37M SNAKE BITE

 

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever 

Following is the view of my case

37 year old male born in 1986 in Medak district by normal delivery.

Milestones achieved normal

Was born in lower socioeconomic status.

Father of four children.

Studied till 2nd standard and then joined his father for work to earn money from childhood.

Got married in 2008. Consagious wedding. In 2009 first child (daughter) was born.

He worked as a daily wage labourer till 2009 and moved to Hyderabad in 2010 and started working as garbage collector .

In 2010 second child was born (daughter).

Daily routine past : wakes up by 4am freshen up and go to work, have breakfast at work station provided for free. Come back home at 10.30 am have a cup of tea. Lunch at 11.30am. Relaxes for sometime and steps out of home to collect papers.

At 6.30pm comes back home and have one glass of beer and one glass toddy initially and later increased to two bottles of beer and quarter of alcohol. Have dinner and go to bed by 8.30pm.

Started consuming alcohol due to peer pressure after moving to city.

Social relations with family and friends were good.

In 2013 he had his third child (son).

He went to his village in Medak district to collect ration rice provided for free by the government. On one fine evening around 7pm he went to the fields to empty his bladder and stepped on a snake (?russel viper) which bit his leg. He lost consciousness and doesn’t remember anything. Bystanders told him that he vomited, passed urine and stools in his clothes, swelling of left lower limb and was taken him to the nearby herbal medicine doctor who gave him herbal medicines. Gained consciousness in the morning. He used herbal medicines for five months and his left lower limb swelling subsided gradually.

Patient borrowed money and celebrated his sons first tonsure.

After swelling subsided and patient started going back to workstation he noticed numbness and sensation loss in his right leg which worried him but did not get any aid and carried on his daily activities.

In 2017 he had insidious onset of urinary and stool incontinence, erectile dysfunction which was gradually progressive. Due to affordability issues he went back to his town and consulted a local mbbs doctor who took an X-ray and advised him medications(unknown) for 10 days. Patient had no relief and went for herbal medications which he trusted would cure him. But patient had no improvement with herbal medicines.

Patient stopped going for work outside since then and sits idle at home.

Daily routine at present: wakes up at 5am occasionally at 8am and lies ideally on bed watching walls and surroundings. Freshen up and have tea with bread. At 11.30pm have lunch with rice and curry. Takes nap from 2-4pm. Drinks tea after waking up. Stays isolated most of the time. Gets anger outbursts often when children irritates him.

He tried homeopathy medicine for one month. On advice of homeopathy doctor he stopped consuming alcohol since two months but because of cravings he still drinks on Sundays.

Bought a garbage van and hired a man to collect garbage through which he earns a little amount and runs the family.

Sometimes patient have anxiety and feels generalised weakness. Worried about his children future. At times he feels taking off his life would be better than to be bed ridden.

He also feels low and his pride hurt for not been able to perform sexual activities.

Hourly routine

Wakes up by 6am pass stools and urine occasional incontinence. Sometimes go to washroom, sometimes defecate in clothes.

Have tea (sugar and milk ) with bread at 7am

At 8am He drops children at school by bike (xl) and bring groceries for home. While riding bike on a bumpy road he feels abdominal discomfort followed by stool and urine incontinence

From 9am patient passes time sitting idle or watching tv

Have lunch at 11am usually rice and dal. Non veg weekly thrice.

At 12pm he brings back children from school and have nap till 4pm

Wakes up at 4pm drinks tea.

6-9pm he watch TV serials

Dinner at 9.30pm usually rice and go to bed by 10.30pm

Wakes up middle of night once for washroom.

His concern

* to be able to get back to normal and carryon his daily activities. 

[21/03/23, 11:55:13] Abhishek Choudhary: [09/03, 1:55 pm] Abhishek Choudhary: The snake bite - infection appears to have been a 10 year old incident. 

His current complaints are:

1. No touch sensation from hip down

2. Incontinence and unable to control defecation

3. He has a tenacity to get severely hurt in the legs without realizing that he is hurt.

[09/03, 2:00 pm] Abhishek Choudhary: On a quick check of the lower  extremities:

1. No plantar response

2. Knee jerk response is marked prominent (couldn't find my clinical hammer... But   slight tapping with knuckles produced knee jerk) 

3. He appears to have some oedema around the feet

4. He is able to walk without support, but uses side to side  slipping gait. Straight line is maintained.

[09/03, 2:01 pm] Abhishek Choudhary: Patient was conscious and cooperative, and the origin is unlikely to be somatization.

[09/03, 2:02 pm] Abhishek Choudhary: Have asked him to share *all* reports and medication pictures by evening or tomorrow. 

Will share after anonymization

[09/03, 2:08 pm] Abhishek Choudhary: His upper extremity ROM is unrestricted and muscle grade 4+ (did not evaluate resistance against gravity) 

Hand stretch test also showed unlikely involvement above waist. 

Lower extremity muscle grades are a mix, but unlikely better than 3+. He was unable to comfortably lift the feet while sitting. 

I could not tell if there any hypertonia

[21/03/23, 11:57:21] Abhishek Choudhary: I have history of his bowel issues, now and 5 yrs back. And a few other videos. 

Will share post lunch

[23/03/23, 16:48:28] Rakesh Biswas Sir HOD GEN MED: Well done 👍

Just a few nit pickings 

"Got married in 2008. Consagious wedding. In 2009 first child (daughter) was born."

Can you pinpoint the degree of consanguinity he has with his wife although it will have implications on his offspring and not his current problem per se which now on reading this detailed report appears to be a non compressive myelopathy related to snake bite injury. 

Can we review the literature around snake bite and myelopathy and share here asap? 

Rest of the workflow around this patient will be to develop assistive device solutions with @919966699473 's team after understanding his current daily workflow and barriers to it due to his disability in detail? I guess this next step can also be done through this PaJR group?

[23/03/23, 16:53:51] Abhishek Choudhary: https://pubmed.ncbi.nlm.nih.gov/15311570/

@919121046928 this may be your case report

[23/03/23, 16:56:41] Rakesh Biswas Sir HOD GEN MED: Thanks. Yes. This current patient tells me that what we at that time (20 years back) thought to be due to antivenom may have been directly due to the snake bite too

[23/03/23, 17:06:19] Rakesh Biswas Sir HOD GEN MED: We can only provide solutions (aka treat) once we understand the patient's requirements in detail. 

Tell us in detail about his incontinence 👇

Currently it's only this and to quote from @918790889907 's case report :

In 2017 he had insidious onset of urinary and stool incontinence

Unquote 

Tell us how in his current regular workflow what does he do hourly and what is the problem he experiences in those same hourly slots due to his disabilities so that we can have a grasp on his requirements that may enable us to design better solutions for him

[23/03/23, 17:10:05] Rakesh Biswas Sir HOD GEN MED: We need a representative day to understand his hourly problems to be able to provide a more meaningful solution

[23/03/23, 17:19:48] Dr.Dinesh Datta: @919966699473 Do you have any biopolymers at your dispense which can help us make a custom made 'reusable diapers' for this patient at minimal or easily crowd funded cost?

[23/03/23, 17:21:42] Abhishek Choudhary: No... Sorry

Bio compatibility issues will arise unless any material is siliconized enough. 

We may need to think / design a little out of the box

[23/03/23, 17:23:28] Rakesh Biswas Sir HOD GEN MED: Yes think beyond diapers which are already available. 

By the way what is the solution the patient is currently using?

[23/03/23, 17:34:20] Abhishek Choudhary: https://www.mdpi.com/2072-6651/14/7/436

They have reviewed some good cases

From the article... 

_Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment_

[23/03/23, 17:36:36] Abhishek Choudhary: Please correlate with other versions of the history. 

10 years is a huge recall window in the target demography. Opinion: latest would be the most accurate, with the only risk of *scripting errors*

Will share some links on *scripting in recall*

[23/03/23, 17:41:41] Abhishek Choudhary: https://link.springer.com/article/10.3758/bf03195836

Three classes of evidence demonstrate the existence oflife scripts, or culturally shared representations of the timing of major transitional life events.

[29/03/23, 15:07:49] Himaja: Wakes up by 6am pass stools and urine occasional incontinence. Sometimes go to washroom, sometimes defecate in clothes.

Have tea (sugar and milk ) with bread at 7am

At 8am He drops children at school by bike (xl) and bring groceries for home. While riding bike on a bumpy road he feels abdominal discomfort followed by stool and urine incontinence

From 9am patient passes time sitting idle or watching tv

Have lunch at 11am usually rice and dal. Non veg weekly thrice.

At 12pm he brings back children from school and have nap till 4pm

Wakes up at 4pm drinks tea.

6-9pm he watch TV serials

Dinner at 9.30pm usually rice and go to bed by 10.30pm

Wakes up middle of night once for washroom.

[29/03/23, 15:08:03] Himaja: He says his urine and stool incontinence is occasional

[29/03/23, 15:08:19] Himaja: And he has no idea when and what factors trigger it

[29/03/23, 15:22:47] Rakesh Biswas Sir HOD GEN MED: Thanks. This is valuable input.

So is that his current requirement from us:

Occasional episodes of mild soiling of clothes due to urinary and fecal incontinence due to reflex neurogenic bladder aka UMN bladder due to his past spinal cord injury following snake bite? 

What is his own current solution for this? Does he use diapers?

[29/03/23, 15:23:18] Himaja: He is not using diapers sir

[29/03/23, 15:23:58] Himaja: Spoil his clothes whenever he has incontinence

[29/03/23, 15:24:06] Rakesh Biswas Sir HOD GEN MED: Well changing clothes during such very occasional accidents is also a good solution

[29/03/23, 15:25:36] Rakesh Biswas Sir HOD GEN MED: So what is his requirement that needs a robotic solution from us?

What about his daily motor movement requirements? Does he experience any difficulty with that?

[29/03/23, 15:26:56] Himaja: His concern

* to be able to get back to normal and carryon his daily activities.

[29/03/23, 15:28:11] Himaja: He says his gait is staggering

[29/03/23, 15:32:41] Rakesh Biswas Sir HOD GEN MED: Tell us what normal activities is he sacrificing currently 

According to you he appears to have a normal life

[29/03/23, 15:40:35] Himaja: He stopped going for work and sitting idle due to his bladder and bowel irregularities, and patient had sensation loss in both lower limbs Due to which he occasionally injured himself

[29/03/23, 21:29:00] Rakesh Biswas Sir HOD GEN MED: Since when has he stopped work?

Is it due to his motor disability? What work did he do before he stopped work? What is his current income source?

[29/03/23, 21:48:40] Himaja: Bought a garbage van and hired a man to collect garbage through which he earns a little amount and runs the family

[29/03/23, 21:52:00] Rakesh Biswas Sir HOD GEN MED: So he hasn't stopped work? 

Probably not doing the same kind of work as earlier? 

Since when is he doing his current work?

[29/03/23, 22:29:46] Himaja: Since 4 years sir

[29/03/23, 22:29:58] Himaja: He stopped going by himself for collecting garbage

[30/03/23, 08:11:11] ~ Asha Reddy: Good morning sir...I might not be able to explain it in medical terminology, however I can explain his problem in detail.

Srinu has been suffering with numbness in his left leg for over 4 years now, which has become chronic and now as per our(Abhisek and Myself) observation from different tests conducted here he has lost sensation in almost 60% of his whole body. He has for the last 1 year lost control over his nature calls too. Though he has sansation, he says he can't hold it long coz of which he has stopped coming to his regular duty of garbage collection. Having 4 kids keeps worrying him about their future. He can barely walk and it has been a long time since he had a sound sleep. We would want him to get back on his legs, to boost his self confidence and support his family and take care of them.

[30/03/23, 08:32:49] Rakesh Biswas Sir HOD GEN MED: Excellent summary of the patient requirements 👏👏

Now for the solutions plan after we break up his requirements one by one priority wise 

Priority 1: 

Bowel bladder accidents frequency and mitigation 

Priority 2:

Barely able to walk 

Priority 3:

Numbness 

Currently medical science has to depend on engineering solutions to all the above and there is no effective pharmacological solution for the above except if he has pain along with the numbness















[31/03/23, 13:14:40] Rakesh Biswas Sir HOD GEN MED: @918790889907 Hypertonia of lower limbs

[31/03/23, 13:16:52] Rakesh Biswas Sir HOD GEN MED: Increased jaw jerk taking the level of the lesion to cortico bulbar tracts above mid pons

[31/03/23, 13:18:36] Rakesh Biswas Sir HOD GEN MED: There was another video @918317669334 showing the reduced pharyngeal movement well?

[31/03/23, 13:52:21] Rakesh Biswas Sir HOD GEN MED: Found some very interesting changes after evaluating him face to face as opposed to our previous telephonic collaborative sharings here. 

His father and brothers all have slurring of speech, even his children suggesting an autosomal dominant genetic disorder possibly involving the speech cranial nerves and on examination we found that he had palatal weakness (9,10,11 cranial nerves) along with brisk jaw jerk again suggesting a UMN corticobulbar pathway lesion above mid pons that can also explain all his other problems and findings! 

So we have come a long way from an acquired snake bite induced myelopathy to a genetic brainstem neurodegenerative disorder!

[01/04/23, 10:55:39] saicharan Sir Gen Med: https://jnnp.bmj.com/content/91/4/373

Primary lateral sclerosis (PLS) is a characteristically slowly progressive and selective neurodegenerative disorder primarily affecting the adult central motor system. Progressive muscle stiffness leads to an insidious loss of mobility typically with the development of corticobulbar dysfunction, which may be the initial symptom for a minority. Diagnostic criteria for PLS proposed 75 years ago recognised the potential for clinical overlap in the early symptomatic phase with the more common disorder amyotrophic lateral sclerosis (ALS).1 Like PLS, upper motor neuron (UMN)-predominant ALS has a significantly slower rate of progression compared with classical forms of ALS, with survival frequently extending into a second decade from onset of symptoms.2 The development of clinically obvious and functionally significant, progressive lower motor neuron (LMN) involvement is inevitable in ALS, in contrast to PLS, but may not emerge for several years from the initial clinical UMN syndrome.3 As a result, criteria for the definite diagnosis of PLS have enshrined a minimum duration of symptoms, varying from 3 to 5 years.

[01/04/23, 10:55:47] saicharan Sir Gen Med: The core clinical syndrome

There have been consistent clinical observations reported across multiple case series in PLS.8 Mean age at symptom onset is around 50 years which is at least a decade earlier than non-familial ALS, and a decade later than HSP. While there have been cases reported with symptoms beginning in childhood, many of those might now be linked to developmental or monogenetically mediated disorders. A male predominance has been consistently noted in PLS (range 2–4:1).

An insidious onset is the rule in PLS, so that individuals are unlikely to reach specialised neurological services soon after the very earliest symptoms. For the majority of patients, symptoms emerge in the lower limbs first, but for a significant minority in the corticobulbar pathways with dysarthria and often prominent emotionality (pseudobulbar affect). Although dysphagia may become marked, the value of gastrostomy is far less clear than in ALS, and the need for non-invasive ventilation in PLS more exceptional. Lower limb involvement in the early symptomatic phase may be articulated as a sense of dysequilibrium or loss of fluidity in gait. Prominent sensory involvement should not be evident. Spasticity with pathological hyperreflexia are invariable examination findings. Although PLS typically generalises to include the upper limbs, a focal upper limb onset to symptoms is very unusual in PLS.





[01/04/23, 11:10:59] Rakesh Biswas Sir HOD GEN MED: Well done @919493340818 👏👏

In our patient, can we explain bowel bladder and sensory involvement with PLS? As per your review apparently not? 

Let's further review to accomodate these two features as well as the possibility of a genetic autosomal dominant disorder

[01/04/23, 12:04:32] Pradeep Sir Gen Med: Adrenomyeloneuropathy (AMN) presents in adulthood and affects the spinal cord and peripheral nerves, with a slower progression leading to gait and balance disturbances, sensory impairment, and bowel and bladder dysfunction

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789359/







[01/04/23, 14:19:18] Rakesh Biswas Sir HOD GEN MED: Share the images asap

[01/04/23, 14:21:55] Rakesh Biswas Sir HOD GEN MED: Looks like our approximation regarding the neuroanatomical localization was better correlated with these MRI findings before we actually got to examine him in detail yesterday!







[01/04/23, 15:34:35] Rakesh Biswas Sir HOD GEN MED: Share these in separate frames 

@919885321401 Unexpectedly this MRI was very very very useful in the patient's evaluation 👍

The next step would be neurosurgical evaluation asap





[01/04/23, 15:52:41] Rakesh Biswas Sir HOD GEN MED: Show us some coronal and transverse sections







[01/04/23, 16:29:45] Rakesh Biswas Sir HOD GEN MED: FAQs on further course of action for spinal cord pathology 

[4/1, 4:16 PM] Query:

 Doctor, what is the next course of action for our spinal cord pathology patient? How serious is the issue and what is the hope for recuperating...plz advice

[4/1, 4:19 PM] Rakesh Biswas: Let's hope it's an infective or a benign lesion of the spinal cord. 

The next step is operating his spinal cord and seeing the pathology under the microscope to understand if it's infective, benign (easily treatable) or malignant (not easily treatable)

[4/1, 4:20 PM] Query: Ok, how much wud this entire treatment mount to?

[4/1, 4:22 PM] Rakesh Biswas: It would depend on where it is done 

At our place it may be much less compared to say Yashoda and we currently have a young neurosurgeon who may be keen to operate him asap

[4/1, 4:23 PM] Query: Can a benign lesion cause a slow and progressive problem like he is currently facing?

[4/1, 4:24 PM] Query: If it cannot, can we say it cud be a malignant lesion?

[4/1, 4:25 PM] Rakesh Biswas: Yes it's a slow progressing lesion and hence we are hoping it's benign (could even be an infection like TB). 

If it had been malignant it would have progressed faster

[01/04/23, 17:48:23] Rakesh Biswas Sir HOD GEN MED: Look at the climax today 

We shall always remember this case as one where our clinical neuroanatomical localization through this PaJR discussion without seeing the patient was more accurate and correlating radiologically than after actually having seen the patient here with our accurate supposedly better clinical examination and history taking skills. 

Lesson learnt: More clinical data may not necessarily translate to better diagnostic outcomes unless there actually two pathologies, the other explaining his familial autosomal dominant speech disorder and subtle brain stem features

[01/04/23, 17:48:44] Abhishek Choudhary: T2 weighted? CSF dark...

[01/04/23, 17:51:02] Rakesh Biswas Sir HOD GEN MED: T1 is CSF dark 

This one is T2 weighted and doesn't show much findings as it's a lateral saggital section

[01/04/23, 18:22:20] Abhishek Choudhary: We need PaJR protocols across the ICD spectrum...

ICLE proponents may suggest SCT 🙂

Sorry, Dr Rho proto was open and non functional during this case initiation... later I did think of repurposing AusculAid 1.0 for remote examination in the absence of TARA/Dr Tho

[01/04/23, 19:36:24] ~ Asha Reddy: Hi All, 

 Request you to provide an estimate for the treatment. I feel it cud be an expensive one. 

I would like to be practical with regards to financial assistance to the patient and establishing their hopes in terms of support both from you and our side.

We have raised around 35k from our society to support their medical expenses from which we have already spent 8k on his MRI. I am left with only 27k now with no hope of raising any funds further . As per my discussion with the patient sometime back they have already exhausted their resources for his treatment for the last 4 years and are in no state to afford further expenses.

So, having an estimate(approximate at least) wud be of much help for us to give them a heads-up and  for them to decide on how to proceed.

Thank you in advance.

[01/04/23, 20:23:18] Rakesh Biswas Sir HOD GEN MED: We'll try to finish his surgical treatment and subsequent medicines , if a benign infection on biopsy(for example TB) in 27,000. 

If it turns out to be a malignancy or even localized lymphoma it may require more but that's later

[01/04/23, 20:40:49] Abhishek Choudhary: Let's hope it's a benign infection...

Informed guess / wish... he does manual collection of waste and follows up with manual sorting...

No tetanus inoculation! I have learnt from my more conscientious worker friends they take a TT shot twice or thrice a year...

[01/04/23, 20:41:33] Abhishek Choudhary: How likely is a vitamin B / D deficiency being a causative factor for similar presentation?

[01/04/23, 20:46:46] Abhishek Choudhary: Sorry for the share based on enthusiasm...!

Just wishing for something mundane... given the known possibilities 

https://medlineplus.gov/ency/article/000723.htm#:~:text=SCD%20is%20caused%20by%20vitamin,mainly%20affects%20the%20spinal%20cord.

[01/04/23, 22:04:31] Rakesh Biswas Sir HOD GEN MED: Vitamin B or D deficiency is unlikely with the kind of pathology that is visible in MRI

[01/04/23, 23:18:23] Abhishek Choudhary: Is this the prominence we can palpate on the spine around the level of the lower margin of his scapula?

[01/04/23, 23:40:42] Rakesh Biswas Sir HOD GEN MED: No there doesn't appear to be any such suggestion in the MRI

[04/04/23, 08:53:10] Himaja: Patient attender concerns

Will 37M gets cured completely after surgery ? And will the patient have to undergo any more further surgeries after this?

[04/04/23, 10:58:01] Abhishek Choudhary: They both met @919885321401 Asha garu and me today morning. 

Other concerns they shared 

1. Children have exams in the next 1 month. Can the surgery be delayed?

2. Will there be adverse outcome from the treatment?

Is is feasible to get a plan from a neuro surgeon and help them understand

A. Possible negative outcome of *not* getting treated (like mets in case of malignancy, or further  degradation of sensory motor functions etc)

B. Risk profile and prognosis for such cases 

C. Possible adverse outcome of the proposed treatment, if any

Just some humble thoughts 🙏

[04/04/23, 11:42:31] Rakesh Biswas Sir HOD GEN MED: 1) Perhaps. Who knows how old the pathology is and going by his symptoms it could be years old 

2) They will need to meet the neurosurgeon face to face unless @919059022329 can add him or the appropriate surgery PG here 

A) Only after excising the pathology can one see it under the microscope and then figure out from a prior database the pattern of what outcomes such pathologies produce. If only we had an MRI that could show us the pathology at the cellular level things may have been different 

B)Ditto 

C) He could become worse after treatment losing full control and power and becoming bed ridden. Medicine is always a gamble and all our current thesis projects are to elucidate the factors that makes one win or lose and be able to predict the game better for each individual. Not sure how successful these projects will be

[04/04/23, 17:52:18] Manasa Mam Gen Med Kamineni: Spoke with neurosurgeon ,Sir asked them to meet him in opd tomorrow... shall we call them sir ?

[04/04/23, 20:19:48] Rakesh Biswas Sir HOD GEN MED: Did he see the MRI images?

[04/04/23, 21:15:48] Manasa Mam Gen Med Kamineni: Yes sir , Sir saw the MRI , as it was intramedullary lesion plan of action was to do biopsy and then based on report further plan of radio or chemotherapy sir. He also  said excision of  intramedullary lesions will lead to neurological deficit so we can't do total excision for this case sir .

[04/04/23, 22:38:46] Rakesh Biswas Sir HOD GEN MED: Yes as mentioned above earlier biopsy will provide us a direction regarding the probable outcomes in his illness

[05/04/23, 02:53:04] Abhishek Choudhary: Thank you. That is very reassuring.

[05/04/23, 03:02:43] Abhishek Choudhary: Is a minimal access biopsy feasible / indicated? 

FNAC for spinal cord lesions?

[05/04/23, 03:28:36] Abhishek Choudhary: The patient is very concerned about adverse outcomes and how they impact the future of his children. A central theme during his 10-15 mins interaction with me yesterday was this.

Given that the condition may deteriorate even without any intervention, we may want to explain the narrative to him.

How much of that will be understood apart from the risk factors is arguable.

The downside is that without an acceptable supportive management, the patient may return to the quacks he purportedly visited earlier.

If post Biopsy, radiotherapy / chemo are indicated would it be feasible to get him an affordable solution? Basvatarakam does offer discount based on needs, but how much depends. Anyway, that's only after biopsy, if needed

[05/04/23, 07:49:36] Manasa Mam Gen Med Kamineni: Outcomes will be depend on the type of pathology whether it is benign or malignant ( if malignant grade is important ) . In grade 1 and 2 there are better outcomes compared to grade 3 and 4.  As our plan is to get a biopsy not subtotal  or total resection chances of iatrogenic damage to neuronal structure will be less and post procedure morbidity.. He may only complicate by the disease persae ( growth and extent of the lesion ) . 

   Do they have arogyasree ??  if he needs radiotherapy or chemotherapy ,it can be covered under Arogyasree in NIMS , Hyderabad.

[02/06/23, 09:24:12] Abhishek Choudhary: We had tried to work out crowd funding for them (mainly Asha ji's initiative), but things are taking a bit too long. 

If feasible, please explore whether the case can be handled at Narketpally. The involved cost etc. 

Just a heads up... The patient party is under time pressure, so let us commit only if feasible with the 25k or so that remains from the society collection.

Thanks in advance for your time on this.

@919121046928 @918790889907 @919885321401

[02/06/23, 09:27:39] Rakesh Biswas Sir HOD GEN MED: From my take away from the last time we discussed him it was clear that a neurosurgical intervention would only bring us the diagnosis that would be useful only if it turned out to be tuberculosis or lymphoma both of which appear unlikely given the absence of any systemic symptoms. There is the danger of his losing whatever current function he has. The patient and his funders needs to understand this before taking the plunge