Narketpally Syn CBBLE: Participatory medical cognition Web 2.0-3.0, February 2025

 

01/02/2025, 08:20 - cm: Somewhat similar to this?👇

https://youtu.be/PaXzo3qRgu0?feature=shared

01/02/2025, 15:04 - cm: Ward afternoon session: 

Patient centred notes on longevity:

I'm right now looking at an 87M lying in front of me in the ward bed 6 and clearly he has lived long but since last 3 years he has slowly lost his brain functioning and even when I ask his name he is unable to tell me more than 10% of it in Telugu! He is not oriented well enough to time, place and person and while remembers his past and family members his communication with them and ability to form new connections is seriously hampered due to his inability to communicate as well as remember!

@cr is preparing his case report from his data shared earlier in the collective group but overall on going through his external medicine events and internal medicine findings, we think the cause is a vascular neurodegenerative disorder. Will add him to our project on it here: https://96sanjanapalakodeti.blogspot.com/2023/05/ajnd-paper.html?m=1

I wonder what longevity really depends on?

Is it just good genes?

Or is it good environment (non toxic, non damaging to cells and vessels made of cells)?

Or is it behavioural? How we behave with other beings and this planet to create persistent and long connections?

01/02/2025, 15:26 - cm: The two ECGs above and below are a minute apart

01/02/2025, 15:30 -cm: Today is Day 5, K2

01/02/2025, 16:30 -cm: Case report compiled by @cr here 👇https://pajrcasereporter.blogspot.com/2025/02/31f-congenital-obesity-metabolic-syn-wb.html?m=1

01/02/2025, 16:34 - pajr.in CEO, NHS Endocrinologist: Junctional rhythm with frequent sinus capture?

01/02/2025, 16:36 - cm: Or the opposite with sinus arrest and junctional escapes?

01/02/2025, 16:50 - cm: PaJR case report: https://pajrcasereporter.blogspot.com/2025/02/87m-with-cerbral-vascular.html?m=1

01/02/2025, 16:57 - cm: Further video Imageology:

https://youtube.com/shorts/oeqTfy0f3bc?feature=shared

01/02/2025, 16:59 - cm: 👆 Notice the change in the sphenoidal mass from 2022 here

01/02/2025, 17:18 - pajr.in CEO, NHS Endocrinologist: Yes. How can we differentiate between the two?

02/02/2025, 14:47 - cm: @cr would it be possible to add these feedback received from another group where i shared your case report of this patient?👇

[01/02, 19:40] cm: Will be grateful for your comments on the day 4 and 5 (today's) ECG of this patient of inferior wall myocardial infarction which are accessible here 👇https://pajrcasereporter.blogspot.com/2025/01/68m-of-acute-myocardial-infarction.html?m=1

[01/02, 22:02] EcG CME India: Thanks with regards 🙏🙏 for these series of ECGs

Ist ECG on the screen:

🔽 Junctional rhythm with Bradycardia (please see the inferior leads with inverted p in these leads),associated Low voltage

🔽 evidence of Acute MI in inferior leads :ST elevation  with tendency to have Q genesis

Plus

Anterior MI -as evident by mild ST elevation with the virtual loss of R > only visible as tiny r  in most of Anterior leads

Comments

Acute MI with inferior as well, site of lesion most possibly proximal LAD ,prior to its Diagonal branch.

I request you Sir to further rearrange the subsequent ECGs directly on the screen,so as to be visualised with more clarity.

My PRANAM SIR

🙏🙏

[01/02, 22:04]  EcG CME India: Proximal LAD with wrap art involvement

[01/02, 22:06] BKS CME India:  Bradycardia HR approximate 48

Recent IWMI, ectopic atrial rhythm 

Possible old AWMI

Possible hypokalemia

Possible SA node infarction or stunning leading to origin of ectopic atrial rhythm 

 Possible Site of origin of ectopic p wave superior to TA annulus

Site of occlusion prox RCA

[01/02, 22:37] cm: Thanks Sir

[01/02, 22:37] cm: Thanks Sir

[01/02, 22:39] cm : Sir if you click on the ECGs their resolution improves and one can zoom in easily

[01/02, 23:00] BKS CME India: @cm, there are many ecg on link you posted . I answered first ecg. It is very unfair to audience that they are reading our post without seeing ecg. Please take screenshot of all  ecg and post it with chronological order with foot note of comments like day,point of pre/post thrombolysis etc . Me and CME india sir will repost . Will be meaningful to our group members.  Thank

[01/02, 23:27] EcG CME India: Thanks cm Sir 

My regards to both of you 🙏🙏

I would like to revise My opinion after seeing the entire series of ECCs ,which I could not see earlier.

🔽 On the first ECG there is evidence of Acute inferior MI with more ST elevation in lead 111and simultaneous mild ST elevation in V1 as well, which should not be ignored and Rt sided chest leads would have been explored to assess it's true nature - 

Now it is more suggestive of the involvement of RCA-Proximal, please see the presence of  rhythm with P inversion in inferior leads with bradycardia - possible involvement due to the SA node leading to bradycardia and inverted p due to low ectopic p.

Initially by seeing the precordial leads this gave me the impression of the simultaneous involvement of anterior MI.

Since on last ECG the precordial leads  comes to normalcy through gradual steps  this confirms 

✅ there is mainly involvement of Proximal RCA with involvement of SA node with resultant Bradycardia and inverted p in inferior leads might be due to low ectopic p

This is known fact that with RCA involvement the changes are transient. may last for a few days only. ✅ There was transient anterior myocardial ischemia as well over anterior leads ,possibly due to shunting of blood therein.

Thanks with Regards 🙏🙏

NB: This would be my request that all the ECGs must have been posted directly serial wise on the front to have direct visualisation by All and then this would be meaningfull and appreciable to All the elite members of this group.. And interpretation would also be easier.

With Regards 

🙏🙏

[02/02, 14:37] cm : Thanks Sir for the valuable inputs along with Dr @⁨BKS CME India⁩ 

We try to record most of our cases as whole case reports that contain clinical, radiological and electrophysiology of the patients and this case report keeps getting updated in real time as a life time health record with all clinical images, radiology and electrophysiology available in a serial manner as per patient's timeline. There are over 5000 such cases available through our dashboard and it keeps growing everday. Our idea behind this is to create a case based reasoning engine toward supplementing what is currently labeled deep phenotypic data in age old precision medicine: https://pmc.ncbi.nlm.nih.gov/articles/PMC6163835/ 

Modern day AI driven LLMs make it easier for us to thematically analyse these case reports toward newer individual patient centred insights.

I can understand that it would be important to segregate just the serial ECGs for the audience here from the over-all patient data and I shall try to do this ASAP and share here again just that portion. 🙂🙏

02/02/2025, 15:40 - Patient Advocate 56F Migraine Hypothyroidism 2000: Sure, names can be added?

02/02/2025, 15:50 - cm: Let's just add their initials

02/02/2025, 15:51 - Patient Advocate 56F Migraine Hypothyroidism 2000: Okay

03/02/2025, 11:54 - Kolkata Medical College Intern: current disease activity of lumbosacral tuberculosis- ESR, CRP

Monitor for drug toxicity due to prolonged anti-TB therapy.

Manage metabolic syndrome components through lifestyle interventions and medication as appropriate.

03/02/2025, 11:57 -cm: Good inputs @huai116 

I may not go for the blood tests to assess systemic inflammatory activity as I feel it's easier and more effective to do it clinically but we are doing the others that you suggested 👍

03/02/2025, 11:58 - cm: Any thoughts on what could be responsible for his congenital bilaterally symmetric elbow arthritis causing bilateral fixed flexion deformity of his elbows since birth @13135550002?

03/02/2025, 11:58 - Meta AI: A very specific and intriguing medical question!

Congenital bilaterally symmetric elbow arthritis with bilateral fixed flexion deformity since birth is a rare condition. While I'm not a medical professional, I can try to provide some general insights and potential causes. Keep in mind that a definitive diagnosis and treatment plan should only come from a qualified medical specialist.

Possible causes or contributing factors to consider:

1. *Genetic disorders*: Certain genetic conditions, such as arthrogryposis multiplex congenita, can cause congenital joint contractures and arthritis.

2. *Developmental abnormalities*: Abnormalities during fetal development, like joint or muscle malformations, can lead to congenital deformities.

3. *Infectious or inflammatory conditions*: In utero infections, such as maternal autoimmune disorders or infections, might contribute to congenital arthritis.

4. *Musculoskeletal disorders*: Conditions like congenital elbow dislocation or radial head subluxation can cause fixed flexion deformities.

5. *Rare bone disorders*: Certain rare bone disorders, such as osteogenesis imperfecta or achondroplasia, can increase the risk of congenital joint deformities.

It's essential to note that each individual's situation is unique, and a thorough medical evaluation is necessary to determine the underlying cause of the condition.

A medical professional, such as an orthopedic specialist or a geneticist, would need to assess the individual's medical history, perform physical examinations, and potentially order imaging studies (e.g., X-rays, MRI) or genetic testing to diagnose the underlying cause of the condition.

If you or someone you know is affected by this condition, I encourage you to consult with a qualified medical professional for personalized guidance and care.

03/02/2025, 12:02 - Kolkata Medical College Intern: @cm yes sir, present is TB - to care treatment to give.

03/02/2025, 12:03 - Kolkata Medical College Intern: Yes sir, possible.

03/02/2025, 13:14 - cm: null

03/02/2025, 13:56 - Patient Advocate 56F Migraine Hypothyroidism 2000: Updated

03/02/2025, 15:13 - cm: This patient is also Diabetic since 10 years! Trying to fix his insulin dose. Wife is expert with the glucometer! @cr I guess she may get attached to PaJR

03/02/2025, 15:36 - Kolkata Medical College Intern: Chek Cardiac Enzymes (Troponin, CK-MB), 

I think,Beta-blockers, antiplatelets, ACE inhibitors, and statins might be considered as per clinical time

04/02/2025, 13:39 - huai25: Revision surgery followed by prosthesis. Currently crutch gait, iron supplements, DM control

04/02/2025, 16:19 - cms: Thanks

Yes notice from her image above she is still walking to our OPD using the limb prosthesis inspite of the ulcers. She should have been using a crutch!

04/02/2025, 16:38 - huai25: Pair. PT can train her for proper use after cardio clearance

04/02/2025, 19:08 - cm: Patient of Hodgkin's lymphoma who underwent an autopsy getting discussed in tomorrow's:

Staff CPC at PGI Chandigarh 

Time 8-9 am

Venue:LT1

The session will also be available on the Webex platform. Kindly follow the link below to join.

https://pgitelemed.webex.com/pgitelemed/j.php?MTID=mc03dd9d2c596303a145e8ffbce5478cd

In case you join in through WebEx, kindly ensure that your microphone and camera are switched off and PLEASE DO NOT SHARE YOUR SCREEN.

The Clinical handout of the case to be discussed is given below.

The clinical protocol will be presented by Dr. Sunil Taneja

Radiology will be presented by Dr. hb

Autopsy pathology will be presented by Dr. s

Clinician incharge - Dr. gp 

Chairperson - Prof. sj

Thank you

04/02/2025, 19:14 - cm: @se @919505766290 @cr @huai2I am biased to think that the patient of Hodgkins lymphoma, admitted with us till recently and case reported by our team here 👇https://narmeenshah.blogspot.com/2024/12/57m-tb-cervical-lymphadenopathy.html?m=1 is done better! 04/02/2025, 19:24 - pajr.in CEO, NHS Endocrinologist: That is probably because we have trained our eyes and all 4 cortical lobes to dismantle the proforma based patient data (like HOPI, past illness, drug history etc.) and build a narrative based patient data?

05/02/2025, 10:20 -  Kolkata Medical College Intern: Sir date..?

05/02/2025, 11:36 - cm: Yesterday it was mentioned as tomorrow. That means it was today

05/02/2025, 14:24 - cm: 👆@cr this patient's first admission

05/02/2025, 14:24 - cr: 👆will share his EMR summary from that time

05/02/2025, 14:26 - Patient Advocate 56F Migraine Hypothyroidism 2000: Okay

05/02/2025, 15:36 - cr: Yesterday's ultrafiltrate removal presumably was 3 liters

05/02/2025, 15:45 - Patient Advocate 56F Migraine Hypothyroidism 2000: Case report done

05/02/2025, 18:38 - cm: Clinical meet tomorrow 

Timing - 8 AM

Unit - Psychiatry 

Case: Two patients in Scotland, and Social determinants of Mental Health

Presenter - Dr.DB Prof. and HOD @huai2 he too spent some time like you in UK earlier and I guess will be sharing that experience.

Chairperson - DrSM

The session will be available on online webEx platform link details provided below. https://pgitelemed.webex.com/pgitelemed/j.php?MTID=mc03dd9d2c596303a145e8ffbce5478cd

05/02/2025, 21:48 -cm: Thanks

Here's the link: https://pajrcasereporter.blogspot.com/2025/02/59m-with-trunkal-obesity-hypertension.html?m=1

05/02/2025, 21:52 - pajr.in CEO, NHS Endocrinologist: Impressive.

06/02/2025, 07:27 -cm: Morning PaJR session between mutiple agents:

https://chat.whatsapp.com/DlAlL6pcfyYCZI4TFoeJ7O

Conversational Transcripts from yesterday between multiple agents:

[05/02, 08:21]pm: Let us know his blood sugar after two hours

[05/02, 20:18] pa1: How many units take?

[05/02, 20:19] pa1: Plain insulin

[05/02, 20:20] pa: Night test

[05/02, 20:52] pm: How much taken before lunch?

[05/02, 20:53] pm: Take 14U plain insulin

8U mixtard

[05/02, 21:30] pa1: 6 plain insulin 4 mixtard

[05/02, 21:31] pm: That was too less! Why? What was the blood sugar after lunch?

[05/02, 21:32] pa1: 370 sugar

[05/02, 21:32] pm: Before lunch should have been only plain insulin 10U

[06/02, 07:09] pa1: Morning test

[06/02, 07:18] pm: Today before breakfast take 16U plain and 10U mixtard and share the sugar value two hours after that

Dynamic EHR here 👇

https://pajrcasereporter.blogspot.com/2025/02/40m-with-diabetes-since-10yrs.html?m=1

06/02/2025, 08:09 - cm: Morning diabetes PaJR agent analytics query (at the bottom):

https://chat.whatsapp.com/HnnZ7fKgAm4IBlBABqkJhO

Agent conversational Transcripts:

[03/02, 18:25] Patient Advocate 2F Diabetes1: 03.02.25

7.45am fasting blood sugar 53

7.45am milk with 2/3 packet of chocos

8.15am nuts 

9.45am mixed fruits and 1/4 of sandesh (prasad)

1.15pm blood sugar 365

1.15pm 6u lispro insulin 

1.20pm khichudi, brinjal fry one pc, cabbage (ghonto)

[03/02, 19:10] pm: Time to reduce lantus to 4U tonight

[04/02, 07:07] Patient Advocate 2F Diabetes1: 6.45pm oats 

9.15pm 5u lantus 

9.30pm blood sugar 211

9.30pm 1u lispro insulin 

9.35pm dinner with rice, brinjal, cabbage, geen peas, butter , 1/2 pc pakoda (mashroom) and salad

[04/02, 07:09] Patient Advocate 2F Diabetes1: এটা পরে দেখেছি স্যার

[04/02, 08:22] pm: Fasting sugars today?

[04/02, 10:02] Patient Advocate 2F Diabetes1: 7.45am fasting blood sugar 228

7.45am nuts 

8.00am milk 

9.45am 5.5u lispro insulin 

9.50am rice with pulses, brinjal, tomato, beans, bitter gourd, chayote, green peas, carrot, cauliflower, cabbage, egg and salad

[04/02, 22:43] Patient Advocate 2F Diabetes1: 11.45am orange 

1.30pm blood sugar 130

1.30pm 1u lispro insulin 

1.35pm rice with pulses, brinjal, spinach, carrot, cauliflower, fish and salad 

6.00pm 1/4 of samosha (except potato)

6.45pm banana 2pcs

9.15pm 5u lantus insulin 

9.45pm blood sugar 397

9.45pm 3.5u lispro insulin 

9.50pm dinner with as same as morning dish

[05/02, 09:42] Patient Advocate 2F Diabetes1: 5./02/25

7.45am fasting blood sugar 249

7.45am nuts 

8.00am milk

[06/02, 07:12] Patient Advocate 2F Diabetes1: 9.45am 2pcs chocolate biscuit 

10.45am 6u lispro insulin 

10.50am rice with pulses brinjal, tomato, pumpkin, carrot, cauliflower, cabbage, beetroot, beans, chayote, green peas, butter and salad  

11.30am lays 1/2 of small packet 

12.00noon pomegranate 

1.45.pm blood sugar 316

1.45pm 5.5u lispro insulin 

1.50pm lunch with same previous dish except butter and include fish 

4.00pm blood sugar 182

7.00pm oats

9.15pm 5u lantus insulin 

9.45pm blood sugar 259

9.50pm dinner with as same as lunch dish

[06/02, 08:05] pm: What drove the point of hypoglycemia to a sharp and sustained rise of hyperglycemia inspite of other parameters perhaps remaining constant? Off coupon one of the issues here is that we don't know if those parameters were actually constant

06/02/2025, 08:12 - cm: Yes shared by CME India although again proving causality may necessitate re challenge with the same drug

06/02/2025, 08:52 - cm: PaJR diabetes type 1 multi agent driven medical cognition analytics translated to shared decision outcomes:

https://chat.whatsapp.com/FhsR6McUGkTHueTmOWNYDZ

Multi Agent conversational Transcripts:

[04/02, 20:58] Patient Advocate 19f Diabetes Type 1: Good evening sir, today at 8:50pm pre dinner sugar level:133mg/dl.at 6:30am|18ulispro mix.at 1pm|16u lispro plain.at 9pm|lispro mix 20u

[05/02, 07:21] Patient Advocate 19f Diabetes Type 1: Good morning sir,today fasting sugar level:105mg/dl.

[05/02, 07:21] Patient Advocate 19f Diabetes Type 1: Lispro mix 16u

[05/02, 07:27] pm1: Three times lispro seems to be giving ideal control 👏👏

[05/02, 15:51]pm2: Agreed. In fact this is a reasonably good strategy and is followed here as well.

[05/02, 15:52] pm2: Can @⁨Patient Advocate 19f Diabetes Type 1⁩ your patient consider getting a Freestyle Libre 2 continuous glucose monitor just once?

We can see the Target in range with this strategy and perhaps make it long term.

[05/02, 19:18] Patient Advocate 19f Diabetes Type 1: Sorry sir, she couldn't offer that cost it was around thousand

[05/02, 19:18] Patient Advocate 19f Diabetes Type 1: 5 thousand

[05/02, 21:2: Yes I understand. Let me see if I can help in any other way.

[06/02, 06:15] Patient Advocate 19f Diabetes Type 1: Good morning sir, on6th february.at 6:10am fasting sugar level: 209.this may due to the cause of less units of lispro mix taken.9u instead of 20u because it was completed yesterday night itself.so patient will take plain and lantus from today sir

[06/02, 08:33] pm1: Does the patient want to switch back to 4 pricks as opposed to the good control obtained with the three pricks of lispro alone? 

[06/02, 08:41] pm3: The total dose also needs  to be taken into consideration sir, to say one is better over the other...3 pricks is more convinient to the patient we can continue the same sir...

[06/02, 08:43] pm3: Currently she's on 18- 16- 20 units (total - 54 units).

[06/02, 08:45] pm1: What was the previous total dose with 4 pricks that gave her the same ideal control?

[06/02, 08:45] pm3: Earlier 10-14-12 (+ 16 Lantus) = 52 units

[06/02, 08:46] pm3: No much difference

Dynamic EHR: https://pajrcasereporter.blogspot.com/2024/12/19f-denovo-type-1-diabetes-mellitus.html?m=1

06/02/2025, 12:19 - Patient Advocate 56F Migraine Hypothyroidism 2000: Definitely I can create PaJRs, but they are simply sending me the reports. One of the patient was sending me her BP readings and when asked for consent form, no response.

06/02/2025, 12:34 - cm: Yes will need to see how we may be able to harness multi agent AI to resolve this challenge.

Let me introduce @17169396005 who is a data scientist and has joined us yesterday to see what are the pressing AI healthcare requirements we and others have that can be tackled and scaled impactfully

06/02/2025, 12:37 - US Data Science AI Healthcare: Thanks for the introduction, Dr. Rakesh. Kindly let me know if anything related to AI is required

06/02/2025, 12:41- MD.AKRAM Kolkata Medical College Intern: PC- 

Post-operative abdominal issue

Arm adiposity with suspected familial inheritance

Blood Tests

1) Fasting blood glucose, HbA1c

2) profile (HDL, LDL, triglycerides)

3)Liver enzymes (AST, ALT)

4) Serum insulin levels

5)BP monitoring

••Referral for LMNA gene mutation testing commonly implicated in FPLD Type 2.(inheritance pattern)

Suggest lab - CCMB - hydrabad .

•• regular Follow-Up Every 3 months.

06/02/2025, 12:46 - cm: Appreciate the first para of what you wrote (the other inputs are good data for our medical education project where we are dealing with this current pandemic of over-testing and overtreatment trying to utilise medical cognition solutions looking to benefit from AI agents)

I vaguely recall you may not have diagnosed the previous similar post operative abdominal issue and will now share that answer without further ado. It's incisional hernia

06/02/2025, 12:54 - cm: I also appreciate the third para where you have talked about the genetic association of the phenotype we described. Although the genetic tests may be an overkill in terms of overall meeting the patient requirement it would be nice if you could share more about familial lipodystrophy especially the phenotype and let's also ask @13135550002

06/02/2025, 12:54 - Meta AI: Familial lipodystrophy is a rare genetic disorder characterized by the abnormal distribution of body fat, often resulting in a lack of fat in certain areas of the body. There are several subtypes, including:

1. Familial partial lipodystrophy (FPLD): characterized by loss of fat from the arms, legs, and buttocks.

2. Familial generalized lipodystrophy (FGLD): characterized by a near-total loss of body fat.

3. Mandibular lipodystrophy: characterized by loss of fat from the face and neck.

These conditions are often associated with metabolic complications, such as insulin resistance, diabetes, and cardiovascular disease.

Genetic mutations in various genes, such as LMNA, PPARG, and AKT2, have been linked to familial lipodystrophy. These genes play critical roles in adipocyte development, differentiation, and function.

If you'd like to know more or discuss further, please let me know!

06/02/2025, 12:55 - cm: @13135550002 what about lipodystrophy patient phenotypes where there is excessively abnormal fat distribution or is it always loss of fat?

06/02/2025, 12:56 - Meta AI: While the term "lipodystrophy" often implies fat loss, some forms of lipodystrophy can indeed present with excessive or abnormal fat distribution.

For example:

1. *Generalized lipodystrophy with excess fat*: Some patients may experience an abnormal distribution of fat, with excess fat accumulation in certain areas, such as the face, neck, or abdominal region.

2. *Lipohypertrophy*: This is a condition characterized by the accumulation of excess fat in specific areas, such as the abdominal region, buffalo hump (fat accumulation on the upper back), or lipomas (benign fat tumors).

3. *Mixed lipodystrophy*: Some patients may exhibit a combination of fat loss and excess fat accumulation in different areas of the body.

These phenotypes can be associated with various genetic mutations, metabolic disorders, or other underlying conditions.

It's essential to note that lipodystrophy can manifest differently in various individuals, and a thorough medical evaluation is necessary to accurately diagnose and manage these conditions.

06/02/2025, 12:56 - cm: Our patient's condition should have been termed lipo-hypertrophy

06/02/2025, 12:58 - Kolkata Medical College Intern: Yes, sir.

06/02/2025, 13:02 - cm: Thanks.

We are hoping you will be able to formulate some plans once you keep seeing how we use AI in our day to day healthcare workflow along with how we share AI keywords such as "multi agent" shared above to describe the users in one of our PaJR groups that are currently human human agents but are also amenable to becoming AI agents.

Overtime you will get to figure out the pattern and the best possible scalable requirement that you may want to work on

06/02/2025, 13:06 - Kolkata Medical College Intern: Sir, doplar USG HA. any report..!

06/02/2025, 13:07 - cm: HA?

06/02/2025, 13:11 - cm: 👆@17169396005 on seeing some terms in the PaJR post of ours above today in another group one of the AI enthusiasts from that group had the following Inputs :

[06/02, 09:40] AC: Nice. Would you like to get your interns / proteges to pick up "bits" of "multi agent systems" a little more formally? Usually these are not delivered from applications in healthcare perspective.

Will share a link as a part of MedInnovate 2030

[06/02, 10:56] AC: For those looking for a summary - multi Agent systems in general are about "decision" problems 

Given a set of knowledge sources - which can be human experts - how do we optimize "problem solving". There are many different approaches to multi agent systems - some may be familiar with collaborative agents, or may even be familiar with multi agent systems in AI and robotics.

There is a (slightly underdeveloped) system of incorporating these in complex systems modelling. Used to be a 7xx course for PhD reqs earlier. May have been brought down to 5xx or even 4xx by now

For Health IT these allow for non monolith CDSS clinical decision support systems

There are direct applications across the hospital from appointment scheduling to every aspect of hospital management

06/02/2025, 13:10 - Kolkata Medical College Intern: hole abdomen USG this present.

06/02/2025, 13:15 - cm: HA means whole abdomen?

06/02/2025, 13:15 -cm: Why do you need a USG abdomen?

06/02/2025, 13:57 - cm: https://nautil.us/why-doctors-test-too-much-1188119/

06/02/2025, 14:34 - cm: He died today at 2:00AM

06/02/2025, 14:59 - Kolkata Medical College Intern: hematuria.

06/02/2025, 15:43 - cm: Check what medication we mentioned giving her yesterday. What does that medication do to the colour of the urine

06/02/2025, 16:45 - Kolkata Medical College Intern: Rifampicin is the one that can cause a change in urine color.

Rifampicin used to treat tuberculosis and can turn the urine a reddish-orange color.

06/02/2025, 18:29 - Patient Advocate 56F Migraine Hypothyroidism 2000: Doctor please check the group icon of this patient was changed by the patient advocate.

06/02/2025, 21:19 - PaJR Physicist: Was the patient hypokalemic too?

06/02/2025, 21:54 - cm: Good point. But no he wasn't

06/02/2025, 21:54 - cm: Yes texted in that group

07/02/2025, 06:58 - cm: I shall share his serial potassium trends today especially if diuretics for his pulmonary edema may have precipitated his hypokalemia and will check if there's a possible causal correlation to the development of his arrhythmia

07/02/2025, 13:10 - cm: Can we correlate her no menarche, wide carrying angle with the vitiligo? Can you get any popular AI LLM to provide a diagnosis by sharing this multi modal data?@huai24 @huai54 

07/02/2025, 18:56 - PaJR Physicist: The prompts to the LLM have to be well defined to provide responses that are picked up from reliable/responsible sources backed by evidence. Open AI/co-pilot gives references. Gemini does not by default but would if prompted. Deepseek servers are overloaded so the 'thinking time' can be extended to a few hours. I've developed a prompt using Gemini to pick up labelled data into a CSV file which strings this data as a prompt indicating very clearly the purpose of the response, a physician's advisory or a patient counselling checklist.

07/02/2025, 19:02 - PaJR Physicist: Am using this process to assist GPs understand use of Audicor in the DDx at primary care centres.

07/02/2025, 19:03 - US Data Science AI Healthcare: The regular LLM wouldn't have much knowledge about these medical terms so they might hallucinate.

07/02/2025, 19:05 - Patient Advocate 29M Quantified Self: Cgpt - just used text in the messages here as they are already text translation of clinican's sensesory data collection.

Output -

Yes, there seems to be a possible syndromic correlation between her primary amenorrhea (never having menstruated), skeletal deformities (gibbus deformity, wide carrying angle), and vitiligo. One possible explanation could be a genetic or endocrine disorder affecting her development.

### **Possible Differential Diagnoses:**  

1. **Turner Syndrome (45,X or Mosaicism)**  

   - **Primary Amenorrhea** (due to ovarian dysgenesis)  

   - **Wide Carrying Angle** (cubitus valgus is common in Turner syndrome)  

   - **Skeletal Abnormalities** (short stature, kyphoscoliosis, osteoporosis)  

   - **Autoimmune Association** (Turner syndrome is associated with autoimmune diseases, including vitiligo)  

2. **Congenital Adrenal Hyperplasia (CAH) or Androgen Insensitivity Syndrome (AIS)**  

  - **Primary Amenorrhea** (AIS patients have XY karyotype but appear female)  

   - **Skeletal Features** (CAH can lead to bone abnormalities)  

   - **Vitiligo** (associated with autoimmune endocrinopathies)  

3. **Polyglandular Autoimmune Syndrome (PGA Type 1 or Type 2)**  

  - **Vitiligo** (common autoimmune feature)  

   - **Hypogonadism / Amenorrhea** (due to adrenal insufficiency or ovarian failure)  

   - **Skeletal Issues** (possibly linked to autoimmune osteoporosis)  

4. **Mucopolysaccharidosis or Lysosomal Storage Disorder**  

   - **Gibbus Deformity** (common in conditions like Hurler syndrome)  

   - **Amenorrhea** (if associated with endocrine dysfunction)  

   - **Skin Pigmentation Changes** (though not classical vitiligo)  

### **Next Steps for Diagnosis:**  

- **Karyotyping** (Turner Syndrome or XY disorders of sex development)  

- **Hormonal Workup** (FSH, LH, Estradiol, AMH)  

- **Autoimmune Panel** (Anti-TPO, ANA, adrenal antibodies)  

- **DEXA Scan** (Osteoporosis evaluation)  

- **Spinal Imaging** (To evaluate the gibbus deformity)  

There is a strong likelihood of an underlying genetic or autoimmune disorder linking her symptoms. Would you like to focus on a specific condition for more details?

07/02/2025, 19:05 - Patient Advocate 29M Quantified Self: Prompt - OPD today: 55F with metabolic syn complain of low backache

She also has a marked gibbus with a sharp angular deformity in the lumbosacral area

She has never experienced menstruation in her 55 years of existence!

She also has all these vitiliginous patches noticeable even in the prior images around different locations of her skin surface

Can we correlate her no menarche, wide carrying angle with the vitiligo?

07/02/2025, 19:05 - Patient Advocate 29M Quantified Self: ❤️👌

07/02/2025, 19:07 - Patient Advocate 29M Quantified Self: The clinicians and compliance team have to be alert about that. For awareness about use of device, it should work fine now AFAIK.

07/02/2025, 19:12 - PaJR Physicist: Prompting is key to prevent any hallucinations, just like humans I guess.

07/02/2025, 19:13 - US Data Science AI Healthcare: No, prompting won't prevent hallucination.

07/02/2025, 20:04 - cm: I guess he meant a prompt optimized to produce least hallucinations (we prefer the term confabulation)

07/02/2025, 20:05 - cm: 👆This is actually a pretty good lead @US Data @huai54

07/02/2025, 20:07- US Data Science AI Healthcare: Even an optimized prompt won't guarantee less hallucination if the model don't have access to those information

07/02/2025, 20:09 - Patient Advocate 29M Quantified Self: Yes.

That's why I said in case of audicor or common medical devices for awareness, there may not be any / significant hallucinations.. but if something unique / new / rare then probability increase. 

Using same prompt everytime is a way to try to minimize hallucinations but there may not be any benefit in current or any similar case, rather the benefit here may be to get same (like standard) output for all users / learners.

07/02/2025, 20:11 - Patient Advocate 29M Quantified Self: Fed this xray to gemini, it's avoiding medical work. I don't have access to grok that recently started interpreting radiological images.

07/02/2025, 20:13 - cm: Yes off course! We were assuming a model with optimal access to all the necessary information but then we know and always keep cribbing: The quality of our AI driven workflow will be as good as the quality of data we feed our AI models

07/02/2025, 20:15 - cm: Can you use your medical expertise to diagnose this x-ray? Also @huai113

07/02/2025, 20:16 -cm: 👆Start counting the vertebrae from L5 which is just above the sacrum and then see the size of each vertebrae till you reach L2 and L1

07/02/2025, 20:17 -Kolkata Medical College Intern: Sir please re- send this picture. Download failed show.

07/02/2025, 20:19 - Patient Advocate 29M Quantified Self: Spondylolisthesis?

07/02/2025, 20:21 - US Data Science AI Healthcare: I would suggest to using LLM such as med PALM from Google that is more specific to medical

07/02/2025, 20:22 -US Data Science AI Healthcare: I am new to medical terms, so I am trying to pick up the terms mentioned above

07/02/2025, 20:34 -Kolkata Medical College Intern: Lumbar Spondylosis with Intervertebral Disc Degeneration.

07/02/2025, 20:35 -Kolkata Medical College Intern: lumbosacral region of the spine, which includes the lumbar vertebrae (L1 to L5) and potentially part of the sacrum (S1). This area supports much of the upper body's weight and is a common site for degenerative changes like disc degeneration and spondylosis.

07/02/2025, 20:39 - huai85: Collapsed vertebra..

07/02/2025, 20:58 -cm: Ah I recall you had seen a spondylolysthesis during your first elective!

Why don't you look carefully at the size of each lumbar vertebrae?

07/02/2025, 20:58 - huai70: Sir was this present from the childhood?

07/02/2025, 20:58 - cm: Look carefully at the size of each lumbar vertebrae

07/02/2025, 20:58 - cm: No few days

07/02/2025, 21:00 - Patient Advocate 29M Quantified Self: Reduced size of lumbar vertebrae

07/02/2025, 21:00 - huai70: Osteoporosis?

07/02/2025, 21:02 - Patient Advocate 29M Quantified Self: Osteoporosis, Degenerative Disc Disease, Vertebral Compression Fractures, Aging. (Differentials from cgpt. I needed to take help)

For this patiet can rule out aging, can rule in possible influence of hormones causing *osteoporosis*. 

Degenerative Disc Disease - unable to identify any reduction in space between vertebrae. Probably rule out.

07/02/2025, 21:04 - Patient Advocate 29M Quantified Self: Collapsed / fractured because of osteoporosis 

07/02/2025, 21:05 -cm: Yes vertebral fractures present as a wedge shaped collapse

07/02/2025, 21:06 - huai25: But this is osteoporosis most probably

07/02/2025, 21:07 - huai25: ATT?

07/02/2025, 21:10 - cm: Even the size of the second and third appears reduced

07/02/2025, 21:10 - cm: Yes

07/02/2025, 21:11 - cm: More about him here👇

https://pajrcasereporter.blogspot.com/2025/02/40m-with-diabetes-since-10yrs.html?m=1

08/02/2025, 07:47 -huai25: Any one page infographic stating difference between various insulins? A JR may prepare and share please🙏🏻

08/02/2025, 07:48 - huai25: Something like this 7 years old regarding health for Divyangjan👇🏻 08/02/2025, 08:37 - cm: I'm sure @huai54 or @ or huai115 @huai24can easily ask chatGPT to create that

08/02/2025, 08:41 - cm: Just for hilarity: @13135550002 

Any one page infographic stating difference between various insulins in English not Russian?

08/02/2025, 08:41 - Kolkata Medical College Intern: 1. Rapid-Acting Insulin

Examples: Lispro, Aspart, Glulisine

Onset: 10-30 minutes

Peak: 30-90 minutes

Duration: 3-5 hours

Usage: Taken just before or after meals to control blood sugar spikes

2. Short-Acting Insulin (Regular Insulin)

Examples: Humulin R, Novolin R

Onset: 30-60 minutes

Peak: 2-4 hours

Duration: 5-8 hours

Usage: Taken 30 minutes before meals

3. Intermediate-Acting Insulin

Examples: NPH (Humulin N, Novolin N)

Onset: 1-2 hours

Peak: 4-12 hours

Duration: 12-18 hours

Usage: Used for baseline control; often combined with rapid- or short-acting insulin

4. Long-Acting Insulin

Examples: Glargine, Detemir

Onset: 1-2 hours

Peak: Minimal to no peak

Duration: Up to 24 hours

Usage: Provides steady insulin levels throughout the day and night

5. Ultra-Long-Acting Insulin

Examples: Degludec

Onset: 1 hour

Peak: No peak

Duration: 36+ hours

Usage: Ideal for maintaining stable blood sugar over long periods

6. Pre-Mixed Insulin

Examples: Humulin 70/30, Novolog Mix 70/30

Onset: Varies by combination

Peak: Varies

Duration: Varies

Usage: Combines rapid or short-acting with intermediate insulin

08/02/2025, 08:41 - cm: 👆meta I guess?

08/02/2025, 08:42 - Kolkata Medical College Intern: No, it's doctor AI

08/02/2025, 08:42 - cm: @13135550002 what is this language in the infographic image you just shared?

08/02/2025, 08:42 - Meta AI: The infographic I generated earlier contains English text. If you'd like, I can try to generate another infographic in a different language or make any necessary adjustments. Just let me know!

08/02/2025, 08:43- Kolkata Medical College Intern: Any more

08/02/2025, 08:43 - cm: @13135550002 please check your output (which you may not be able to). It was definitely not English

08/02/2025, 08:44 - Rakesh Biswas: I guess it can't provide image based infographics?

08/02/2025, 08:44 - Kolkata Medical College Intern: Information not clear sir...

08/02/2025, 08:45 - Kolkata Medical College Intern: Algorithm not identified this image.

08/02/2025, 08:45 -cm: Yes that's what we are trying to tell meta AI

08/02/2025, 08:45 - cm: Even humans can't

08/02/2025, 08:46 -Kolkata Medical College Intern: Yes sir.

08/02/2025, 08:47 -cm: Minor hiccups at the current formative infantile stage of AI? @huai115

08/02/2025, 08:47 - cm: Oh wow! Is that doctor AI?

08/02/2025, 08:48 -cm: Still some apparently Russian flaws but largely much better than meta AI!

08/02/2025, 08:49 - cm : Wonder what happens if you ask it to change the language to Hindi?

08/02/2025, 12:21 - cm: The previous was Russian syntax mixed English! Is this Gujarati mixed Hindi syntax? @huai25

08/02/2025, 12:25 - huai25: Looks like Meta Language😄

Mixed up languages😇

08/02/2025, 12:27 - huai25: Making it develop fast from neck holding to running on joggers track🫡

08/02/2025, 12:29 - huai25: મને નથી લાગતું કે તે ગુજરાતી છે.

08/02/2025, 14:36 - PaJR Physicist: Maybe, am not understanding reference to 'hallucinations' that you are alluding to. But, I just had a spat with co-pilot on an inappropriate use of a terminology in a physical property of a material. With logic and some cross examination of the LLM, I was able to trace the source where the inappropriate use of that the terminology was made (IIT Mumbai) and the reference to the research paper which had the word in the title line used wrongly. Another clinical instance, it picked up a obvious hallucinatory phrase (crystal bowl kind) from the author's 'conclusion' in his paper, which I would'nt attribute to the LLMs capability to hallucinate.

08/02/2025, 15:06 -Kolkata Medical College Intern: Posible, Acute on Chronic Pancreatitis (ACP).

If family financial good - conform diagnosis -,

1)CECT abdomen or MRCP.

2) Serum trypsinogen-2 and pancreatic elastase-1

3) lipid profile.

08/02/2025, 15:35 -cm: Good inputs 👏

08/02/2025, 18:40 -cm: 👆@cr this patient shared in the case reporters group yesterday

08/02/2025, 18:43 -cm: 👆@918074725352 first mention of the same case here

08/02/2025, 21:09 -US Data Science AI Healthcare: The current image generation models are good but I haven't tried it. Text based images still needs improvement

08/02/2025, 21:11 - US Data Science AI Healthcare: Current web based chatgpt has access to the web to retrieve that info but if it could not find it, it would still hallucinate.

09/02/2025, 13:49 - cm: Today's Morning PaJR update by ward resident:

Patient got admitted today morning at 6:30 am 

With complains of vomitings 2 episodes at 9 pm food material as content, non bilious

Pain abdomen since 10 pm epigastric and umbilical region non radiating pain, pain is getting relieved on lying in prone position 

Vitals at presentation 

PR: 96/min 

BP:120/70 mmHg

RR:22 cpm 

Spo2:96% on RA

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

09/02/2025, 13:50 - cm: [09/02, 13:42] pm: Pancreatitis? Steroid or azathioprine induced?

Why did they not share any updates since 21st January?

[09/02, 13:45] pm: "The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission).The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents)."

Unquote

https://fg.bmj.com/content/12/5/423

[09/02, 13:46] pm: Azathioprine induced pancreatitis usually runs a benign self limited course with rapid disappearance of signs and symptoms upon with drawl of the drug. 

Unquote

https://www.primescholars.com/articles/azathioprine-induced-pancreatitis-in-a-patient-with-coexisting-autoimmune-pancreatitis-and-hepatitis-97835.html

09/02/2025, 14:15 - cm: [09/02, 13:59]wr: On per abdominal examination there was tenderness in umbilical region sir 

And the patient was also comfortable on lying in prone position

[09/02, 14:09]pm: Pain relieved by prone position was our initial cue to suspect pancreatitis

[09/02, 14:06] pm: Other than inflammatory bowel disease that we had been considering for a few weeks since her first usg few weeks back showed this bowel thickening, the other important pathology to rule out is tuberculosis. @huai108 do they do free colonoscopy there in Gandhi medical college as this patient is not affordable? 

Also wr can you share the previous latest chest X-rays and sputum AFB and CBNAAT?

[09/02, 14:09]wr: Today's chest x-ray

[09/02, 14:09] pm: Looks clear

10/02/2025, 11:22 - cm: Still having the same pain and abdomen findings as Saturday

10/02/2025, 12:05 - huai70: Sir T wave inversions in V2 and V3 ?

10/02/2025, 12:05- Kolkata Medical College Intern: Right-sided ECG, assess right ventricular involvement,this cases of suspected right ventricular infarction.ST elevations in right-sided leads (V3R to V6R), suggest right ventricular infarction, inferior wall MI.

• T-wave inversions indicate right heart strain or conditions pulmonary embolism.

2. Incidental findings subtle changes are seen, such as incomplete right bundle branch block (RBBB) or mild ST changes,Q waves or significant ST changes are present, myocardial ischemia, prolonged PR intervals.

•• T wave abnormalities,might point to electrolyte imbalances or ischemic changes.

10/02/2025, 12:08 - Kolkata Medical College Intern: not clearly show pancreatic calcification sir.

10/02/2025, 12:10 - cm: Can you notice the changes in both the ECGs taken in the few minutes gap here today?

Are you sure you have examined each and every lead of that ECG? @huai70

10/02/2025, 12:16 - huai70: Sir Also there are inversions in lead 1 and aVL ?

10/02/2025, 12:19 - cm: Other leads? Look carefully

10/02/2025, 12:39 - cm: Look at lead aVR @huai113

10/02/2025, 12:43 - Kolkata Medical College Intern: ST elevation in lead aVR with diffuse ST depressions in other leads, it might suggest left main coronary artery (LMCA) stenosis or severe ischemia.

•• ECG might indicate the need for further cardiac evaluation if ischemic changes are present.

10/02/2025, 12:46 - cm: There's no ST elevation in aVR or anywhere else.

What does a normal aVr look like @huai70?

10/02/2025, 12:53 -huai70: Sir there should be t wave inversion in normal avR

10/02/2025, 13:04 - cm: Nailed it!

So what does she have and why?

10/02/2025, 13:04 - cm: @Pushed Comm22 did they review with her chest X-ray?

10/02/2025, 13:07 - Pushed1Comm22: No sir

10/02/2025, 13:22 - huai107: For students:

Please see the progression of R wave in chest leads and compare. What if the heart is not in its usual place?

10/02/2025, 14:27 - cm: Maybe now they are back in the OPD?

10/02/2025, 14:47 - cm: So she's having situs inversus also along with her dextrocardia. The relative said her previous ultrasound suggested that Liver was in the right side and that has been proven wrong!

10/02/2025, 14:55 - cm: The inflammatory bowel issue needs further investigation with a colonoscopy to rule out tuberculosis.

Let's hold the iv methyl prednisolone till then

10/02/2025, 15:01 - cm: 👆

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

10/02/2025, 16:05 - cm: @huai81 please share the update of this patient. I was busy in the ward with the other patients today but i was told that he was being seen by you and started on iv prophylactic valproate for raised ICT other than iv mannitol etc

10/02/2025, 16:11 -cm: Just let me know what has been the changes in his CNS examination findings from friday till today @huai81

10/02/2025, 16:15 - cm: 👆@huai70 @huai113 same patient of today morning ECG. Now tell us what are the expected ecg findings that we see there

10/02/2025, 16:17 - huai96: Sir after admission we have done an MRI in suspicion of PCA stroke and it turned out to be AIS large infarct involving b/l cerebellar hemispheres & vermis

Managed his AIS + CAD combinedly

10/02/2025, 16:18 - cm: AIS?

10/02/2025, 16:18 - huai96: Even though his vomiting subsided he stated complaining of severe headache since today morning and is a bit drowsy 

O/E:

PR was fluctuating b/w 45 - 55 BPM

Apnea episodes were there in between with fall in SpO2 to 80 - 85%

10/02/2025, 16:19 - cm: Can you share the MRI image showing that?

10/02/2025, 16:21 -huai96: So in suspicion of raised ICT (Reactive vasogenic edema) we gave him mannitol IV stat & started on 3% NACL infusion sir

10/02/2025, 16:23 - huai96: Dexa & lasix were also given sir as a Rx for reactive vasogenic edema sir

10/02/2025, 16:23 - huai96: Yes sir

@huai100 @huai69

Plz share the MRI images

10/02/2025, 16:23 - cm: Good

What about prophylactic iv valproate? Is there any literature to suggest that it reduces incidence of Seizures in stroke with raised ICT patients?

10/02/2025, 16:27 - huai96: Reactive vasogenic cerebral edema typically intensifies over 3 to 4 days after the initial infarct. 

Cerebellar strokes, especially after the first day, tend to develop progressive edema and potential subsequent herniation. Early symptoms often include severe headache, altered mental status, vomiting, and drowsiness. The important neurological signs for these patients are impaired level of consciousness, new or worsened cranial nerve deficits, gaze paresis, and downward gaze conjugation.

In the acute setting, temporary reduction of intracranial pressure can be achieved using agents like mannitol, hypertonic saline, or hyperventilation.

In cases of large strokes with significant cerebral edema, especially if the intracranial pressure is elevated, neurosurgical interventions such as extraventricular drains, ventriculostomy, or decompressive suboccipital craniotomy may be necessary.

Neurosurgical procedures like removal of infarcted tissue or hematoma are occasionally required. https://www.ncbi.nlm.nih.gov/books/NBK470416/

10/02/2025, 16:28 - Kolkata Medical College Intern: if have better-quality PA chest X-ray or CT scan could provide more detailed findings. Can't find out any problem this x ray picture sir.

10/02/2025, 16:35 -huai96Sir usually it's not indicated as a prophylaxis in case of ischemic strokes (although used in routinely in neuro ICUs)

But there is some evidence of prophylactic antiepileptics in patients with traumatic brain injury sir 

10/02/2025, 16:35 - huai96: Coming to this patient sir I have observed some jerky movements in left upper limb during my morning rounds which could be a focal seizure in the context of his neurological injury 

So I started him on antiepileptic also sir 

10/02/2025, 16:39 - cm: Which side is the heart pointing to?

10/02/2025, 16:40 - cm: Thanks. Good. Was the jerky movements documented in the file?

10/02/2025, 16:40 - cm: Thanks

10/02/2025, 16:47 -Kolkata Medical College Intern: I think, cardiovascular conditions.

10/02/2025, 16:51 - cm: @huai70

10/02/2025, 17:30 - huai70: Dextrocardia Sir...there will be right axis deviation

10/02/2025, 17:30 - huai70: Right side

10/02/2025, 19:09 - cm: And the liver in which side in that chest X-ray @huai113?

10/02/2025, 23:52 - pajr.in CEO, NHS Endocrinologist: Full verbal consent taken and documented.

Also, shame on me for not carrying my tendon hammer.

11/02/2025, 12:26 - cm: Can publish this as a multipurpose utility of the stethoscope diaphragm!

11/02/2025, 12:30 - cm: This one here was even more delayed but then this patient was denovo👇https://pmc.ncbi.nlm.nih.gov/articles/PMC3038018/

14/02/2025, 08:41 - huai25: Not poem, perhaps serious🤦🏻‍♂️

14/02/2025, 08:41 - huai25: How is psittacosis different?

14/02/2025, 13:06 - cm: Psittacosis is an infection and this is an allergy

14/02/2025, 13:12 -cm: 👆The first CBBLE post here for the Crohn's patient shared with you in the case reporters group @cr

14/02/2025, 13:16 -huai25: I mean difference in epidemiology - too high incidence claimed here with allergic lung disease😳

14/02/2025, 13:17 - cm: Yes will need to look at data if available

14/02/2025, 14:32 - Patient Advocate 56F Migraine Hypothyroidism 2000: Is this info of the 23F chest pain patient?

14/02/2025, 15:52 - cm: No

14/02/2025, 15:52 - cm: Its partly this patient 

14/02/2025, 15:53 - Patient Advocate 56F Migraine Hypothyroidism 2000: Second half I have added to the case report.

14/02/2025, 15:54 - cm: Renal biopsy done today by @huai47. Please share the image of the tissue you took

14/02/2025, 18:01 -Kolkata Medical College Intern: I think, radiation pneumonitis, lymphangitic carcinomatosis, or infection.

If present are financially well,

Urgent CT Thorax to assess lung involvement, effusion, and airway compression.

ABG.

14/02/2025, 18:33 - cm: The image is a CT thorax

14/02/2025, 18:37 - Kolkata Medical College Intern: No sir this image not CT- thorax.

14/02/2025, 18:38 -cm: Ignore the light bulbs inside became of the PET FDG uptake but what else can produce that image of the lungs?

14/02/2025, 18:44 -Kolkata Medical College Intern: Possible sir, previously any HRCT, BAL CYTOLOGY, this present.

14/02/2025, 18:44 - Kolkata Medical College Intern: This message was deleted

14/02/2025, 18:46 -  Kolkata Medical College Intern: Pulmonary Metastases with Possible Lymphangitic Carcinomatosis.

14/02/2025, 22:49 - pajr.in CEO, NHS Endocrinologist: Addisons!!

15/02/2025, 08:04 - cm: Thanks for one valuable endocrine differential to keep in mind for this psychoneuroendoimmunology patient. @huai3 any other differential you would like to suggest?

15/02/2025, 16:36 - cm: An interesting paper relevant to one of our PaJR patient's recent visit to the emergency with chest pain and subsequent diagnostic and therapeutic uncertainty 👇

Highlights

•

Acute coronary syndrome (ACS) overdiagnosis is more common than underdiagnosis

•

Male sex and elevated high-sensitivity troponin are the main causes of ACS overdiagnosis

•

Female chest pain (CP) patients have lower pre-test probability of ACS according to emergency department (ED) physician management

•

Women with CP are more likely discharged early from the ED without apparent differences in 6-month cardiovascular outcomes

Unquote

https://www.sciencedirect.com/science/article/abs/pii/S0914508725000553

15/02/2025, 16:55 - cm: Morning OPD data capture of a patient being reviewed after 2 years:

This was her gait in today's OPD 👇

https://youtu.be/jmoiU_dT0C4?feature=shared

Her previous EHR case report along with the previous gait video (providing an estimate of the change in her gait) is linked in the above description box and will share more data for @cr to prepare this fascinating landmark EHR case report that was extensively engaged with by our UGs and PGs in 2023 around this time! @huai2 @huai3@huai53

15/02/2025, 20:53 - cm: Two years around this time she presented with paralysis of all four limbs and while such a presentation is commonly thought to be Guillain Barre @huai25, the K+ of 1.8 was an indicator to a hypokalemic muscle paralysis and she improved with iv potassium, and although the ABG wasn't mentioned in the initial informal EMR here: https://vignatha45.blogspot.com/2023/02/40-year-female-with-hypokalemia.html?m=1

she was also found to have metabolic acidosis with a normal anion gap that was thought to be distal RTA perhaps due to severe hypokalemia.

15/02/2025, 20:56 - cm: Also had dry eyes and hence a lingual biopsy was taken that was consistent with Sjogrens syn as mentioned in the previous EMR case report link

15/02/2025, 21:03 - pajr.in CEO, NHS Endocrinologist: Hope no muscle wasting and winging here. Can try TRAWL (Trapezius weakness wings laterally) and SWIM (Serratus weakness wings medially)

15/02/2025, 21:05 - pajr.in CEO, NHS Endocrinologist: It is way too excessive and sometimes heavily research driven institutes can lose track of patient centered outcomes.

The idea could have been that she may have mixed RTA and thus Vitamin D deficiency and perhaps will have Secondary Hyperparathyroidism and Osteoporosis!

I don't even know what to make of that scan tbh

15/02/2025, 21:15 - pajr.in CEO, NHS Endocrinologist: Interesting that the wrist is involved - the consultants here have told me that distal radius osteoporosis is very sensitive and specific for Primary Hyperparathyroidism

Was a PTH done and Urine Ca Cr ever done sir?

15/02/2025, 21:18 - pajr.in CEO, NHS Endocrinologist: So, was the risedronate stopped?

15/02/2025, 21:24 -cm: Can ask her advocate in the PaJR group

15/02/2025, 21:26 -cm: 👆 there's a urinary calcium mentioned here altogether not sure how useful that is

Will need to fish out her EMR summary from two years back through Saidulu

17/02/2025, 10:53 - cm: Here's her neck flutter initially thought to be localised segmental fasciculations on history but hyperdynamic pulsations on examination 👇https://youtube.com/shorts/mGRwVVe68EE?feature=shared

17/02/2025, 15:45 - Unknown Medical Student: Cardiogenic pul edema sir?

17/02/2025, 15:54 - Kolkata Medical College Intern: ARDS, Severe pneumonia (possibly multilobar or aspiration-related).

refine the diagnosis, (ABG), echocardiography and cultures.

17/02/2025, 16:04 - cm: Look carefully. Recall your own previous patient. This patient too became immediately swollen all over!

17/02/2025, 16:04 - cm: Is this chat GPT?

17/02/2025, 16:05 -cm: Compare the two chest X-rays and look outside the chest

17/02/2025, 16:08 - Kolkata Medical College Intern: Pesent any privious case - Covid -19

17/02/2025, 16:08 - Kolkata Medical College Intern: ??

17/02/2025, 16:09 - Dr. Amrita Verma Mumbai MD Medicine: Severe subcutaneous emphysema in the latest chest xray

17/02/2025, 16:16 -  Mumbai MD Medicine: Sir, Probably due to tracheal injury during intubation? Thank you for sharing, this is so rare (tracheal injury during intubation). I mean the extent of injury to cause this extent of subcutaneous emphysema bilaterally <This message was edited>

17/02/2025, 16:19 - cm: Yes. Well it extended to his whole body across the fascial planes all to the way to his scrotum below and his entire face above

18/02/2025, 16:15 - Patient Advocate 56F Migraine Hypothyroidism 2000: Have they given the Consent form?

18/02/2025, 16:19 - cm: Yes shared same day in the case reporters group. Tagged there again

18/02/2025, 16:21 - cm: Bedside clinical imageology of 64M with metabolic syn:

https://youtube.com/shorts/dzGBlCR981s?feature=shared

19/02/2025, 10:42 - Rakesh Biswas: https://pajrcasereporter.blogspot.com/2025/02/40f-with-recurrent-hypokalemic.html?m=1

19/02/2025, 11:08 - pajr.in CEO, NHS Endocrinologist: It is funding for Teriparatide?

19/02/2025, 11:21 - cm: Yes apparently!

19/02/2025, 13:05 -cm: OPD Reviewed this patient just now 👇https://pajrcasereporter.blogspot.com/2025/02/64f-with-recurrent-laryngeal-nerve.html?m=1

19/02/2025, 13:24 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

19/02/2025, 13:41 - pajr.in CEO, NHS Endocrinologist: Hypertriglyceridemia - - Acute Pancreatitis - - Splenic Vein Thrombosis - - Splenomegaly due to Pre hepatic Portal Hypertension - - Hypersplenism?

19/02/2025, 13:42 - pajr.in CEO, NHS Endocrinologist: Did he ever have malaena at all?

19/02/2025, 14:40 - cm: Possible although they may haven't noticed. They had simply come for the bone marrow test referred by their nearby physician and didn't want to share much

19/02/2025, 14:55 -cm: Bedside questions: 28F with type 1 diabetes and getting mixtard 5U twice daily for 6 years was being evaluated for hypoglycemia in the district hospital 2 years back when they also noticed Hypertension to the tune of 180 systolic (they can't recall the diastolic) and then was on antihypertensives but they didn't know anything about her creatinine then. Six months back was operated for gall stones and still no one informed them about her creatinine. Only one month back she developed pedal edema along with shortness of breath and during that time when she was admitted again in the district hospital her creatinine was told to be 5. 

Over-all her main problem appears to be heart failure as echocardiography also shows severe LV dysfunction but then whether it's due to microvascular coronary artery disease in her 20s secondary to her type 1 diabetes is the question.

Again what's the reason for her accompanying renal failure? Is it type 1 diabetes or is it what in common parlance these days is called NDKD non diabetic kidney disease (due to unexplained immune dysfunction)? 

20/02/2025, 10:19 - cm: Congratulations @se and the rest of our team who have been looking after this patient's PaJR for this note acknowledging your positive contribution to their life:

"Yesterday, Narmeen Shah madam asked how I was doing. Based on that, I wrote a story about my current life situation and translated it into English with the help of Google Translate."

Over the past two and a half years, I have noticed a profound transformation in myself. Now, I no longer let weak thoughts control my mind so easily. I don't know whether I have become good or bad—I simply follow the path shown by the great souls who came before us.

I have learned that there is no law requiring me to be like everyone else. If I feel anger toward someone, I can forgive them easily, but that doesn’t mean I won’t criticize them when necessary. I have understood that by controlling emotions, one can overcome great obstacles. However, that doesn’t mean circumstances will always be in my favor. Sometimes, I will have to create an entirely new path for myself, even if it requires a bit of strategic thinking.

It doesn’t feel good; sometimes, I feel afraid. But I strongly believe that as long as the worst hasn’t happened yet, nothing truly terrible will happen. Perhaps the universe has already set everything in place.

It feels like being summoned to a battlefield to save my country during a crisis. I was completely unprepared, but I had no choice but to go. At first, I fought by running and dodging, but eventually, I came face-to-face with the enemy. I was captured—purely by fate (if fate exists). Then, by some divine intervention, I met a few enlightened beings who taught me battle strategies. In the end, I emerged victorious.

But now that I have learned to fight, I realize that every day is a new battle, and I must continue fighting—with myself or with my circumstances.

I have learned to understand that whatever we think gets transferred through our mind to different parts of our body, causing changes that the body then signals back to us. The best way to control this process is through proper mindset training, which I try to practice regularly.

How do I do it? Through pranayama, deep breathing, yoga, and, most importantly, by being mindful of the food we eat.

Every day, I try to follow a healthy diet. In the morning, I start by drinking two glasses of warm water after waking up. Then, I have a light meal, such as puffed rice or muri, along with almonds, cashews, pistachios, raisins, and various seeds. Finally, I drink red tea—always without sugar.

All of us in the family—my wife, son, mother, and I—sit together at the table to have this morning meal. Initially, my mother and son didn’t want to eat it, but I continued eating mine silently. After a few days, seeing that I was consistent, they also started eating, and now it has become a habit for them too. We completely avoid sugar and refined flour.

Throughout the day—whether it’s breakfast, lunch, evening snacks, or dinner—we try to include a balanced mix of proteins, carbohydrates, vegetables, fruits, and probiotic foods like yogurt.

I do yoga for 15-30 minutes in the morning, and apart from office hours, I have a habit of reading books on two to three different topics daily. I also make an effort to maintain the boundaries of my family, tell my son a story every day, work on improving my weaknesses, ensure 7-8 hours of sleep, spend time with my family on holidays, and keep learning new things.

I personally prepare the morning meal for everyone. My English was once a weakness, but I have improved a lot—though I still use Google Translate for assistance when writing.

If I don’t have a proper bowel movement, I feel a little down, but I manage to deal with it. If someone speaks harshly to me, I feel hurt, but then I remind myself that they are not like me, just as I am not like them.

Honestly, compared to before, I feel much better now. I am living a more planned and conscious life, enjoying every moment with greater awareness.

🙏🙏🙏

https://ssahamedicalcases.blogspot.com/2022/10/patient-history-pt-is-37-yr-old-male.html

@cr would you like to prepare a mirror case report of this patient and also include the latest updates? @huai2 this is what keeps our patient capital treasury from drying up?

20/02/2025, 10:32 - Patient Advocate 56F Migraine Hypothyroidism 2000: Sure

20/02/2025, 11:40 - cm: Previously admitted and case reported

20/02/2025, 12:19 - Patient Advocate 56F Migraine Hypothyroidism 2000: Mirror case report done. But updates?

20/02/2025, 12:20 - cm: Thanks.

Let's begin with the patient's testament shared today as an update.

Rest I shall share

20/02/2025, 13:04 - Inner Strength Engineer1: Sir 🙏🙏🙏🙏🙏🙏

Sir it is truly inspiring to experience a person's journey and incredible to see their mental strength and power they hold. 🍁

20/02/2025, 13:05 - cm: Yes our patients and their lives have been the most inspiring elements in our own life!

20/02/2025, 13:14 -Kolkata Medical College Intern: axial sections of the brain at the level of the brainstem and cerebellum,

"Eye of the Tiger" Sign,pantothenate kinase-associated neurodegeneration (PKAN), a type of neurodegeneration with brain iron accumulation (NBIA), central hyperintensity with surrounding hypointensity in the globus pallidus on T2-weighted MRI.MRI finding in Wilson’s disease.

20/02/2025, 14:03 - cm: Your answer contains a paradox! Is it formulated by ChatGPT?

On one hand you rightly say that you are seeing the brain stem and cerebellum but then the findings you are sharing are seen in the Globus pallidus!

If it's chatGPT we can pardon it

20/02/2025, 14:06 -Kolkata Medical College Intern: Please re-send picture sir <This message was edited>

20/02/2025, 14:09   Kolkata Medical College Intern: Seen, Hot Cross Bun Sign, I think -Multiple System Atrophy - Cerebellar Type (MSA-C).

20/02/2025, 14:09 - Kolkata Medical College Intern: My final opinion sir.

20/02/2025, 14:09 - cm: 👏

20/02/2025, 14:12 -Kolkata Medical College Intern: Sir, I think this diagnosed is correct. 

20/02/2025, 14:17 -cm: The clap signified that👍

But thats the MRI diagnosis and the neet MCQ answer. But if that will be useful for the real patient here or not is yet to be seen

21/02/2025, 13:23 - cm: Patient consent for case reporting shared in the other group for case reporters @cr

21/02/2025, 15:01 - Patient Advocate 56F Migraine Hypothyroidism 2000: Done

21/02/2025, 15:31 - cm: Thanks

22/02/2025, 09:00 - cm: "There are many reasons why an individual will engage a physician. The individual may want to learn about the cause of the symptoms they are experiencing and what to expect if there is no intervention, and/or obtain care that gives a reasonable chance to change the course of their health state. The physician is valuable in such cases, as they will often possess expertise that is not otherwise accessible to the individual. What makes that expertise valuable is that claims physicians make in service of their patients are not arbitrary—rather, they are grounded in a system of knowing that produces reliable and valid claims. In a recent paper published in the Journal, Baker [1] raises concerns about how ideology can undermine the physician's system of knowing, potentially compromising patient care."

Unquote 

https://onlinelibrary.wiley.com/doi/10.1111/jep.14292

22/02/2025, 15:37 - cm: Afternoon bedside now:

55M with a sudden onset of this movement disorder and shortness of breath since two days

https://youtu.be/Olp8khYrbyE?feature=shared

22/02/2025, 16:18 - cm: Although rare this has been reported also in the past by others 👇https://pmc.ncbi.nlm.nih.gov/articles/PMC4996610/

@cr will be reporting this from our team

23/02/2025, 07:31 - cm: Morning PaJR pruritis:

PaJR Transcripts:

[16/02, 14:02] Patient Advocate 56F Migraine Hypothyroidism 2000: The patient applies coconut oil when itching. It is more in the night. Day time it is occasional. It feels like thorns pricking on the body. Pricking continues for half an hour. Itching is for 10-15 min on hands, fingers, palms and ears. Rest of the body itching is mild.

[16/02, 15:08] pm : Can take tablet avil 25 mg one hour before dinner to reduce the itching at night

[16/02, 15:10] Patient Advocate 56F Migraine Hypothyroidism 2000: Itching kosam Avil 25mg  rathri annam thine 1 hour  mundara vesukovachu.@⁨Patient Advocate 75F Metabolic Syn⁩ 

[16/02, 19:21] Patient Advocate 75F Metabolic Syn: One full tablet? Or half tablet?

[16/02, 19:28]pm: 25mg half tablet

[23/02, 05:23] Patient Advocate 75F Metabolic Syn: Avil 25 use chestundi 4 days nundi nyt time 1hr before food, itching,podavatam 70%varaku taggindi

[23/02, 05:24] Patient Advocate 75F Metabolic Syn: Rare ga okati rendu sarlu vastundi only itching, konchem sepu

[23/02, 06:46] Patient Advocate 56F Migraine Hypothyroidism 2000: With Avil 25mg, the patient had 70% relief. Experiencing itching for very short time.

[23/02, 07:27] pm: Yesterday from OPD we admitted a similar patient who had refractory pruritus and we started avil although we were not aware of this patient's positive avil outcomes yesterday (perhaps our previously undocumented avil outcomes data was simply driving our decision making from some unknown corners of our mind)!

EHR PaJR case report: https://pajrcasereporter.blogspot.com/2024/09/74f-metabolic-syn-diabetes-15yrs-heart.html?m=1

23/02/2025, 07:33 - cm: 👆@huai101 any update on the similar patient with pruritus and additional dissimilar DILI we admitted from OPD yesterday?

23/02/2025, 07:35 - CKD Anemia 2022 Project PI: We advised admission but they said they would come for admission on Monday sir

23/02/2025, 09:41 - cm: Oh this does provide an interesting angle to her pruritus!

24/02/2025, 13:26 - huai25: TB🤔

24/02/2025, 13:56 - huai76: Which is the dominant hand, Sir?

24/02/2025, 15:25 - cm Right

24/02/2025, 15:29 - cm: He has an inflammatory arthritis of the right hand joints including wrist. Also seems to be having alcohol withdrawal tremor although he denies consuming anything since a month (although again we have a word for that and it's called confabulation, which is what an LLM often does)!

24/02/2025, 19:55 - pajr.in CEO, NHS Endocrinologist: ? Hyperparathyroidism

25/02/2025, 23:24 - pajr.in CEO, NHS Endocrinologist: Cerebral Palsy?

25/02/2025, 23:27 - pajr.in CEO, NHS Endocrinologist: Early changes of Charcot visible here. Loss of hair on legs, skin changes, almost flat foot arches, LMN type of wasting (minimally) all pointing to poor glycemic control and long duration of diabetes.

Whats the current HbA1c and long term management plan?

26/02/2025, 07:42 - cm: @huai81please check the data on file to answer these

26/02/2025, 07:50 - PI Portal Hypertension Project 2022: HbA1c is 7.3 sir 

She was non complaint to treatment

26/02/2025, 07:52 - PI Portal Hypertension Project 2022: Her history is suggestive of Type 1 DM sir, planning to discharge her on injectable insulin after DKA subsides

26/02/2025, 08:04 - cm: Any reasons the treating team found for her non concordance with the treatment?

26/02/2025, 08:06 - PI Portal Hypertension Project 2022: She herself told that she was on OHAs and she used to not take them regularly sir

26/02/2025, 08:08 - cm; Based on feedback from the global UGs in this group I am sharing a few Inputs to yesterday's OPD patient case (@crthey may get in touch with you) as to how a UG may develop a  current neurology approach to such a patient from first principles of bedside clinical assessment:

1) Neuroanatomical localisation:

Is it UMN or LMN?

What does the gait indicate?

UMN or LMN?

Tone?

Reflexes?

If UMN then which part of the UMN is involved beginning with the cortical pyramidal cells of Betz and anywhere between those and the anterior horn cells anywhere in the spinal cord? Which areas of spinal cord?

What about the extrapyramidal system in this boy? Isn't that involved as well? What are the suggestive markers for that in the video?

Could it be LMN?

Once we have the neuroanatomical localisation we can then home in on to the pathology and etiology

@huai113 @huai116 @huai105

26/02/2025, 08:08 - cm: Oh! Since when was she on OHAs? How long is her diabetes?

26/02/2025, 08:31 - PI Portal Hypertension Project 2022: Since 6yrs she’s having sir, i.e from the age of 13/14yrs.She was on OHAs since only 1 year and non complaint to medication

26/02/2025, 08:53 - cm: From age 13 to till 1 year back what was she taking for her diabetes?

26/02/2025, 09:15 - PI Portal Hypertension Project 2022: She did not take anything sir

26/02/2025, 09:21 - PI Portal Hypertension Project 2022: Since 6 years she has complaints of polyuria, polyphagia and polydypsia 

And since 1 year she is using medication occasionally 

There was no apparent reason why she decided to go to hospital 1 year ago for treatment sir

26/02/2025, 09:39 - cm: Very interesting!

Then it couldn't have been a type 1 since 6 years although it now looks like a type one with ketoacidosis! @huai2 ?

26/02/2025, 09:41 - PI Portal Hypertension Project 2022: Why couldn’t it be type 1 sir?

26/02/2025, 09:48 -cm: Type 1 essentially means completely destroyed beta cells and hence prone to ketoacidosis and death if left untreated with insulin!

However there's a possibility that her beta cells behaved like type 2 initially with just 60-70% destruction and took 6 years to get totally destroyed producing severe insulinopenia enough to generate ketoacidosis!

But then the above scenario would be labeled rapidly progressive type 2. What other labels can one use from the diabetes ontology for a similar scenario @huai2?

26/02/2025, 09:50 - cm: We have a long distance patient family currently from Nashik on train and likely to reach us by evening at Narketpally. Any idea who are on call? I shall prepare a separate PaJR group for them to be further followed up for our local workflow surrounding them there

26/02/2025, 10:19 - cm: Morning PaJR patient's  neurological recovery outcomes:

Conversational Transcripts from immediate patient's advocate and PaJR moderator 👇

[26/02, 09:08] Patient Advocate 56M Quadriparesis WB OPLL NKP Operated: https://youtube.com/shorts/3p_E5BBMPl8?si=gb61LW4XWhqJdjcL

[26/02, 09:08] Patient Advocate 56M Quadriparesis WB OPLL NKP Operated: 

56/M . Current Situation After 54 Days Of Surgery.👇

Sir, The Upper Limbs have been better than ever. The left hand is fairly free and the right hand is better than before. The physio therapy by a therapist and the exercise are continuing.

But, after all the medicine are stoped the right leg is just getting sick as before the surgery and left leg is just as okay as before.

And Sir one more thing to note is that in sleeping time the lower limbs are pulled by themselves and this problem is increasing day by day.

[26/02, 09:09] Patient Advocate 56M Quadriparesis WB OPLL NKP Operated: Sir just amitriptyline is continuing.

[26/02, 09:59] PaJR moderator: Alright so this means he is somewhat back to the same position that he was prior to the surgery?

We know that the lower limbs getting pulled by themselves (aka flexor spasms due to UMN spinal cord involvement) was there earlier before the operation but was it less for few weeks after his operation?

Entire PaJR case report can be accessed here👇

https://pajrcasereporter.blogspot.com/2025/01/56m-spastic-quadriparesis-5-years-wb.html?m=1

Previous similar projects from project PIs in medicine department:

https://drkulkarnithesis.blogspot.com/2020/09/dissertation-plan-activity.html?m=1

@huai3

https://vivekkurma.blogspot.com/2023/04/thesis.html?m=1

@huai11 

Other projects:

https://medicinedepartment.blogspot.com/2022/06/linking-students-to-our-departmental.html?m=1

https://medicinedepartment.blogspot.com/2023/04/2022-25-medicine-department-allocated.html?m=1

26/02/2025, 10:21 - PI Portal Hypertension Project 2022: Tushara is on duty sir

And ajay sir 

26/02/2025, 12:23 - pajr.in CEO, NHS Endocrinologist: I don't believe that HbA1c for half a second.

26/02/2025, 12:24 - PI Portal Hypertension Project 2022: Our hospital lab generally gives a lesser value than outside labs sir

It will be around 9/10, if our lab gives HbA1c as 7.3 

26/02/2025, 12:25 - pajr.in CEO, NHS Endocrinologist: It is very likely a Type 1 with a long honeymoon phase.

26/02/2025, 12:28 - pajr.in CEO, NHS Endocrinologist: While that is the pathophysiology, Type 1 is now basically diagnosed with a C-peptide level of <200 pmol/l paired with a serum glucose of 72mg/dl or above and either Anti GAD, Anti IAA2, Anti Zn8 or any Anti ICA antibodies.

Can happen that she was teetering along the borders of these numbers for quite a while (honeymoon phase)

26/02/2025, 12:31 -Kolkata Medical College Intern: Cerebral Palsy

1) If non-progressive UMN signs (spasticity, hyperreflexia, gait abnormalities) with a history of perinatal.complications, then CP is right.

2) involuntary movements (dystonia, choreoathetosis), dyskinetic CP should be suspected.

3) NO -LMN signs (atrophy, fasciculations, hyporeflexia), then alternative diagnoses must be considered.

••Cerebral Palsy (spastic or dyskinetic) is a strong possibility. requires MRI and detailed neurodevelopmental evaluation.

26/02/2025, 12:31 - pajr.in CEO, NHS Endocrinologist: This is euphemism for "our hospital lab is incredibly corrupt and immoral in that in several cases it calculates the HbA1c by using a formula with fasting blood glucose and also does not upgrade itself to perform HPLC and still performs enzymatic based tests"

I've been there and done that.

26/02/2025, 12:32 - cm: This I assume is an LLM

26/02/2025, 12:35 - pajr.in CEO, NHS Endocrinologist: This is exactly where PaJR wins hands down - while LLMs suggest for "MRI and detailed Neurodevelopmental evaluation" (either through self learning or American vested interests, it simply cannot tells us why this would be required and whether getting these would improve any outcomes for the patient.

26/02/2025, 12:36 - pajr.in CEO, NHS Endocrinologist: Ambedkar, our biochemistry in house lab tech told me this when I probed on this issue. He himself gets his and his family tests done elsewhere, inspite of having KAP

26/02/2025, 12:37 - cm: This is a 19 year old girl with a younger brother and a mother with two amputated limbs and a long dead father and no one else in this world other than us (for the time being)! Even while giving consent in the file for something it was she who had to painfully write using the cardiac table in her ICU bed even as she continued her acidotic breathing as her brother looking after her in the ICU is just a minor.

While our departmental fund and devotion may tackle her issues we need to gear up foundationally to work around expensive lab test driven diabetes ontologies and develop our own low resource settings ontology for diabetes classification @919604701505

26/02/2025, 12:39 - pajr.in CEO, NHS Endocrinologist: Yes, none of those tests will add any value to her current clinical condition.

However, what insulin she will be put on matters and I'm curious to know

26/02/2025, 12:40 - pajr.in CEO, NHS Endocrinologist: I also believe a thorough and detailed neurological and vascular examination would be excellent value addition to her care.

26/02/2025, 12:41 - cm: We have discussed this with the Principal who used to be from Biochemistry department and the HOD biochemistry who agreed that our latex agglutination approach to Hba1c isn't great but we must remember again that we work in a low resource setting with sparse manpower and resources and have to make do with other perhaps even better current PaJR portable means of blood sugar control assessment than expensive Hba1c.

26/02/2025, 12:42 - cm: Mixtard 50:50 sponsored by "we the people"/tax payers/government

26/02/2025, 12:43 - cm: Yes that's not difficult. Can be easily done and maintained on PaJR follow up

26/02/2025, 12:44 - pajr.in CEO, NHS Endocrinologist: It's a solid bet and should be as good as those Lispros and Levemirs.

If anyone of the interested PGs can kindly share a head to head trial on this for further discussion and optimisation of treatment.

26/02/2025, 17:16 -huai24: How do trials work in this case? eg let's say we have a clinical trial with 10 patients where it did not have any harmful effect on the patient but neither did it do anything positive for 8/10 patients. But it cured the remaining 2 patients without any harm. 

Will this treatment be approved?

26/02/2025, 17:37 - pajr.in CEO, NHS Endocrinologist: Sir if you're buying into this scarcity mindset eyewash, then God help us all!

26/02/2025, 17:43 - cm: Here we were discussing a particular strategy of getting Hba1c results through either latex agglutination assay as in our lab vs the gold standard HPLC.

I reviewed the literature even as I was comprising this text and couldn't find useful studies that may have validated the test strategy we use.

Here's one unsatisfactory trial I came across 👇

https://www.researchgate.net/publication/329553282_COMPARISON_OF_HBA1C_LEVEL_USING_TURBIDIMETRY_INHIBITION_IMMUNOASSAY_LATEX_AGGLUTINATION_INHIBITION_METHOD_AND_HPLC_METHOD

26/02/2025, 17:44 - pajr.in CEO, NHS Endocrinologist: I have it on good authority (as I personally know the chief auditor of Kamineni Group) that Kamineni Group made a 140 cr profit (not revenue but profit) in the year 2020.

And here is the cost of getting a HPLC - https://dir.indiamart.com/impcat/high-performance-liquid-chromatographs.html

And imagine what value addition you could do with a HPLC. Introduce better HbA1c, Cortisols, advanced urine tests, free T4, T3 and so much more.

And if you think people cannot afford this - then you simply have to look across the pond at River NIMS and other budding centres in Nalgonda who are striving to offer these.

Patients and their families will be aware of what facilities a hospital is offering and thus we never see those patient strata in Kamineni, those who can afford are going elsewhere and those who can't are ending up here out of sheer helplessness.

26/02/2025, 17:46 - pajr.in CEO, NHS Endocrinologist: And this is purely from an Endocrinology perspective only. Now imagine they setup a department of Endocrinology and over the next few years you can setup DM seats and attract eye watering fees. And once you attract talent and human capital, the society around and surroundings too get better.

That's how growth happens, not the scarcity mindset puppets installed in positions of power.

26/02/2025, 17:46 - cm: However if you mean the different varieties of insulin, the cheaper current government supply vs the expensive big pharma hyped insulins then again it would be difficult to find a suitable trial given the complexity.

However through PaJR informational continuity we have managed to see that the government supply cheaper insulin can also provide comparably fair outcomes and it's the monitoring and dose titration using the PaJR system that scores

26/02/2025, 17:47 -cm: Agree but one can't make them see that reason!

26/02/2025, 17:49 - cm: Oh they can see this very well but here too there wouldn't be much patient capital because that is a very rare variety of capitalising

26/02/2025, 17:49 - pajr.in CEO, NHS Endocrinologist: Thankfully, which allows for enthusiastic and fresh faced youngsters like @huai81 and @huai109 to breach this market and trump them all.

26/02/2025, 17:51 - pajr.in CEO, NHS Endocrinologist: Of course they cannot, they had her highness Shruti Mohanty as their leader

27/02/2025, 11:04 - cm: OPD right now:

Many interesting cases since morning but the most interesting has just arrived @23fpa @G ceo Can you help us with two long distance patients who are visiting us and have been homeless since quite some time?

Can you see if they can get some accommodation near the temple there where they can stay free of cost? 

27/02/2025, 11:16 - cm: Hope to share the urate crystals we are going to aspirate today @huai35

28/02/2025, 10:03 -cm: @917013392774 @919908540769 please send

Hemogram, LFT, creatinine, urine CUE, Chest X-ray, ECG, echocardiography and ultrasound abdomen for yesterday's patients 55M and 62F and if possible ask an intern to record their echo videos and share that with me.

Please send them to psychiatry OPD for evaluation and share the deidentified psy notes in their PaJR group

28/02/2025, 10:07 - Communicating Learner 1N23: Ok sir

28/02/2025, 10:09 -cm: Thanks

28/02/2025, 11:31 - Kolkata Medical College Intern: Any more somthing sir.. 

28/02/2025, 11:41 - cm: Inputs from another pan India general medicine residents group👇

[28/02, 11:32] pg1: Pain?

[28/02, 11:32]pg2: Lymphoedema

[28/02, 11:32] pg3: Any past history of surgery?

[28/02, 11:33]pg3: If there's pain then it can be cellulitis 

Lymphedema

Thrombophlebitis

[28/02, 11:36]pg3: Post mastectomy might be the cause

[28/02, 11:36] cm: Painless

[28/02, 11:37]cm: What clues in the skin made you think of it?

[28/02, 11:39]cm: No history of mastectomy but history of a right breast abscess when axillary lymphnodes were also removed 22 years back!

Question is why is she having the lymphedema now! Also why isn't her arm involved, why just the forearm?

28/02/2025, 11:59 - Kolkata Medical College Intern: I think, delayed-onset secondary lymphedema due to past axillary lymph node removal.chronic, progressive lymphatic insufficiency. worsened by aging or a minor trigger.

1) History of axillary lymph node removal (22 years ago) → impaired lymphatic drainage

2)lymphatic obstruction (possibly at the elbow), gravity-dependent fluid accumulation, and preserved collateral drainage in the upper arm.

28/02/2025, 12:02 - cm: Why delayed onset? Why now?

28/02/2025, 12:03 - Kolkata Medical College Intern: Reactive Arthritis reason are Chikungunya virus post-streptococcal arthritis, or viral arthritis. ( My opinion) <This message was edited>

28/02/2025, 12:06 - Kolkata Medical College Intern: delayed onset reason - progressive lymphatic insufficiency over time.

First- collateral lymphatic pathways compensated for the removed axillary nodes.

 fibrosis, and possible minor triggers -trauma, dependency edema,then system decompensated this pesent body , results are leading to lymphedema now.

28/02/2025, 12:26 - cm: Well done @huai113 👏👏

28/02/2025, 12:27 -cm: Reviewing him again now!

28/02/2025, 12:44 - cm: @huai32 what happened to the fnac of his joints? We promised @huai35 that we would share the image of his crystals here!

01/03/2025, 08:39 - cm: Morning PaJR session on a young patient with indolent lupus nephritis responsive to azathioprine and yet developing possible pancreatitis due to cumulative dose toxicity looking for other lower cost alternatives such as cyclophosphamide and yet she's a young unmarried woman where cyclophosphamide runs the risk of gonadal toxicity:

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

[27/02, 07:30: Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating

However having said that I guess we should stop azathioprine for now

Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission

[27/02, 14:35] pg: Can we plan renal biospy for her sir?!

[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.

Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today

So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!

Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!

[28/02, 14:24] pm: @huai3 you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @huai51 also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.

We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @919505766290 just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet

[28/02, 15:55]apmalum : Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.

[28/02, 15:59] apmalum: Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.