[6.37 am, 7/8/2026] cm: 👆Gait quiz shared by intern @huai142 @huai143 @huai144
[8.01 am, 7/13/2026] cm: Because of our current multiple LLM testing project for real PaJR patient queries, I have developed this obsession for testing many of the multiple online user driven queries I come across in various groups and often tend to run them both through the PaJR search engine here: https://pajrhealth.com/
as well as Google Gemini here: https://gemini.google.com
Wish I had time to run them through more LLMs. This particular query may be of interest to @huai22@huai145 @huai13 @huai130
As one can see the evaluation of the LLMs is left to human qualitative judgement for now but would be nice to see if there is a rubric for that we can use to evaluate which of these two LLMs below score over the other? @huai24
UDLCO CRH:Naku ipudu 5th month NT scan normal report vachindi but NIPT screenings test lo border line risk for trisomy -21 chromosome ani vachindi
[13/07, 07:17]hu1: This is from a group.
Please advise what she should do. 🙏
Hello all nenu chala tension and bada to ee post rastunna 3 months back 36 years pregnancy gurinchi post chesanu Naku ipudu 5th month NT scan normal report vachindi but NIPT screenings test lo border line risk for trisomy -21 chromosome ani vachindi next test aminocentesis suggest chesaru em cheyalo ardam avadam ledu tension ga undi Evarina ee pblm face chesara and NIPT lo risk vachi aminocentesis positive vachina vallu unnara ee group lo chala experience vallu unnaru so please chepandi..
[13/07, 07:36]hu2: Can paste the above text here👇 https://pajrhealth.com and see the answer
PaJR health answer:
It is completely understandable that you are feeling anxious; receiving a "borderline" or "high-risk" result on a screening test is a stressful experience for any expectant parent. Please know that you are not alone in facing this, and it is important to understand what these results actually mean.
### Understanding the NIPT Result
It is vital to remember that **NIPT (Non-Invasive Prenatal Testing) is a screening test, not a diagnostic test.**
* **Screening vs. Diagnostic:** A screening test like NIPT only tells you the *statistical probability* of a condition. It does not provide a definitive "yes" or "no" diagnosis.
* **"Borderline" Results:** A borderline result means the probability is higher than the general population, but it is still a probability. Many women who receive a "high-risk" or "borderline" NIPT result go on to have perfectly healthy babies after further testing.
### The Role of Amniocentesis
Your doctors have suggested an **amniocentesis** because it is a **diagnostic test**.
* **Why it is recommended:** Unlike NIPT, which looks at DNA fragments in your blood, amniocentesis analyzes the actual chromosomes from the baby's cells. It provides a definitive answer regarding whether the baby has Trisomy-21.
* **The Decision:** This is a deeply personal decision. Many parents choose to proceed with amniocentesis to gain certainty and prepare for the future, while others may choose not to for various personal or medical reasons.
### Next Steps for You
1. **Genetic Counseling:** Before making any decisions, request a session with a genetic counselor. They are trained to explain these complex results in the context of your specific pregnancy, help you weigh the risks and benefits of amniocentesis, and provide the emotional support you need right now.
2. **Ask Your Doctor:** Ask your obstetrician or the genetic counselor specific questions:
* What was the exact "risk score" or probability provided by the NIPT?
* What are the specific risks of amniocentesis at your hospital/clinic (e.g., risk of miscarriage, which is typically very low in experienced hands)?
* Are there other diagnostic options available?
3. **Take Your Time:** You do not need to make a decision immediately. Take the time you need to process this information, talk it over with your partner or a trusted family member, and get all the information you need to feel comfortable with your choice.
Please lean on your healthcare team—they are there to guide you through this process, not just to provide tests. You are doing the right thing by seeking information and support.
Google Gemini:
This is an incredibly stressful situation, and it is completely natural for her to feel anxious and overwhelmed. Receiving a borderline risk result on an NIPT (Non-Invasive Prenatal Testing) screening can be terrifying, but it is important to understand exactly what this test means and what the next steps look like.
Here is a breakdown of the situation and the best medical advice to guide her through this:
1. Understanding NIPT vs. Amniocentesis
NIPT is a screening test, not a definitive diagnosis: NIPT looks at fragments of fetal DNA circulating in the mother's blood. While it is highly accurate, a "borderline risk" or "high risk" result does not mean the baby definitely has Down syndrome (Trisomy 21). It simply means the probability is higher than average, flagging the need for further evaluation.
Amniocentesis is a diagnostic test: This test analyzes the actual fluid surrounding the baby. It provides a definitive, clear "yes" or "no" answer regarding chromosome conditions.
2. Can NIPT be positive while Amniocentesis is normal?
Yes, absolutely. There are many documented cases where an NIPT indicates a risk for Trisomy 21, but the subsequent amniocentesis comes back completely normal (this is called a false positive). False positives can happen for several reasons, such as confined placental mosaicism (where abnormal cells are present only in the placenta, but the baby is perfectly healthy). The fact that her 5th-month NT/anomaly scan was normal is a reassuring sign, though it does not completely rule out the risk on its own.
3. Recommended Next Steps
1. Consult a Fetal Medicine Specialist or Genetic Counselor Immediately:
Before making any hasty decisions, she should sit down with a specialist who can look at her specific risk ratios from the NIPT report alongside her scan details. They can explain the exact probabilities and walk her through the diagnostic options.
2. Proceed with the Amniocentesis:
If she and her family want a definitive answer to prepare for the future or make informed decisions, proceeding with the amniocentesis is the standard and recommended medical path.
Safety Note: Amniocentesis is performed under continuous ultrasound guidance by experienced specialists. While it carries a very small risk of complications (less than 0.5%), modern medical protocols make it a highly controlled and safe procedure.
3. Emotional and Psychological Support:
Waiting for these results is agonizing. She should lean heavily on family support and avoid spending hours reading random online forums, which often increase panic. Every pregnancy is unique, and statistical probabilities on a screening test do not equal a final outcome.
Advice to pass along to her:
Please reassure her that a borderline NIPT is an invitation to look closer, not a final diagnosis. Proceeding with the amniocentesis will give her the clear answers she needs to move forward with certainty. She should book an appointment with a fetal medicine expert as soon as possible to discuss the logistics of the test.
[8:12 AM, 7/13/2026] cm: @PaJR Health what could be the reason for his high pulse pressure where one would expect to clinically palpate a water hammer pulse in this situation?
[8:12 AM, 7/13/2026] cm: The digital blood pressure monitor displays a blood pressure of *145/50 mmHg, representing a profoundly widened **pulse pressure (PP) of 95 mmHg* in this 82-year-old patient.
Clinically, this hemodynamically extreme presentation is highly characteristic of the pathophysiological mechanisms detailed below, where a bounding, rapid-rising, and collapsing *water hammer (Corrigan's) pulse* would be expected upon physical palpation.
Double line breaks separate the distinct clinical sections:
*1. ACCELERATED ARTERIAL STIFFNESS & MEDIAL CALCINOSIS*
The combination of advanced age (82 years), a 30-year history of diabetes, and a 13-year history of Stage 4 CKD creates a perfect storm for severe arterial remodeling. In chronic kidney disease, mineral bone disorder (CKD-MBD)—characterized by hyperphosphatemia and abnormal calcium-phosphorus products—drives extensive vascular calcification, particularly within the medial layer of the large conduit arteries (Mönckeberg's medial sclerosis). This calcification destroys the elastic fibers of the aorta, leading to a rigid, non-compliant arterial tree. During systole, the stroke volume is ejected into a stiff aorta that cannot expand, driving the systolic blood pressure (SBP) up to 145 mmHg.
*2. LOSS OF THE WINDKESSEL EFFECT*
In a healthy, compliant vascular system, the elastic aorta stretches during systole to store kinetic energy and recoils during diastole (the Windkessel effect) to maintain perfusion pressure, keeping diastolic blood pressure (DBP) within a normal physiological range. When the aorta is calcified and rigid, it fails to store this energy. Consequently, systolic flow runs through the arterial tree too quickly, and during diastole, there is a rapid, steep drop in arterial pressure down to 50 mmHg. This precipitous diastolic drop, combined with the high systolic peak, generates a bounding arterial pulse that rapidly swells and immediately collapses—the classic "water hammer" sensation felt on palpation.
*3. HEMODYNAMIC INSTABILITY AND VENTRICULAR MISMATCH*
This widened pulse pressure of 95 mmHg indicates a highly non-compliant, steep volume-pressure relationship. As documented in the literature, this makes the patient exceptionally prone to hemodynamic instability [[Arterial hypertension, chronic renal insufficiency and dialysis]. - PMID:18340681](https://pubmed.ncbi.nlm.nih.gov/18340681/). Small fluctuations in fluid volume can cause rapid swings from severe hypertension to deep hypotension (such as the critical 86/43 mmHg hypotensive episode logged previously). Furthermore, a low diastolic blood pressure of 50 mmHg significantly compromises coronary artery perfusion, which occurs almost entirely during diastole, placing this geriatric patient at high risk for subendocardial myocardial ischemia.
[8:12 AM, 7/13/2026] PaJR Health: *PHYSIOLOGICAL MECHANISM OF HIGH PULSE PRESSURE*
A high pulse pressure (the difference between systolic and diastolic blood pressure) is primarily driven by two hemodynamic mechanisms:
1. *Increased Stroke Volume:* A large volume of blood is rapidly ejected into the arterial system during systole.
2. *Decreased Peripheral Vascular Resistance or Diastolic Runoff:* Blood rapidly exits the arterial tree during diastole. This can occur either backward into the left ventricle (as in aortic regurgitation) or forward into a low-resistance vascular bed (such as in a large arteriovenous fistula, patent ductus arteriosus, or severe systemic vasodilation/hyperdynamic states like thyrotoxicosis, severe anemia, or sepsis).
---
*CLINICAL PALPATION OF A WATER HAMMER (CORRIGAN'S) PULSE*
To optimally elicit and clinically palpate a water hammer pulse (also known as Corrigan's pulse in the carotid arteries, though the term "water hammer" specifically refers to the peripheral arteries), you should use the following physical examination technique:
1. *Position the Patient:* Have the patient lie supine.
2. *Palpate the Radial Artery:* Grasp the patient's wrist by wrapping the palmar surface of your fingers (specifically using the fleshy pads of your fingers, which are highly sensitive to rapid pressure changes) across the patient's radial artery.
3. *Elevate the Arm:* Raise the patient's arm vertically above the level of their heart.
4. *Clinical Reasoning for Elevation:* Elevating the arm utilizes gravity to accelerate diastolic runoff. This causes the diastolic pressure in the elevated limb to drop even further, maximizing the contrast between the rapid, forceful systolic distension and the sudden, complete diastolic collapse of the arterial wall. You will feel a sharp, tapping impact (the "water hammer" blow) against your fingers at the start of systole, followed by an immediate empty sensation as the vessel collapses.
*Citations:*
1. [Water hammer and Corrigan's pulses. - PMID:35846943](https://pubmed.ncbi.nlm.nih.gov/35846943/)
[9.01am, 7/13/2026] huai19: https://github.com/maziyarpanahi/openmed
Clinical examination continued
[12:11 PM, 7/14/2026] cm: Question:How do we know what is the normal time in seconds expected for a 52 year old man to keep appreciating a tuning fork vibration applied to his shin?
[11:46 AM, 7/14/2026] cm: Seeing him in OPD now
Answer:
Medical professionals establish the normal duration of vibration perception by comparing a patient's response to standardized, age-adjusted normative data gathered through clinical studies. For a 52-year-old man, the expected duration on the shin or ankle is determined by starting with a baseline expectation for young adults and applying age-based subtractions. [1, 2, 3, 4]
How the Standard is Determined
* Baseline Norms: Using a standardized low-pitched tuning fork (typically 128 Hz) struck with identical force, healthy young adults (under 40) generally perceive vibrations on bony prominences for ≥ 10 to 15 seconds.
* Age-Adjusted Decline: Scientific literature indicates that vibration thresholds decrease by approximately 1 to 2 seconds for every decade of life beyond age 40.
* Examiner Comparison: To account for subtle differences in the tuning fork and striking force, examiners will often apply the vibrating fork to the patient and immediately transfer it to their own body (such as their own wrist) to compare when the vibration naturally fades. [6, 7]
Why This Test Matters
* Anatomical Consistency: Sensations are expected to last longer on the arms (upper extremities) than on the legs (lower extremities).
* Clinical Significance: Timed perception of <10 seconds at the great toe or ankle usually prompts a more detailed neurological evaluation to screen for conditions like peripheral neuropathy. [1, 2, 7, 8, 9]
Specialized Tools
Instead of a simple timed test, many neurologists rely on a calibrated, numbered tuning fork known as the Rydel-Seiffer tuning fork. This tool features a scale that allows clinicians to read the exact vibration threshold number when the patient stops feeling the vibration, automatically correcting for variables like age. [1, 2, 8]
Would you like to know:What a typical Rydel-Seiffer score for a 52-year-old looks like?
[5] https://www.droracle.ai/articles/1329883/what-is-the-normal-duration-of-vibration-sense-perception
[3.03 pm, 7/14/2026] cm: There is a FM position in Richmond Indiana at Reid health for PGY1 open. The candidate couldn’t get visa. They require good scores, no visa requiring and within 5 years graduation.
For the Reid Health Family Medicine Residency (PGY-1) opening in Richmond, Indiana, here is the contact information:
Program Contact
* Tiffany Ridge, CPPM, DASPR
* Director, Medical Education & Research / Residency Program Coordinator
* Email: fmresidency@reidhealth.org
* Direct Email: Tiffany.Ridge@reidhealth.org
* Phone: (765) 935-8808
Program Director
* Dr. Donald G. Smith, MD
* Program Director, Family Medicine Residency
Program Address
* Reid Health Family Medicine Residency
* 1100 Reid Parkway
* Richmond, IN 47374
Eligibility (per program)
* Medical school graduation within the past 5 years
* USMLE ≥227 (or COMLEX Level 2 ≥450)
* No visa sponsorship (must already be authorized to work in the U.S.)
* ECFMG certification accepted for IMGs who otherwise meet eligibility requirements.
This would be the best contact for candidates interested in the unexpected PGY-1 opening.
[10:15 AM, 7/19/2026] cm: Tomorrow's academics:
Student CPC
Venue: LT1
Time: 8-9 AM
Case 1:
Type 1 Respiratory Failure with Refractory Shock. Sepsis with MODS(HAP).
High Grade Lymphoma involving Liver, Spleen, BM and Pancreas
👆Critical care with internal medicine aka pathology @huai146 @huai147
Clinical discussant:
Dr. Kamrul
Pathology discussant:
Dr.Ruchika
Clinical Incharge:
Prof Pankaj Malhotra
Case 2:
Hodgkin Lymphoma(treatment naive), conjugated hyperbilirubinemia (?Liver infilteration), CAP, AMS under evaluation (HE,IC Bleed, HLH)
Clinical discussant:
Dr Vivek
Pathology discussant:
Dr.Nitin
Clinical Incharge:
Dr Arihant
Chairperson:
Dr. Mallika Y
The session will be available on online webEx platform link details provided below.
Thank you
[1:51 PM, 7/20/2026] huai34: https://www.nejm.org/doi/pdf/10.1056/NEJMoa2501006
[3:12 PM, 7/20/2026] cm: 👆@huai4 @huai135 @huai148 @huai24 @huai2 @huai27 would you have the full text access to this article?
[3.30 pm, 7/20/2026] huai2: https://1drv.ms/b/c/83fd19b3363f46cd/IQBqNmDU4AHVRbJ_SpCOWOcoAbju8cpKjLTEvGkNjLFsi58?e=wJPwu3
[3:32 PM, 7/20/2026] cm: 👆@huai34
[3:32 PM, 7/20/2026] cm: https://medicinedepartment.blogspot.com/2025/03/udlco-crh-soulful-journal-club-on-oral.html?m=1
[3:48 PM, 7/20/2026] huai2: My experiences and I'm sure the department's experiences here have been very different.
[3:48 PM, 7/20/2026] cm: Please share here if possible
[3:54 PM, 7/20/2026] huai2: Dramatic changes in A1c, weight and as a result insulin resistance.
Very often patients with complex diabetes do not get clear cut labels of Type 1, 2 etc. They get KPD, LADA / 1.5 etc. and are not included in these trials?
But they have such remarkable improvements in their outcomes that it has certainly made a mark on us.
Quite often patients who have been labeled as Type 1, I get a c-peptide and paired glucose for then and turns out quite a few have a modest reserve of C-peptide and they respond very well to GLP1 (particularly the injectables)
This saves potential Insulin pump costs, discharge from tertiary Healthcare services once they reach A1c targets, slowed retinopathy and foot disease etc.
[3:55 PM, 7/20/2026] huai2: Has helped with PCOS, sleep apnea and other insulin resistance syndromes too! No trial is ever seeing that
[3:56 PM, 7/20/2026] huai2: Even for my skepticism, I think like Insulin (and antibiotics) in the last century, these will define this century.
[4:22 PM, 7/20/2026] huai27: Yes, our experience in adult Hepatology with GLP 1 has been great. The only problem is a lack of clarity on the endpoints and the rebound weight gain. Also, lack of long term AE data. I personally can't use much as they aren't licensed for pediatric MASLD
[4:24 PM, 7/20/2026] huai27: Our endocrinologists are using sema and liraglutide for childhood obesity and T2DM with great results. Marked weight loss, significant reduction in HOMA IR and HbA1C and in those with MASH, reductions in AST/ALT
[10.24 pm, 7/21/2026] cm: Welcome to the New Academic Session, 2026
The First Wednesday CPC of the academic session will be held tomorrow, July 22, 2026 at 08.00 hours (IST) in Lecture Theatre 1
The session will also be available on the Webex platform. Kindly follow the link below to join.
[9.20 am, 7/23/2026] cm:
[12:42 PM, 7/23/2026] huai54: Stop asking LLMs for the medical 'answer'—start auditing the reasoning. 🩺
I built a clinical case bench ( https://avi33tbtt.github.io/bench.html ) that lets you control the cognitive flow:
Dialogue: Socratic questioning for active learning.
Analytics: Fast, high-level diagnostic synthesis.
Pipeline: Deep-dive, multi-step cognitive scaffolding.
Run your own API keys, test different models, and see which one actually holds up under clinical scrutiny. #MedEd #HealthTech #AI
(Dm me to help setting your api key if needed)
[12:42 PM, 7/23/2026] huai54: https://youtu.be/--ooVySiPtE
[9.49 am, 7/24/2026] cm: OPD now
On examination:
Hypertonia in all four limbs
Hyperreflexia particularly in knees
Gait: ataxic
Rest CNS normal
Looked for his neck movements and found a new sign: Inability to touch the chin to the chest but able to touch his occiput to the bed (negative Narketpally sign)
Impression hypothesis:
Cervical OPLL as a result of the prevalent elemental toxin
https://youtu.be/it70h5mjEaw?is=8ZUhMSCugt0l_gsA
https://www.sciencedirect.com/topics/immunology-and-microbiology/vibration-sense https://youtu.be/it70h5mjEaw?is=8ZUhMSCugt0l_gsA
[4:13 PM, 7/24/2026] cm: 👆@huai145 did this quick study in her batchmates using the protocol above and to everyone's surprise found that all of them had perception lower than normal!
[4:14 PM, 7/24/2026] cm:👆We began to wonder if the tuning forks sent through Amazon were the culprit!
[4:33 PM, 7/24/2026] huai2: Joint position and movement more reliable
[8:00 PM, 7/24/2026] huai54: https://classworkdecjan.blogspot.com/2026/07/vibe-rounds-what-vibe-coding-looks-like.html?m=1
[9:08 PM, 7/24/2026] cm: We checked out this paper👇
Looks like 8 seconds is good enough, which is what the current intern batchmates demonstrated
Now we need to test the same on the great toe of all those individuals
[8:05 PM, 7/26/2026] cm: Tomorrow's academics:
Student CPC
Venue: LT1
Time: 8-9 AM
Case 1:
Aplastic Anemia with IC Bleed with pulmonary hemorrhage, refractory shock with respiratory failure
Clinical discussant:
Dr. K. Bala Saraswathi
Pathology discussant:
Dr. Hannah
Clinical Incharge:
Dr Ankur
Case 2:
Fever with sore throat for 9 days, swelling in the neck for 5 days, D/D: Strep TST, Diphtheria, DRESS Syndrome
Clinical discussant:
Dr Sreepriya
Pathology discussant:
Dr. Sudipa
Clinical Incharge:
Dr Sanjay Verma
Chairperson:
Dr. Sunitha G
The session will be available on online webEx platform link details provided below.
Thank you
[1.47 pm, 7/31/2026] huai144: What does this report says @huai147 ma'am?
She is a patient from West Bengal
[2:18 PM, 7/31/2026] huai147: Thrombocytopenia definitely
Hb is less but l don't agree with erythrocyte morphology at this MCV. .
[2:20 PM, 7/31/2026] huai144: Ohkk! Mam
[2:33 PM, 7/31/2026] cm: Ma'am what is your opinion on the possible reason for her thrombocytopenia given the MPV?
These were incidental findings on routine hemogram
[2:41 PM, 7/31/2026] huai147: Increased peripheral destruction of platlet is leading to release of early / immature platelets reflecting as High MPV
[2:41 PM, 7/31/2026] cm: Is this a usual finding in immune thrombocytopenia?
[2:42 PM, 7/31/2026] huai147: Yes sir
[3:10 PM, 7/31/2026] huai148: Start with common things
1. B12 and/or Folate deficiency with Iron deficiency
2. ITP
3. Myelodysplasia
[3:14 PM, 7/31/2026] cm: Thanks Ma'am.
Agree. An increased mean platelet volume (MPV) is commonly observed in immune thrombocytopenia (ITP), while truly "giant" platelets are more characteristic of inherited macrothrombocytopenias.
Perhaps a further review of the patient's slide may tell us if they're truly giant platelets
[3:45 PM, 7/31/2026] huai147: A microscopic review is a must because large or giant platlets are misinterpreted by the analyzer as RBC .. so both the platelet and RBC values may be wrong.
[3:57 PM, 7/31/2026] huai144: Ok ma'am
[4:56 PM, 7/31/2026] cm: However in the context of this patient being from West Bengal, this could be a new disease that was first discovered in 2002 from Bengali long distance patients traveling to South Indian hospitals aka Bengal Macro thrombocytopenia first reported from CMC Vellore!👇
Later it was renamed Harris syndrome after the first author from CMC Vellore:
The syndrome was subsequently developed further by pathologist, Kanjaksha Ghosh's team (later retired as ICMR director) who studied the differential expression of genes in Bengal macrothrombocytopenia (BMTCP) here: https://www.sciencedirect.com/science/article/abs/pii/S1079979615001710?via%3Dihub
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