While contemplating whether to begin with the first patient I encountered or the one who deeply affected me, I will commence with the account of my initial patient since that marked the beginning of my journey.
The first patient I encountered was a 42-year-old male who was admitted to the ICU with symptoms of fever, headache, and altered sensorium. However, what caught my attention was the fact that despite being diagnosed with hypertension six months ago, he was still experiencing high blood pressure (160/100) despite being on three different antihypertensive medications. I initially suspected that the patient was not adhering to his medication regimen and personally supervised his intake, but his blood pressure readings remained elevated. This prompted me to raise questions and delve deeper into the case.
Considering the triad of symptoms (fever, headache, altered sensorium), meningitis, either bacterial, viral, or TB, became a potential diagnosis. Furthermore, we needed to determine the cause of his resistant hypertension and whether it was secondary hypertension. Further investigations revealed heart failure with a mid-range ejection fraction (47%), acute kidney injury on chronic kidney disease, and a CT brain scan conducted outside the hospital showed a lacunar infarct. A lumbar puncture was performed, and the cerebrospinal fluid analysis indicated bacterial meningitis. The patient was subsequently managed conservatively.
https://himajav.blogspot.com/2022/12/42m-fever-headache-and-altered-sensorium.html
CASE OF 65 YEAR OLD MALE WITH CHRONIC VOMITINGS
In another case, I encountered a 65-year-old male with chronic vomiting lasting two months. It was a Friday evening when I noticed the elderly patient in a wheelchair near the entrance of the casualty area, having just vomited. I approached the patient's attendants to gather his medical history and learned that he had been experiencing vomiting for two months. The family members were amazed if he could eat a single idly without vomiting. The patient had seen numerous doctors and undergone various investigations. His concerned daughter insisted on a brain imaging, as he had been examined for everything except the brain. We reassured her and explained that a brain imaging was not immediately necessary. We decided to rule out other possible causes before considering it. After admitting the patient, we took a detailed history. He had previously been an energetic man taking care of oxen, but his knee pain due to osteoarthritis forced him into retirement and gradually confined him to bed due to weakness after vomiting episodes. One afternoon, while struggling to walk with the support of his wife, we noticed an abnormality in his gait. Initially, we attributed it to severe arthritis, but upon closer observation, our seniors recognized a swaying movement to the left side. A thorough examination led us to order an MRI of the brain, which revealed a large lesion in the left cerebellar hemisphere extending into the vermis. The lesion was causing compression and displacement of the fourth ventricle, resulting in mild dilatation of the lateral and third ventricles suggestive of acute hydrocephalus. Additionally, periventricular hyperintensity indicated transependymal seepage of cerebrospinal fluid. It astonished me how such a significant lesion could manifest with only vomiting as a symptom.
https://himajav.blogspot.com/2022/12/65m-chronic-vomitings-since-2-months.html
CASE OF 35 YEAR OLD FEMALE WITH SKIN LESIONS
In an interesting case of a 35-year-old female, she visited the dermatology outpatient department (DVL OPD) and was subsequently admitted for allergic dermatitis. Upon further investigation, we discovered that the patient had a history of scalp psoriasis, possibly psoriasis vulgaris, for which she had been taking methotrexate tablets for a month. Here's the twist: the patient had been taking methotrexate daily instead of once weekly, resulting in her admission with skin lesions and pancytopenia. She was diagnosed with methotrexate toxicity. Since tab folinic acid was not available in nearby or city pharmacies, we managed her condition conservatively with tab folic acid.
CASE OF 35 YEAR OLD MALE DIABETIC NEPHROPATHY
During my early days as a resident, I encountered a patient who deeply touched my heart. He was a 35-year-old male with dark skin, presenting with lower limb swelling and facial puffiness. Upon admission to the hospital, an ulcer in the webspace between his great toe and second toe of the right foot was discovered. The patient had a history of diabetes mellitus for the past 10 years, and he had been on insulin therapy for the last 4 years. Additionally, he had been diagnosed with hypertension 1 year ago. There were suspicions of diabetic nephropathy and acute kidney injury on a background of chronic kidney disease (CKD) with anemia, possibly secondary to the CKD with heart failure with preserved ejection fraction (HFpEF) at 53% EF.
Recognizing the patient's low hemoglobin level of 6.2, I requested the attendants to arrange blood donors for a transfusion. Regular dressings were conducted for the ulcers, and the patient's clinical condition showed signs of improvement.
One afternoon, after completing his dressing, I noticed silent tears streaming down his face. It puzzled me why the patient was experiencing sadness despite his improving condition and imminent discharge. I inquired about the reason for his tears, wondering if they were related to pain from the dressing. However, he denied any physical discomfort. I further asked if there were other sources of distress, but he shook his head sideways. When I inquired about potential family issues, he refused to answer. In that moment, I sat beside him and contemplated the weight of his experience. I imagined the emotional toll of living with diabetes since the age of 25, followed by the added burden of hypertension and subsequent hospitalization for kidney injury. He carried responsibilities, a family to care for, and dreams of living a normal life like any other 30-year-old man. Psychologically, it was undoubtedly challenging for him to cope with these circumstances. While doctors focus on his biological treatment and subsequent discharge, he alone must endure this illness for the rest of his life, adhering to regular medications and follow-ups. I provided counseling and discharged him after a few days.
I did not see him again until one Friday around noon when an intern informed me of a patient with shortness of breath and altered sensorium arriving in the emergency department. In the casualty area, I noticed a woman greeting me as though we were acquainted. As I recollected who she was, I approached the patient and recognized him as the one I had cared for previously. This realization shocked me because just two months ago, he had been in good health and happily returned home. Upon assessing his vital signs, I observed high blood glucose levels. Initially suspecting diabetic ketoacidosis (DKA), I took a thorough history, discovering that he had missed his insulin doses for the past two days. I stabilized the patient and promptly transferred him to the intensive care unit (ICU). Further examination revealed gangrene in his right foot, prompting a referral for surgical intervention, which recommended amputation of the great toe. The surgery proceeded without complications, and postoperative blood transfusions were necessary. The following day, there was a significant drop in his blood sugar levels, and his sensorium improved. We gradually discontinued the insulin infusion and transitioned him to subcutaneous insulin therapy. During this time, we contemplated whether his condition indicated DKA, type 1 diabetes, or latent autoimmune diabetes in adults (LADA). However, one of our senior colleagues advised against stressing over the specific type of diabetes, emphasizing that he would require insulin for the rest of his life due to the presence of CKD. The patient received counseling on insulin therapy, diabetic diet, hypoglycemic symptoms, and regular dressings before being discharged.
During the patient's follow-up visit after one week, I reviewed his sugar profile and found that the numbers were not within the optimal range. I asked him if he had been taking his insulin regularly, and he assured me that he had been without any omissions. Considering the possibility of increased insulin requirements, I contemplated whether the dosage needed to be adjusted. However, before making any changes, I wanted to verify the details and asked him about his diet. He patiently described his daily intake, and there appeared to be no issues that would significantly increase his insulin requirements beyond what we had already established. To be thorough, I requested him to demonstrate how he administers his insulin. He presented a Human Actrapid Insulin (HAI) vial and a syringe, showing me the process. Everything seemed to be followed correctly, but I noticed that he was only using HAI and had neglected to include NPH insulin. Upon further questioning, he explained that his wife, out of ignorance, had argued with him, insisting that he had been advised to use only a single type of insulin, which led her to purchase only HAI from the store. I provided counseling to both the patient and his wife regarding proper insulin therapy and personally supervised their acquisition of the appropriate insulin, ensuring they obtained the correct type in front of me. Subsequently, I discharged them to return home.
https://abhignya83.blogspot.com/2023/02/35-yr-old-male-with-altered-sensorium.html
He was admitted after three months later
https://pranathikrothapalli.blogspot.com/2023/05/39-year-male-with-sob.html
In summary: this was a case of 35 year old male and his journey to dialysis
Diagnosed as
UNCONTROLLED SUGARS (?DIABETIC KETOACIDOSIS-UNRESOLVED) LEFT LL CELLULITIS (RESOLVING) HEART FAILURE WITH PRESERVED EJECTION FRACTION WITH AKI ON CKD WITH ANEMIA (NC/NC) SECONDARY TO
? CKD WITH THROMBOCYTOPENIA WITH K/C/O DM SINCE 12 YEARS
K/C/O HYPERTENSION SINCE 2 YEARS WITH 2FFP TRANSFUSION
1 SESSION OF HEMODIALYSIS
S/P RAYS AMPUTATION OF GREAT TOE
S/P FASCIOTOMY OF LEFT FOOT ON 13/5/23
After encountering this patient, I came to realize the profound influence that biopsychosocial factors have on individuals' lives.
CASE OF A 37-YEAR-OLD MALE WITH SPINAL CORD UPPER MOTOR NEURON (UMN) PARALYSIS AND UMN BLADDER PROBLEMS FOLLOWING A SNAKE BITE IN 2015.
On Women's Day, I had the opportunity to participate in a group discussion on women's health, which also included a focus on Patient journey record(PaJR). During the discussion, Abhishek, a 37-year-old male garbage collector, volunteered to initiate PaJR activities within his community. In order to further evaluate his situation, I offered to conduct a telephonic assessment before advising him to visit our hospital. This particular case served as a valuable lesson for me, emphasizing the importance of Patient journey record
Here is the sample of PaJR discussion and case based learning through PaJR
https://himajav.blogspot.com/2023/03/37m-snake-bite.html
[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
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