml warm water with honey at 9:30am

[9/8, 11:41 AM] PA: Breakfast, pesarattu at 11:00am

[9/10, 11:53 AM] PA: Sir, She is inhaling asthalin and budecort rotacaps for last two days, wheezing still exists and respiration rate not improved

Request for your guidance please.

[9/10, 2:58 PM] PaJR PHR Moderator: How many times is she inhaling asthalin?

Please share her respiratory rate hourly

[9/10, 3:00 PM] PA :  Asthalin 3 times in a day

[9/10, 3:01 PM]PA: And budecort twice in a day sir

[9/10, 3:02 PM] PA: I counted one inhale and exhale as one count sir

[9/10, 3:06 PM] PA: She inhaled for two days, and stoped today as your recommendation

[9/10, 4:36 PM] PaJR PHR Moderator: She needs to continue and the dose needs to be increased and if required we need to move to the next step and add another rotacap such as:

Foracort 200 which contains Formoterol (6mcg), Budesonide (200mcg)

[9/10, 4:37 PM] PaJR PHR Moderator: That's right but it needs to be repeatedly checked every hour or every two hours and shared here

[9/10, 4:45 PM] PaJR PHR Moderator: Another additional monitoring device such as this 👇

https://m.indiamart.com/proddetail/mini-wright-peak-flow-meter-5374638762.html

will help us to decide the treatment better

@⁨PaJR Coordinator⁩ can help you to procure and operate it

[9/11, 9:20 AM] PA: Drinking 600 ml warm water with honey at 8:45am

[9/11, 9:21 AM] PA: Eating dry fruits

[9/14, 5:03 PM] PaJR PHR Moderator: 👍also mention her hourly activities

[9/15, 11:02 AM] PA: Drinking 600 ml warm water with honey at 8:30am

[9/15, 11:02 AM] PA: Had a cup of coffee at 9:00am

[9/16, 10:55 AM] PA: Breakfast, papaya fruit.

[9/16, 11:28 AM] PAJR doctor: This is a good diet. How is the back pain compared to before starting this group?

[9/16, 12:56 PM] PA: Sir, She is unable to discriminate the improvement

[9/16, 12:57 PM] PAJR Doctor: Okay. What is she taking for pain relief?

[9/16, 1:02 PM] PA: Sir, Not taking any medicine for pain relief.

[6:00 pm, 30/10/2025] PA: Hi Sir. This is PA, patient suffering from back pain

[6:01 pm, 30/10/2025] PA: Is it possible to talk to PPM1 sir

[9:21 am, 31/10/2025] PPM 1: Please talk with @PPM4 who is managing similar patients with backache, and she can be assisted by our team comprising of @PPM5 @PPM6@CR @RS

[6:52 pm, 01/11/2025] PA: Sir, Recently patient contacted Dr from Elite pain management, Hyd

[6:53 pm, 01/11/2025] PA: MRI report and Dr prescription forwarded for your perusal

[6:53 pm, 01/11/2025] PA: After his medication, she felt no relief for back pain

[6:54 pm, 01/11/2025] PA: Request advice. MRI lumbar spine films of patient.

[8:29 pm, 02/11/2025] PPM 1: @PPM4 please share your impression from the interview whenever you can find time.

I don't see any reason why the MRI was necessary!

I wonder what made the patient lose follow up here since so many months and what made her visit the doctor recently?

Also please share the patient's daily hourly activities here mentioning especially the hourly slots she feels the pain

[8:56 pm, 02/11/2025] PPM 4: sure sir 

As per the first call I had with the patient I understood that Her pain is chronic and 

All her previous reports their impressions doesn't match with her pain scale and it's chronicity,

As if there is no evidence to prove her pain.

So I asked about her childhood and other emotional Traumas

Seems like there is a possibility of childhood emotional trauma..

and it effected her and manifested into physical symptoms...

But I don't think I can share that history openly here (privacy concerns)

[8:59 pm, 02/11/2025] PPM 4: @PA 

Hello andi could you please share her daily hourly activities

(Like a physical activity journal) right after she wakes up, her chores at home 

type of Exercise and it's duration

[9:01 pm, 02/11/2025] PPM 4: As per the patient's history 

She feels pain All day all time sir and even lying down doesn't help ease it, she says pain doesn't spike ..and it's always there

[9:09 pm, 02/11/2025] PPM 1: How was her pain after she was lost to our follow up since she shared here last on 11 January 2025?

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14F VIRAL ENCEPHALITIS Telangana PaJR

 

29-10-2025

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.

[7:21 am, 30/10/2025] PPM 1: Please share the history and clinical examination findings before the investigations

[8:59 am, 30/10/2025] PPM 3: Yes sir, there is some confusion with the history

[9:00 am, 30/10/2025] PPM 3: Wanted to clarify that

[5:18 pm, 30/10/2025] PPM 3: 14 yr old female 

c/o fever – 10 days duration

c/o vomiting – 5 days

c/o body pains – 5 days

c/o headache – 5 days

C/o involuntary movements of bilateral upper and lower limbs Since today morning  

⸻

2. HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10 days back.

Then developed fever, intermittent, not associated with chills and rigors, relieved on medication.

After 5 days, patient developed vomiting — 3–4 episodes/day, containing food particles, non-bilious, not blood stained.

Associated with generalized body pains, headache

C/o cough since yesterday associated with whitish sputum 

Complaints of involonnrary movements of bilateral upper and lower limbs since today morning 5:30 am duration 5 mins 

Up rolling of eyes +, drooling of saliva + 

No bowel and bladder incontinence 

Seizure activity -3 episodes: 5:30 am, 7:30 am and 8:30 am  

No history of cold, burning micturition

⸻

3. HISTORY OF PAST ILLNESS

No history of tuberculosis, hypertension, or diabetes mellitus.

No history of jaundice in the past.

No similar complaints in the past.

O/e 

Pt conscious 

Bp -140/80 mmhg 

Pr -120 bpm 

Rr -14 cpm 

Spo2 -98% on room air 

Temp -100.4 f 

CVS -s1, s2

Rs -b/l nvbs 

P/a -bowel sounds + 

Cns 

Tone decreased in rt Ul 

Power 3/5 in rt ul 

5/5 in rt ll , Lt ul and ll 

Reflexes 

      B T S K A P 

Rt +2 +1 + +3 +2 mute 

Lt +2 +1 + +3 +2 extensor

[7.15 pm, 30/10/2025] PPM 1: Are you sure the first BP that we found in her was 140/80?

Check out her BP recordings attached and also check the drugs administered.

Now with @PPM7 and already asked @PPM6 please share what are the findings of her fundus, pulses on all major vessels and BP in all four limbs.

[7:17 pm, 30/10/2025] PPM 1: 👆 with the above BP in this 14 years old girl the MRI image shared in the DP takes a new meaning?

@PPM4 @Meta AI does this fit into a posterior reversible encephalopathy syndrome

[7:17 pm, 30/10/2025] Meta AI: Sorry, I can’t help you with this request right now. Is there anything else I can help you with?

[7:49 pm, 30/10/2025] PPM 4: Based on the information provided, here is an analysis of whether this fits Posterior Reversible Encephalopathy Syndrome (PRES):

*Yes, this clinical picture is highly suggestive of Posterior Reversible Encephalopathy Syndrome (PRES).*

Here’s a breakdown of why the evidence points toward PRES:

### 1. The Key Ingredient: Acute Severe Hypertension

The blood pressure (BP) readings you provided for a 14-year-old girl are critically high.

*   *Readings:* Consistently around *130/100 mm Hg*.

*   *Significance:* For a 14-year-old, a normal blood pressure at the 90th percentile is approximately 120/80 mm Hg. A diastolic pressure of 100 mm Hg is severely elevated and meets the criteria for a *hypertensive emergency*, especially when associated with neurological symptoms (implied by the MRI finding). This is the most common trigger for PRES.

### 2. The Neurological Correlate: The MRI Image

While the image itself isn't here, your statement that "the MRI image shared in the DP takes a new meaning" strongly implies that the MRI shows abnormalities. The classic radiological findings of PRES are:

*   *Location:* *Posterior* regions of the brain, particularly the parieto-occipital lobes. This is due to the unique anatomy of the vertebrobasilar arterial system, which has less sympathetic innervation and is more susceptible to changes in blood pressure.

*   *Appearance:* Vasogenic edema appearing as T2/FLAIR hyperintensities on MRI.

*   *Reversibility:* The changes are typically reversible with prompt control of blood pressure.

### Connecting the Dots

The combination of *acute, severe hypertension* and an *MRI suggestive of brain edema* creates a very compelling case for PRES. The high BP disrupts the brain's ability to auto-regulate blood flow, leading to a breakdown of the blood-brain barrier and fluid leakage (vasogenic edema), which is what the MRI shows.

---

### Recommendations and Next Steps (as you are already doing)

Your line of questioning is exactly right for confirming the diagnosis and managing the patient:

*   *Fundus Examination:* This is crucial. The presence of *hypertensive retinopathy* (e.g., papilledema, hemorrhages, exudates) would provide direct evidence of end-organ damage from the hypertension and strongly support the PRES diagnosis.

*   *Pulses and Four-Limb BP:* This is essential to rule out *coarctation of the aorta* as a cause of severe hypertension in a young patient. A significant BP gradient between the arms and legs would be a classic finding.

*   *Review of Administered Drugs:* It's important to identify if any medications (e.g., immunosuppressants, certain chemotherapies) could be contributing to the condition, as these are also known triggers for PRES.

### Conclusion

*In summary, the scenario you describe—a young girl with severe hypertension and an abnormal brain MRI—fits perfectly into the clinical-radiological diagnosis of Posterior Reversible Encephalopathy Syndrome.* Your next steps of a thorough physical exam (fundus, pulses) and searching for a secondary cause of hypertension are the correct and urgent priorities.

*

Disclaimer: This analysis is based on the text provided and is for informational purposes only. It is not a substitute for professional medical judgment. The patient's care should be managed by a qualified healthcare team.

[8:04 pm, 30/10/2025] PPM 5: Given her history of fever preceding encephalitis. wouldn't HTN be unlikely to be the driving cause behind the encephalitis sir?

[8:59 pm, 30/10/2025] PPM 3: That was the bp in the casuality

[9:27 pm, 30/10/2025] PPM 3: These readings were recorded after she was shifted to icu sir

[9:26 am, 31/10/2025] PPM 1: Yes in the light of her Hypertension we are assuming that the history of fever may have been coincidental or a simpler viral fever unmasking brain failure similar to simple viral fever unmasking Hfpef in our prior ProJR patients.

@PPM6 @PPM3 @PPM7 any inputs on the findings of her fundus, pulses on all major vessels and BP in all four limbs?

[9:26 am, 31/10/2025] PPM 1: Who checked that?

[9:28 am, 31/10/2025] PPM 1: And in our country not just coarctation of aorta but Takayasu's arteritis is also quite a common condition to account for this presentation

[10:17 am, 31/10/2025] PPM 3: Sending them now sir

[10:29 am, 31/10/2025] PPM 3: Casualty intern sir.

[10:42 am, 31/10/2025] PPM 1: They didn't have the bias of looking specifically for hypertensive retinopathy changes!

[10:50 am, 31/10/2025] PPM 3: Can the hypertensive retinopathy changes appear so acutely?

[12:51 pm, 31/10/2025] PPM 4: You are absolutely right. Thank you for that crucial correction and addition. In the context of a *14-year-old girl* with severe hypertension, *Takayasu's arteritis* ("pulseless disease") is indeed a critical and common differential diagnosis to consider, often more so than coarctation in many parts of the world.

This significantly refines the diagnostic reasoning.

### Why Takayasu's Arteritis is a Perfect Fit Here

Takayasu's arteritis is an inflammatory large-vessel vasculitis that predominantly affects the aorta and its major branches. It aligns perfectly with this presentation:

1.  *Demographics:* It classically affects *young women*, most commonly in the 2nd and 3rd decades of life. A 14-year-old girl fits this profile exactly.

2.  *Presentation with Hypertension:* The most common clinical presentation of Takayasu's arteritis is *hypertension*. This occurs due to:

    *   *Renal artery stenosis:* Inflammation and narrowing of the renal arteries, leading to renovascular hypertension. This is a very common mechanism in Takayasu's.

    *   *Stiffening of the aorta:* Loss of aortic elasticity can lead to elevated systolic pressure.

3.  *Link to PRES:* The severe, often refractory hypertension caused by Takayasu's is a well-documented and powerful trigger for *Posterior Reversible Encephalopathy Syndrome (PRES)*. The high pressure disrupts cerebral autoregulation, causing the vasogenic edema seen on MRI.

4.  *End-Organ Damage:* The brain (via PRES) and the eyes (via hypertensive retinopathy) are both targets for the effects of this severe hypertension.

### Refining the Clinical Examination

Your request for findings now takes on an even more specific significance:

*   *Pulses on All Major Vessels:* This is the cornerstone of suspicion for Takayasu's.

    *   Look for *asymmetrical, diminished, or absent pulses* in the radial, brachial, or carotid arteries.

    *   *Blood Pressure in All Four Limbs:* You may find a *significant difference (>10-20 mm Hg) in blood pressure between the two arms*, or between the arms and legs. This is due to asymmetric narrowing of the subclavian, brachiocephalic, or femoral arteries.

*   *Fundus Examination:* In addition to signs of hypertensive retinopathy, look for specific signs of Takayasu's itself, known as *"Takayasu's retinopathy,"* which can include arteriovenous anastomoses, capillary microaneurysms, and retinal ischemia.

*   *Bruits:* Auscultation for bruits over the carotid, subclavian, and abdominal arteries can suggest vascular narrowing.

### Conclusion: A Compelling Syndromic Diagnosis

The combination of:

*   *Young female patient*

*   *Severe hypertension*

*   *MRI findings suggestive of PRES*

*   *The high prevalence of Takayasu's arteritis in your country*

makes *Takayasu's arteritis with secondary hypertensive emergency manifesting as PRES* a leading, and perhaps the most likely, diagnosis.

*Next Diagnostic Steps:*

1.  *Vascular Imaging:* The gold standard would be a *CT Angiography (CTA) or MR Angiography (MRA) of the entire aorta and its branches*. This can directly visualize the classic "wall thickening" ("macaroni sign"), stenosis, dilatations, and occlusions of the great vessels.

2.  *Inflammatory Markers:* ESR and CRP are often (but not always) elevated in the active phase of the disease.

3.  *Echocardiogram:* To assess for cardiac complications and to help rule out coarctation.

Your insight is spot-on. This is no longer just a case of "hypertension causing PRES," but a case of *"what is causing the catastrophic hypertension in a young girl?"* with Takayasu's arteritis at the top of the list.

*

Disclaimer: This analysis is based on the text provided and is for informational purposes only. It is not a substitute for professional medical judgment. The patient's care should be managed by a qualified healthcare team.

[1.10 pm, 31/10/2025] PPM 1: Yes interestingly Talayasu was an ophthalmologist who first discovered the disease through the retina!

[3.38 pm, 31/10/2025] PPM 1: Yes interestingly Takayasu was an ophthalmologist who first discovered the disease through the retina!

[3:40 pm, 31/10/2025] PPM 1: Have symptoms of hypertension and PRES been also explained by encephalitis related cerebral dysregulation in the past? @PPM4

[3:41 pm, 31/10/2025] PPM 1: Have symptoms of hypertension and PRES been also explained by encephalitis related cerebral dysregulation in the past? @Meta AI

[3:41 pm, 31/10/2025] Meta AI: Yes, symptoms similar to those of Posterior Reversible Encephalopathy Syndrome (PRES) have been linked to various causes, including encephalitis-related cerebral dysregulation, but PRES is specifically characterized by vasogenic edema associated with hypertension, eclampsia, or immunosuppressive therapy. While the exact mechanism of PRES remains unclear, theories suggest endothelial dysfunction and cerebral autoregulation impairment play key roles.¹ ² ³

[3:47 pm, 31/10/2025] PPM 1: Nice but incomplete data https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-021-02408-0/tables/1

[4.15 pm, 31/10/2025] PPM 1: @PPM8's findings

[4:26 pm, 31/10/2025] PPM 5: That is definitely interesting, I had no idea!

[4:28 pm, 31/10/2025] PPM 5: That rules out Takayasu then.

[7:44 pm, 31/10/2025] PPM 4: This is an excellent and insightful question that gets to the heart of diagnostic reasoning in complex cases. The new document you've provided adds crucial evidence.

Let's break down your question: *"Have symptoms of hypertension and PRES been also explained by encephalitis related cerebral dysregulation in the past?"*

The answer is *yes, absolutely.* This is a well-documented, though less common, pathway to PRES.

### The New Evidence: The EEG

The document you shared is an *Electroencephalogram (EEG)* report. The finding "*Generalized slowing*" in the context of this patient's acute illness is highly significant.

*   *What it means:* Generalized slowing on an EEG is a non-specific but clear indicator of *diffuse cerebral dysfunction* or *encephalopathy*. The brain's electrical activity is abnormally slow.

*   *What it DOESN'T tell us:* It does not specify the cause of the encephalopathy. The encephalopathy could be due to:

    1.  *The direct effect of severe hypertension* on the brain (Hypertensive Encephalopathy, which is the clinical correlate of PRES).

    2.  *An underlying inflammatory or infectious process* (i.e., Encephalitis).

    3.  Both.

### The Pathophysiological Link: How Encephalitis Can Cause PRES

The traditional view is that severe hypertension causes PRES. However, the sequence can be reversed or intertwined:

1.  *Primary Brain Insult (Encephalitis):* Inflammation from encephalitis can disrupt the delicate signaling and autoregulatory mechanisms within the brain itself.

2.  *Cerebral Dysregulation:* The inflamed brain loses its ability to tightly control its own blood flow. This leads to dysfunctional autoregulation.

3.  *Secondary Hypertension:* The brain may trigger a massive sympathetic outflow (a "autonomic storm") or disrupt central blood pressure control centers, leading to a surge in systemic blood pressure. This is sometimes called *"neurogenic hypertension."*

4.  *PRES Develops:* This resultant hypertension, or even the inflammatory disruption of the blood-brain barrier itself, can then lead to vasogenic edema in the posterior brain regions, i.e., PRES.

In this scenario, *the encephalitis is the primary cause, and both the hypertension and PRES are secondary complications.*

### Reconciling the Evidence in This Case

We now have three key pieces of the puzzle:

1.  *Clinical:* A young girl with severe hypertension (readings up to *170/100* in this new document).

2.  *Radiological:* An MRI image previously shared that is suggestive of PRES.

3.  *Neurophysiological:* An EEG showing *encephalopathy* (generalized slowing).

This creates two primary, competing diagnostic possibilities:

| Possibility | Proposed Sequence of Events |

| :--- | :--- |

| *1. Takayasu's Arteritis (or another primary hypertensive cause)* | *Primary Severe Hypertension* (from renovascular disease) -> *Hypertensive Encephalopathy/PRES* -> *EEG Slowing* (as a result of the PRES/hypertension). |

| *2. Encephalitis* | *Primary Encephalitis* -> *Cerebral Dysregulation & Neurogenic Hypertension* -> *PRES* -> *EEG Slowing* (as a result of the primary encephalitis). |

*It is also possible these are overlapping*, for example, a patient with pre-existing, mild Takayasu's could be pushed into a crisis by an intercurrent infection or inflammatory process.

### Conclusion and Next Steps

Your question is extremely valid. *Encephalitis is a definitive diagnostic consideration here.* The EEG finding of encephalopathy forces us to entertain it seriously.

To distinguish between these possibilities, the following are critical:

1.  *Neuroimaging (MRI Brain with Contrast):* Besides PRES, are there any findings suggestive of encephalitis (e.g., T2/FLAIR hyperintensities in the temporal lobes, limbic system, or other regions atypical for PRES; contrast enhancement)?

2.  *Cerebrospinal Fluid (CSF) Analysis:* This is crucial. A lumbar puncture to look for pleocytosis (white blood cells), elevated protein, and oligoclonal bands would support an inflammatory/ infectious process like encephalitis.

3.  *Autoimmune/Paraneoplastic Panels:* Testing CSF and blood for autoimmune encephalitis antibodies (e.g., anti-NMDA receptor, etc.).

4.  *Vascular Imaging (MRA/CTA):* To definitively rule in or rule out Takayasu's arteritis by visualizing the great vessels.

In summary, *yes, encephalitis can present with neurogenic hypertension and secondary PRES.* The EEG findings make this a mandatory part of the differential diagnosis. The clinical team must now work to determine if the encephalopathy is primary (encephalitis) or secondary (to the hypertension/PRES), or a combination of both.

*

Disclaimer: This analysis is based on the information provided and is for informational purposes only. It is not a substitute for professional medical judgment.

[7:48 pm, 31/10/2025] Rakesh Biswas Sir: Please share any similar real patient case reports of viral encephalitis presenting with PRES

[7:51 pm, 31/10/2025] PPM 4: Of course. While not exceedingly common, there are documented case reports of viral encephalitis presenting with, or being associated with, Posterior Reversible Encephalopathy Syndrome (PRES). The connection is often explained by the severe inflammation and endothelial dysfunction caused by the infection.

Here are some specific case reports from the medical literature that illustrate this association:

| Case Report | Virus/Infection | Key Clinical Presentation | Association with PRES |

| :--- | :--- | :--- | :--- |

| *Dengue Virus* | Dengue | Seizure, confusion, slurred speech, rigidity. Blood pressure was *140/90 mmHg*. Positive dengue NS1 antigen. | MRI showed bilateral white matter changes consistent with PRES. Symptoms and imaging resolved with supportive care, supporting the PRES diagnosis. |

| *Bickerstaff's Brainstem Encephalitis* | Suspected post-viral (followed URTI) | Headache, blurred vision, ptosis, hypertension (*210/100 mmHg), ataxia, ophthalmoplegia. | MRI showed **PRES lesions in occipital lobes* before neurological symptoms fully developed. Linked to autonomic dysfunction and immune response. |

| *Fatal Pediatric Case with Celiac Disease* | Not specified, but context of infection | History of celiac disease, presented with vomiting, seizure, and severe hypertension (*150/100 mmHg*). | MRI revealed parenchymal hemorrhages in parieto-occipital regions, leading to a diagnosis of PRES. Highlights infection/sepsis as a known PRES trigger. |

### 🧠 Understanding the Connection

The cases above demonstrate that PRES can occur in the context of a viral infection. The primary mechanisms thought to link them are:

- *Endothelial Dysfunction*: Many viruses, like dengue, can directly infect and cause damage to the cells lining the blood vessels (endothelium). This disrupts the blood-brain barrier, leading to the vasogenic edema seen in PRES.

- *Inflammatory Cascade*: The body's intense immune response to the infection releases a flood of cytokines and inflammatory mediators. This "cytokine storm" can also contribute to endothelial injury.

- *Hypertension and Autonomic Dysregulation*: Encephalitis can disrupt the brain's ability to regulate blood pressure, leading to acute hypertension, which is a classic trigger for PRES. This is a key feature in the Bickerstaff's encephalitis case.

### 🔍 How to Approach the Current Case

For your 14-year-old patient, these reports underscore the importance of a comprehensive workup:

- *Broad Differential Diagnosis: It is crucial to investigate for both **primary vascular causes* of the hypertension (like Takayasu's arteritis or coarctation) and *primary inflammatory causes* (like viral or autoimmune encephalitis), as they can both culminate in the PRES picture you are seeing.

- *Key Investigations*: The tests you are already considering are essential:

    - *CSF Analysis*: To look for pleocytosis (white blood cells) and elevated protein, which would support an encephalitis diagnosis.

    - *Autoimmune and Viral Panels*: Testing the CSF and blood for a range of autoimmune encephalitis antibodies and viral PCRs.

    - *Vascular Imaging*: MRA or CTA to rule out large vessel vasculitis like Takayasu's.

In summary, viral encephalitis *can indeed fit into a PRES presentation*, as shown by the documented cases. The pathophysiology often involves a combination of infection-induced endothelial dysfunction and inflammatory-mediated disruption of cerebral autoregulation.

I hope these real-world cases are helpful for your diagnostic reasoning. Would you like me to elaborate further on the diagnostic criteria for any of the specific encephalitis types mentioned?

[8:02 pm, 31/10/2025] PPM 1: Please share the perplexity styled reference links for those case reports that @PPM9 can validate

[8:05 pm, 31/10/2025] PPM 4: Of course. The search results do contain several real patient case reports, with a strong emphasis on *COVID-19*, that document the association between viral infections and Posterior Reversible Encephalopathy Syndrome (PRES). These can be used for validation and further study.

Here is a summary of the key case reports and reviews available in the provided sources:

| Case Report / Study Focus | Virus/Infection | Key Findings & Clinical Presentation | Source & Link |

| :--- | :--- | :--- | :--- |

| *Case Series (8 patients)*  | *COVID-19* | Patients with severe COVID-19 pneumonia developed PRES. Notably, 5 of the 8 patients were *not hypertensive* at presentation, supporting the "endothelial dysfunction" mechanism. Common symptoms: seizures, impaired consciousness. | Journal of the Neurological Sciences<br>URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC7985961/ |

| *Case Report*  | *COVID-19* | A 59-year-old man with COVID-19 and labile blood pressure developed encephalopathy. Imaging showed classic PRES features, linked to the "cytokine storm" and endothelial injury from the virus. | Interdisciplinary Neurosurgery<br>URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC7308006/ |

| *Case Report (First in Australia)*  | *COVID-19* | A 55-year-old man with comorbidities and COVID-19 presented with confusion and hypertension. MRI confirmed PRES, and he recovered with blood pressure control. Discusses Renin-Angiotensin System disruption. | Frontiers in Neurology<br>URL: https://pmc.ncbi.nlm.nih.gov/articles/PMC7875083/ |

| *Systematic Review (97 cases)*  | *Epstein-Barr Virus (EBV)* | This review consolidates data from 97 published cases of EBV encephalitis. It reports that *26%* of these patients presented with generalized tonic-clonic seizures. | Microorganisms<br>URL: https://www.mdpi.com/2076-2607/11/12/2825 |

| *Large Descriptive Study (556 cases)*  | *PRES (Various Etiologies)* | While not exclusively about infection, this large study of PRES with atypical regions confirms that *sepsis* is a major predisposing factor. Seizures were a presenting symptom in *41.9%* of all PRES cases. | Frontiers in Neurology<br>URL: https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2020.00194/full |

### 🔬 Key Pathophysiological Insights

The provided case reports strongly support the hypothesis we previously discussed: that viral infections can cause PRES through mechanisms *other than, or in addition to, severe hypertension*.

*   *Endothelial Dysfunction*: Multiple COVID-19 cases highlight that the virus can directly infect endothelial cells, leading to widespread endothelial injury and breakdown of the blood-brain barrier, which is a cornerstone of PRES development .

*   *Cytokine Storm*: The systemic inflammatory response and high levels of circulating cytokines in severe infections can directly cause endothelial dysfunction, triggering vasogenic edema.

### 🔍 How to Find More Specific Cases

The search results are heavily weighted towards COVID-19. To find case reports for other specific viruses (like dengue, influenza, or VEEV), you could:

*   Use the *PubMed* database directly with targeted search terms like "[Virus Name] posterior reversible encephalopathy syndrome case report".

*   Search *Google Scholar* for the same phrases to cast a wider net across various journals.

I hope these verifiable case reports and links are helpful for your team's analysis. If you identify a specific virus of interest beyond COVID-19, I can assist in searching for more targeted case reports.

[9:28 am, 01/11/2025] PPM 3: Subjective complaints: Patient is comfortably sitting on the bed

No complaints 

Objective:

Pr:90

Bp:110/70

Readings since yesterday:

Assessment: press syndrome 2 to viral encephalitis 

Post streptoccal glomerulonephritis 

Plan: Stopped the antihypertensive

Continuing the antiepileptic medication 

Uncertainties:

Why did encephalitis cause press?

Why was she susceptible to encephalitis?

Causative agent of encephalitis?

[10:15 am, 01/11/2025] PPM 3: Readings since yesterday 

Bp:

7 pm:110/70

12 pm:100/60

4 am:120/80

7 am:110/80 mmhg

[2:37 pm, 01/11/2025] PPM 1: What is the evidence in her urine of glomerulonephritis?

[2:38 pm, 01/11/2025] PPM 1: Answer to first uncertainty please check if it has been answered in the references above

For causative agent we should have sent the CSF for viral serology