THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS GUARDIAN'S VIDEO CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
Chest X-ray February 4, 2026 suspicious upper mediastinal enlargement?
Chest X-ray February 6
[4:54 pm, 11/02/2026] PPM 4: Having poor echo window sir...
[4:57 pm, 11/02/2026] PPM 1: Thanks
Lot's of visceral fat in this cardiac viscera contributing perhaps to the poor echoes but while LVH still stands out clearly, there doesn't appear to be anything remarkable about the RV here?
Please share the ECGs if possible.
06/02/2026 10/02/2026
[3.46 pm, 11/02/2026] PPM 1: CT video of the 75M patient
https://youtube.com/shorts/ygOC4OXB7lw?si=EB4F92NYQPg7g7j1
[12:09 pm, 12/02/2026] PPM 1: @PPM4 any luck with getting the HRCT images of this patient showing the blockage with a pointer?
[12:17 pm, 12/02/2026] PPM 4: Sorry for the delay sir.
Busy with yesterday cases. Shared the video in person..
I will try to point it sir.
[10:10 pm, 17/02/2026] PPM 1: CTPA labeled image with pointer showing right middle lobe pulmonary artery suspected thrombus
[10:16 pm, 17/02/2026] PPM 1: 👆Official report that influenced our next treatment plan
[11:06 pm, 17/02/2026] PPM 1: The catch in the history that led to the interesting turn of events in this patient's journey
Came to OPD. Seen by @PPM5 advised admission for LVF status monitoring but went home. Next day brought back as he appeared to have developed further shortness of breath. @PPM4, the local team lead, thought the breathlessness was too disproportionate to the echocardiography findings and hence ordered CTPA and D dimer both of which turned positive.
@PaJR Health @PPM3 what are the sensitivity and specificity for both CTPA as well as d dimer for ruling in pulmonary embolism?
[11:16 pm, 17/02/2026] PPM 1: @PPM6 can you share this patient's current fever chart as he's still in the ward with a possible cauti?
[11:45 pm, 17/02/2026] PaJR Health: The "catch" in this patient's history—the disproportionate breathlessness relative to echocardiography findings—was a critical clinical pivot. While the initial focus was on Left Ventricular Failure (LVF), the persistent and worsening dyspnea despite a relatively stable cardiac window (as noted in the Daily Log) correctly prompted the investigation into Pulmonary Embolism (PE).
Based on the clinical data and current research, here are the sensitivity and specificity metrics for CTPA and D-dimer:
*DIAGNOSTIC ACCURACY FOR PULMONARY EMBOLISM*
🔹 *D-DIMER (RULE-OUT TOOL)*
* *Sensitivity:* ~97% to 100%. Its primary value lies in its high Negative Predictive Value (NPV). A negative result effectively rules out PE in patients with low-to-moderate clinical probability.
* *Specificity:* ~41%. It is notoriously low because D-dimer can be elevated due to age, inflammation, infection (like the possible CAUTI mentioned in the logs), or recent surgery.
* *Clinical Insight:* In patients over 50, using an age-adjusted cutoff (Age x 10 µg/L) can increase specificity without compromising safety.
🔹 *CTPA (GOLD STANDARD FOR RULE-IN)*
* *Sensitivity:* ~94%. It is highly effective at detecting thrombi in the main, lobar, and segmental arteries.
* *Specificity:* ~98%. A positive CTPA is nearly definitive for PE.
* *Patient Correlation:* The HRCT/CTPA report from Feb 6 confirmed an acute 18x5 mm thrombus in the right middle lobe and a 5x6 mm thrombus in the right lower lobe, justifying the clinical suspicion.
*DIFFERENTIAL COMPARISON*
📋 *DAILY LOG FINDINGS*
The patient (75M) presented with metabolic syndrome and a history of stroke. While ECGs showed LVH and early repolarization, the "disproportionate" breathlessness was the key. The local team's decision to move beyond the "poor echo window" to a CTPA was decisive.
📋 *HOSPITAL RECORDS / CASE SUMMARY*
1. 75M Recent Breathlessness Metabolic syn, past stroke, current OA Telangana PaJR
(No direct link available in current retrieval)
*LITERATURE CITATIONS*
1. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. PMID: 24643601.
2. Systematic review and meta-analysis of test accuracy for the diagnosis of suspected pulmonary embolism. PMID: 32915980.
3. Precision in Pulmonary Embolism Diagnosis: Leveraging D-dimer Levels With CTPA Insights. PMID: 39328639.
💡 *CLINICAL LOGIC:* The positive D-dimer in this 75-year-old patient was expected but non-specific; however, the positive CTPA confirmed the diagnosis that the "disproportionate" symptoms suggested. The team should continue to monitor for the suspected CAUTI, as systemic inflammation will keep D-dimer levels elevated regardless of clot resolution.
[11:53 pm, 17/02/2026] PPM 3: *D-dimer* (typically used to rule out pulmonary embolism):
- *Sensitivity*: ~95% (range 90–99%)
- *Specificity*: ~50% (range 40–60%)
*CTPA* (computed tomography pulmonary angiography, the reference standard for diagnosis):
- *Sensitivity*: ~98% (range 95–100%)
- *Specificity*: ~98% (range 95–99%)
These values are approximate and may vary depending on the assay, patient population, and clinical setting. Note that D-dimer’s low specificity makes it unsuitable for ruling in PE, while CTPA is highly accurate for confirmation.
[6:45 am, 18/02/2026] PPM 2: You wouldn't believe how CTPAs are a welcome drink for all patients with breathlessness here in the UK.
Too many poor little frail ladies, who have incidentally detected PEs, are on DOACs and later come in with GI bleeds.
This one appears much on point, although how much of that breathlessness can be attributed to this PE I'm not sure. A 6 min walk test could be a good starter.
[6:47 am, 18/02/2026] PPM 2: I'm also assuming this patient never had a DVT?
The Well's score has run it's course and is unfit for modern medicine!
[8:05 am, 18/02/2026] PPM 1: Agree! Even in this patient I'm still sceptical of the CTPA interpretation inspite of the official radiology report. Also because we can't share the entire dicom with our LLMs it would be difficult to get an LLM second opinion on the radiology.
The other local handling issue was that of a doubtfully indicated Foley's catheter. Ask the nurses and they'll say he wasn't able to walk to the bathroom due to osteoarthritis! Not just the current cauti (@PPM6 will look forward to his fever chart yesterday and serial WBC counts today and was the foleys removed and the urine culture sent during repeat foleys insertion?) but the possibly needless Foleys insertion also instigated a urethral bleed post unfractionated heparin infusion after the CTPA diagnostic whammy!
Following that the urologists have mandated long term Foleys to prevent rebleed and looks like he's more likely to develop a stricture as is the wont of most unnecessary Foleys insertions globally? @PaJR Health @PPM3
[8.51 am, 18/02/2026] PPM 1: Chanced across this foleys associated daily checklist workflow around this patient that may be interesting in the light of the nurses study?
@PPM8 @PPM7
[9.37 am, 18/02/2026] PaJR Health: The clinical skepticism regarding the CTPA interpretation and the "needless" Foley catheter highlights a critical intersection of diagnostic over-reliance and iatrogenic risk. In this 75-year-old patient, the sequence of events—from a "doubtfully indicated" catheter to a heparin-induced urethral bleed—illustrates the "diagnostic whammy" where one intervention's complication necessitates further, often more invasive, management.
*CLINICAL AUDIT: FOLEY'S CATHETER & IATROGENIC RISKS*
🔹 *CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI)*
* *Current Status:* The "Foley's Associated Daily Checklist" (Feb 18) confirms the catheter was in place from Feb 4 to Feb 7. A repeat insertion occurred after the urethral bleed.
* *Red Flag:* The patient's osteoarthritis (OA) was cited as the reason for the initial Foley, despite it being a non-clinical indication. This "convenience" catheterization directly led to the current CAUTI and subsequent urethral trauma under heparinization.
* *Monitoring:* We are awaiting the fever chart and serial WBC counts. The urology mandate for "long-term Foley" to prevent rebleed significantly increases the risk of urethral stricture and persistent infection.
🔹 *HEPARIN & URETHRAL HEMORRHAGE*
* *Mechanism:* Unfractionated heparin (UFH) infusion, initiated for the suspected PE, exacerbated the minor trauma from the initial Foley insertion, leading to the urethral bleed.
* *Urology Conflict:* The mandate for long-term catheterization to "stent" the urethra against rebleed often creates a cycle of irritation and stricture formation in elderly patients with metabolic syndrome and fragile mucosa.
*DIFFERENTIAL COMPARISON: INCIDENTAL PE VS. CLINICAL SYMPTOMS*
📈 *THE "UK PHENOMENON" & OVERDIAGNOSIS*
* *Incidental PE:* As noted in the conversational logs, the rise of "incidental" subsegmental PEs on CTPA often leads to aggressive anticoagulation in frail patients, resulting in high-risk GI or urogenital bleeds.
* *This Case:* While the CTPA (Feb 6) showed an 18x5 mm thrombus (70-80% occlusion) in the right middle lobe, the skepticism regarding how much this contributes to his breathlessness is valid. A 6-minute walk test (6MWT) would be a superior functional assessment once he is stable.
*HOSPITAL RECORDS & CASE CITATIONS*
📋 *RELEVANT CASE RECORDS*
1. 75M Recent Breathlessness Metabolic syn, past stroke, current OA Telangana PaJR
2. 75M PUO, hypotension, complicated UTI, post TURP 1 week, CKD 1yr, Diabetes 2yrs Telangana PaJR
3. 74F UTI Metabolic Syn Stroke, Acute Scald Recent WB PaJR
💡 *CLINICAL INSIGHT:* The "catch" was the breathlessness, but the "trap" was the Foley. The focus must now shift to "de-prescribing" the catheter as soon as the urological bleed is stable to prevent a permanent stricture. The 6MWT will provide the necessary evidence to determine if the "PE" is truly the driver of his dyspnea or merely an incidental finding in a patient with HFpEF and metabolic syndrome.
[9.53 am, 18/02/2026] PPM 1: 👆@PPM9 @PPM10 @PPM7 @PPM11 was this case a flow integrator or a flow disruptor as per the paper shared by Ayushi on email?
[7.13 pm, 18/02/2026] PPM 10: On the one hand, it feels like flow disruption for the usage of Foley’s in a non indicated manner (OA) sir, but then the urethral bleed prompted a re-insertion, so that particular event onwards, flow integration?
[8:47 pm, 18/02/2026] PPM 1: What about the diagnostic uncertainty between initial LVF and later pulmonary embolism?
[8:54 pm, 18/02/2026] PPM 1: On the one hand, it feels like flow disruption for the usage of Foley’s in a non indicated manner (OA) sir, but then the urethral bleed prompted a re-insertion, so that particular event onwards, flow integration?
And what about the fact that this may later lead to urethral stricture.
However flow integration here would be how the PaJR global team is able to integrate with the local workflow around this person with all the real time clinical audit in the sense , is the audit revealing that the PaJR global human platform agents and non PaJR local human hospital agents are in sync and moving smoothly in the same direction toward destination recovery or is the PaJR audit making the local team change directions (often it begins with hearing the GPS say, take a U turn!), which would then be termed flow disruptive? @PPM9 @44FPA @PPM12 @PPM7
[3:51 pm, 20/02/2026] PPM 1: Update
[18/02, 10:29]hu2: Thanks
Any leucocytosis on serial hemograms since admission?
[19/02, 07:21]hu1: No sir
[19/02, 07:28]hu2: We needed to have another fresh chest X-ray after his sudden shortness of breath yesterday?
[19/02, 07:33]hu1: Xray not done yesterday
[19/02, 07:56]hu2: Alright. Currently it may be a bit late to capture if his yesterday's shortness of breath was due to pulmonary edema (characteristic chest X-ray features) or pulmonary embolism (normal chest X-ray)?
[19/02, 07:57]hu2: 👆Please share the updated fever chart
[19/02, 08:09] hu1: He suddenly had shortness of breath yesterday 3am while he wake up and went to washroom, he recovered with in 30 min after shifting to AMC, no fever spikes since yesterday, now he is in the …
[4:44 pm, 20/02/2026] PPM 1: EMR summary:
75M
Date of admission 4/2/26
Discharge Date:
19/2/26
- --
[20/02, 16:40]: DIAGNOSIS
- Submassive pulmonary thrombosis (right middle and lower segments)
- HFPEF with biventricular hypertrophy
- Emphysema with left lower lobe bronchiectasis with Type 1 respiratory failure
- Obstructive sleep apnea
- Known case of hypertension (since 2 years)
- Known case of CVA with left hemiparesis (since 10 years)
- --
[20/02, 16:40] August AI: PRESENTING COMPLAINT & HISTORY
- Shortness of breath since 20 days
- Bilateral pitting pedal edema since 20 days
- Non-productive cough since 20 days
- Asymptomatic 1 month prior; SOB developed insidiously, gradually progressive (Grade II-III)
- Aggravated on eating food
- No chest pain, palpitations, orthopnea, or PND
- Bilateral knee pains with difficulty walking
- No headache, cold, body pains, vomiting, or sweating
- --
[20/02, 16:40] August AI: PAST MEDICAL HISTORY
- Hypertension (2 years) on Tab Telma 40mg (stopped 1 week prior)
- CVA with left hemiparesis (10 years) on Tab Citicoline + Piracetam
- No known history of T2DM, hypothyroidism, TB, CAD, epilepsy, or bronchial asthma
- --
[20/02, 16:40] August AI: PERSONAL HISTORY
- Married, laborer
- Normal appetite, mixed diet
- Regular bowel and bladder habits
- Adequate sleep
- No allergies
- Tobacco smoker (stopped 5 years ago)
- --
[20/02, 16:40] August AI: GENERAL EXAMINATION
- No pallor, icterus, cyanosis, clubbing, or lymphadenopathy
- Pedal edema Grade II
- Vitals: Temp 98.6°F, BP 140/80 mmHg, RR 20 cpm, PR 90 bpm
- --
[20/02, 16:40] August AI: SYSTEMIC EXAMINATION
- CVS: S1 S2 present
- RS: Bilateral air entry present, normal vesicular breath sounds
- Per Abdomen: Soft, non-tender
- CNS: GCS E4V5M6, normal tone in all limbs, power 5/5 in all limbs
- Reflexes: Biceps, triceps, supinator, knee, ankle all +2; plantar flexor bilaterally
- --
[20/02, 16:40] August AI: INVESTIGATIONS
[20/02, 16:40] August AI: Hemogram:
- (4/2/26): HB 12.5, TLC 7000, RBC 4.4, PLT 3.4
- (13/2/26): HB 11.1, TLC 5800, RBC 3.27, PLT 2.6
[20/02, 16:40] August AI: RBS (4/2/26): 91 mg/dL
[20/02, 16:40] August AI: Urine Routine (4/2/26): Albumin nil, sugar nil, pus cells 2-3, epithelial cells 2-3, RBC nil
[20/02, 16:40] August AI: Liver Function Test (4/2/26):
- Total bilirubin 1.0 mg/dL, direct bilirubin 0.2 mg/dL
- SGOT 19.7, SGPT 22.4 mg/dL
- Alkaline phosphatase 189.7 IU/L
- Total proteins 6.3 g/L, albumin 3.7 g/dL, globulin 2.40 g/dL
- A/G ratio 1.32
[20/02, 16:40] August AI: Renal Function Test:
- (4/2/26): Urea 37, creatinine 1.2 mg/dL; Na 138, K 4.3, Cl 98 mEq/L
- (9/2/26): Urea 32, creatinine 1.0 mg/dL; Na 136, K 3.7, Cl 98 mEq/L
[20/02, 16:40] August AI: D-Dimer (6/2/26): 1310
[20/02, 16:40] August AI: Serology: Negative
[20/02, 16:40] August AI: Arterial Blood Gas:
- (4/2/26): pH 7.335, PCO2 29.3, PO2 69.6, HCO3 15.2
- (8/2/26): pH 7.35, PCO2 28.2, PO2 65.5, HCO3 15.4
- (9/2/26): pH 7.36, PCO2 28.3, PO2 63.8, HCO3 15.9
[20/02, 16:40] August AI: 2D Echocardiography (4/2/26):
- Mild aortic regurgitation, trivial tricuspid regurgitation
- No pulmonary hypertension, no pericardial effusion
- Trivial mitral regurgitation
- No regional wall motion abnormality, no aortic/mitral stenosis
- Sclerotic aortic valve
- Good LV/RV systolic function
- Grade I diastolic dysfunction
- No LV clot
- Concentric LVH and RVH present
- IVC 0.5 cm, collapsing
- EF 57%
[20/02, 16:40] August AI: USG Abdomen & Pelvis (7/2/26): Raised echogenicity of bilateral kidneys
[20/02, 16:40] August AI: Venous Doppler of Bilateral Lower Limbs (9/2/26): No DVT; all examined veins show normal color uptake, compressibility, respiratory plasticity, and augmentation positive
[20/02, 16:40] August AI: HRCT Chest (6/2/26):
- Acute thrombus 18×5 mm in right middle lobe segmental pulmonary arterial branch with 70-80% luminal occlusion
- Acute thrombus 5×6 mm in right lower lobe segmental branch wit- h complete occlusion
- Mild paucity of pulmonary vasculature in right middle lobe (pulmonary oligemia)
- Small left apical fibrocalcific area with mild apical subpleural bronchiectasis with fibrotic bands
- Few subcentimetric hyperdense nodules in bilateral lungs (sequelae of old infection)
- Mild left upper lobe panlobular emphysema
- Incidentally detected bilateral lower lobe haziness (dependent atelectasis)
- Left mild apical pleural thickening
- Degenerative changes in spine
- --
[20/02, 16:40] August AI: TREATMENT GIVEN
- Fluid restriction <1.5L/day
- Salt restriction <2g/day
- Inj. Heparin 5000 IU IV stat
- Inj. Heparin 25000 IU in 45ml NS @ 3ml/hr
- Inj. Heparin 3000 IU IV TID
- Inj. Lasix 40mg IV OD
- Tab. Telma 40mg PO OD
- Tab. Ecospirin AV 75/10mg PO HS
- Tab. Metoprolol 50mg PO OD
- Tab. Cefixime 200mg PO BD for 3 days
- Syp. Cremaffin 15ml PO HS
- --
[20/02, 16:40] August AI: DISCHARGE ADVICE
- Tab. Metoprolol 50mg PO OD (8am)
- Tab. Ecospirin 75/10mg PO HS (8pm)
- Tab. Cinod 10mg PO OD (8am)
- Tab. Apixaban 5mg PO BD (8am and 8pm)
- Tab. Cefixime 200mg PO BD for 3 days
- Tab. Pantoprazole 40mg PO OD for 3 days
- Tab. Paracetamol 650mg PO SOS
- --
[20/02, 16:40] August AI: FOLLOW-UP
- Review to Medicine OPD after 1 week or SOS
- --
[11.51 am, 26/02/2026] PPM 1: Reviewing in OPD today after discharge on 19/2/26
Symptomatic largely at night with orthopnea
Yesterday had severe orthopnea for which the local rural medical practitioner was brought to their home for iv after which he passed a lot of urine and his dyspnea reduced
His tablet lasix during discharge had been missed.
The RMP called right now and clarified that he had given 100 mg of iv theophylline
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