30M WEIGHTLOSS

A 30-year-old male presented with a history of progressive weight loss over the past year. Symptoms commenced in November 2022 with severe abdominal pain and vomiting, initially attributed to roadside food consumption. Recurrent monthly episodes of abdominal pain, bloating, and vomiting/loose stools persisted until April. Diagnostic workup, including abdominal scan, CBP, ESR, CRP, TTG antibody, LFT, RFT, sputum for AFB, chest X-ray, Quantiferon Gold for TB, and Montoux test, yielded normal results except for elevated CRP. Ayurvedic treatment resulted in symptom improvement, but weight loss persisted. From November 2022 to April 2023, he lost 10 kgs and maintained stability at 48 kgs thereafter. CRP levels correlated with symptom exacerbations, decreasing post-treatment. Presently, he experiences diminished appetite, eating only twice daily, despite previously consuming 4-5 meals. Daily schedule and eating patterns outlined.

[27/11/23, 10:31:59] ~ A: ‎~ A created this group

‎[28/11/23, 09:46:11] ~ A: ‎image omitted

‎[28/11/23, 20:56:53] ~ A: ‎image omitted

[28/11/23, 21:03:14] H: What treatment is your patient on since April?

[28/11/23, 21:03:35] H: Can you show us which Ayurvedic medication is your patient is using

[28/11/23, 21:04:33] ~ A: Yes dr... He was using a tablet named *Chitrakadi Vati*. He used it like alternative for few weeks. Not in continuation

[28/11/23, 21:05:02] H: Now is he free from medications?

[28/11/23, 21:05:43] ~ A: Yes currently he is not using any medicine. At times when he have to travel or when he eats some heavy food or any stomach discomfort like... He will take it for 2-3 days and then stop.

‎[28/11/23, 21:06:57] ~ A: ‎image omitted

[28/11/23, 21:09:08] H: Has your patient got serology tested anytime in this one year?

[28/11/23, 21:09:25] H: Hepatitis B? C?

[28/11/23, 21:09:40] ~ A: No this test was not done

[28/11/23, 21:10:40] ~ A: The tests done were CBP, ESR,CRP, LFT, TTG antibody, ultrasound scan and TB related tests

[28/11/23, 21:11:02] H: Do you consume alcohol?

[28/11/23, 21:12:25] ~ A: No Dr he doesn't consume.

[28/11/23, 21:12:56] ~ A: No any habits

[28/11/23, 21:13:21] ~ A: He was never sick too in past... This is the first time he have been suffering with this weight loss since an year

[28/11/23, 21:14:08] H: https://www.ncbi.nlm.nih.gov/books/NBK554549/

Patients usually present with anorexia, nausea, vomiting, malaise, pruritus, urticaria, arthralgias, and fatigue. Many times these patients are misdiagnosed as having gastroenteritis or viral infection.

[28/11/23, 21:14:56] ✍🏼: @RB sir what are your thoughts ? Why could this patient have loss of appetite

[28/11/23, 21:29:17] RB: Yes chronic viral Hepatitis is a possibility.

@A Let's check your patient's LFT and viral serology for HBV, HCV and HIV too

[28/11/23, 21:30:39] ~ A: Sir recently his LFT was done a few days ago but not the others . Should I ask him to get them done now ?

[28/11/23, 21:35:25] RB: Lft was normal?

Yes let's get the others done

[28/11/23, 21:39:12] RB: Also can you share his deidentified chest X-ray image here?

Would you like @H to prepare a case report of your patient preserving all the previous reports in a deidentified manner?

[28/11/23, 21:39:37] ~ A: LFT was normal sir

[28/11/23, 21:40:19] ~ A: Okay sir. I'll ask him to get all the previous reports ready and share here

[28/11/23, 21:45:38] RB: That may have been a reason to not have pursued the hepatotrophic viruses earlier

[29/11/23, 08:38:23] ~ A: Good Morning sir. There are different test names in hepatitis. What exactly I need to get among them. Like surface antigen, antibody etc different types are given

‎[29/11/23, 08:40:49] ~ A: ‎image omitted

[29/11/23, 08:41:09] RB: For Hepatitis B suspicion, get Hbsag (is surface antigen)

For hepatitis C suspicion get Anti HCV (it is antibody)

Get HIV also as patient may have had a needle stick injury earlier

[29/11/23, 08:41:34] ~ A: Noted sir . Thank You

[29/11/23, 20:38:21] ~ A: Today's update. He wasn't hungry for the whole day. He just took a glass of milk in the evening that's it.

[29/11/23, 20:42:40] ~ A: And regarding tests he's getting them done tomorrow

[29/11/23, 20:48:15] RB: What were his hourly activities the whole day. Feel free to limit your sharing in a manner that keeps the patient well deidentified

[29/11/23, 20:50:10] ~ A: He was at home the whole day doing system work. Went out twice by walk for some work , and slept for a couple of hours in the evening.

[29/11/23, 20:53:04] RB: How many kms did he walk approximately today?

[29/11/23, 20:54:42] ~ A: Not more than 1 km.

[30/11/23, 11:35:43] ~ A: Today's update... Had breakfast in the morning at outside hotel as he is traveling. It was Idly-3no. Sorry could not share the image as he didn't forward

[30/11/23, 11:36:05] ~ A: And the blood tests reports are expected by today evening. Shall update here once they are ready

‎[30/11/23, 14:28:29] ~ A: ‎image omitted

‎[30/11/23, 14:28:30] ~ A: ‎image omitted

‎[30/11/23, 14:28:31] ~ A: ‎image omitted

[30/11/23, 14:29:47] ~ A: Good afternoon. Reports have just come. Hepatitis and HIV tests seem normal. CRP as it's always, elevated.

[30/11/23, 14:45:39] H: How much was your esr in previous reports

[30/11/23, 14:47:41] ~ A: His ESR was around 15-20 not more than that.

[30/11/23, 15:03:21] ~ A: Btw just to clarify I'm the patient advocate

[30/11/23, 15:04:16] H: I am sorry

[30/11/23, 15:06:11] ~ A: No problem Dr

[30/11/23, 15:06:50] ~ A: I am yet to collect all the old reports... Xray etc. I will be sharing as soon as possible

[30/11/23, 15:28:18] RB: Given the evidence so far including your GI symptoms this appears to be a bowel inflammation

I guess you may have seen these reports of bowel inflammation by our PaJR network here earlier👇

http://medicinedepartment.blogspot.com/2021/04/medicine-paper-for-april-2021-bimonthly.html?m=0

[30/11/23, 15:28:58] RB: Yes please share that chest X-ray

[30/11/23, 15:30:20] ~ A: Not yet sir will see this

‎[30/11/23, 15:32:42] ~ A: ‎image omitted

[30/11/23, 15:35:50] H: Has your patient had cough and fever during that time

[30/11/23, 15:36:05] ~ A: No Dr.

[30/11/23, 15:36:12] ~ A: It was routinely taken

[30/11/23, 15:36:58] ~ A: He used to get some cough in winters due to cold . Once a while .. may be seasonal cold cough.

[30/11/23, 15:37:09] RB: Going by the patient history in your description box and the findings so far, the differentials are :

Small Intestinal

1) mycobacteria or other bacteria

2) Immune mediated inflammation such as crohn's or tropical sprue

3) Intestinal neoplasia

A colonoscopy with intestinal biopsy could be useful

However the most important thing would be to keep following up the data in PaJR

We have a similar PaJR and case report here👇

https://chat.whatsapp.com/HWXjNqquaCY4KH2tjZw06P

[30/11/23, 15:38:18] ~ A: Ok sir

‎[30/11/23, 20:15:44] ~ A: ‎image omitted

[30/11/23, 20:23:17] RB: Potato curry and dosa aka masala dosa?

[30/11/23, 20:23:28] ~ A: Yes sir

‎[01/12/23, 08:54:46] ~ A: ‎image omitted

[02/12/23, 23:16:00] ~ A: Sorry for the delayed input. Yesterday afternoon lunch wasn't taken as he was in journey. In the night he ate at a hotel again- 3 pieces of Idly

[02/12/23, 23:17:34] ~ A: Today morning breakfast was skipped again. Only food for today was lunch in the afternoon. Vegetable rice / Pulav was taken around 3-4 cups.

[02/12/23, 23:18:13] ~ A: And sorry for not updating the plate images. I asked him to share them without fail from tomorrow

[03/12/23, 06:53:39] RB: If possible share his hourly activities keeping his privacy confidentiality intact

simple skeletal format that can be improvised upon is linked here :

https://pdevendrareddyrollno115.blogspot.com/2023/10/daily-routine-format.html?m=1

[03/12/23, 07:05:53] ~ A: Noted sir

[03/12/23, 07:06:01] ~ A: Will do it from today

[03/12/23, 07:06:19] ~ A: I'll ask him to share in this format and I'll update here

[03/12/23, 23:30:28] ~ A: 7.00- wake up time

7.45- fresh up

Breakfast - not taken as no hunger

9 AM-1 PM- work related meeting

1.30 PM- Lunch (2 cups vegetable rice + dal + 3 roti)

2.30- 6 PM- meeting again

6-7 PM- travelling

7-9 PM- system work.

No dinner again

Expected to sleep by 12 post work.

[04/12/23, 23:03:18] ~ A: 04.12.2023 Update

8.00 AM- wake up time

8- 8.45 AM- fresh up

9 AM- breakfast (2 idli + one dosa )

9.30AM- 11 AM- travel to work place

11-3.30 PM - work related meeting attended

3.30 PM- Lunch (3 roti + potato curry + dal)

4- 8 PM- meeting again.

Had a snack at 7PM- 2 samosa , cup of coffee

8 PM - 11 PM- sleeping at room.

11.30 PM-12.30 AM (midnight)- journey to catch a train

‎[05/12/23, 12:56:44] ~ A: ‎image omitted

‎[05/12/23, 12:56:45] ~ A: ‎image omitted

[05/12/23, 12:57:03] ~ A: One additional information to add is that he had been getting this rash on the skin , since this stomach upset and weight loss issue started

[05/12/23, 12:57:26] ~ A: This image is of the right hand elbow region

[05/12/23, 12:58:41] ~ A: There is no itching or any other complaint. It just comes and goes... Mostly proportional to the stomach upset. And while using the ayurevdic medicine and diet, along with stomach issue this also used to come down.

[05/12/23, 12:59:16] ~ A: It's in both hand elbow region and back of neck. At times increasing and at times decreasing.

[05/12/23, 14:00:21] RB: This could be an important clue

[05/12/23, 14:01:03] RB: We need to show this to a dermatologist. Let me try online

[05/12/23, 14:01:45] H: Is that keratitis sir?

[05/12/23, 17:34:59] RB: More like Keratosis Pilaris

https://en.m.wikipedia.org/wiki/Keratosis_pilaris

[05/12/23, 17:35:20] H: Yes sir

[05/12/23, 17:36:41] H: Sadly no cure but best way to control is that to avoid harsh chemical products

[05/12/23, 17:36:48] H: And moisturise regularly

[05/12/23, 23:14:53] ~ A: 05.12.2023 Update

Was traveling in train till 3 PM

6.00 AM- wake up time

6.45 AM- fresh up

8 AM- breakfast (2 idli + 2 vada ), one cup coffee

1 PM- lunch (vegetable biryani around 200 grams)

3-4 PM- travelling in auto till home

4-5.30 PM- fresh up and then rested for an hour

6 PM- had food again (rice + dal + potato curry)

9 PM- had a cup of coffee

[06/12/23, 22:13:03] Rakesh Biswas Sir: ‎Rakesh Biswas Sir changed the group description

[07/12/23, 00:02:43] ~ A: ‎This message was deleted.

[07/12/23, 00:02:56] ~ A: ‎This message was deleted.

[07/12/23, 00:03:37] ~ A: 06.12.2023 Update

9.00 AM- wake up time

9-9.30 AM- fresh up

9.30 AM- breakfast (2 cups upma), one cup tea

10 AM-1AM- attending clients calls

1 PM- lunch (3 cups rice + dal + 5 medium sized pieces of chicken tikka )

2-4 PM- sleeping

4-4.30 PM- went out on a casual walk for almost 1.5 km.

6.30 PM- had a snack of french fries, medium portion of approximately 150 grams

7-7.30- walking back to home approximately 1.5km

12.30- expected sleep time

[07/12/23, 22:10:01] ~ A: 07.12.2023 Update

8.00 AM- wake up time

8-8.30 AM- fresh up

8.30 -9.00AM-walking

9 AM- breakfast (poori 5 pc ), one cup coffee

9.30- 1 PM- system work

1 PM -1.30 pm- lunch (3 cups rice + sambar + 2 chicken legpiece + beans curry )

2-4 PM- travelling out on some work and came back in 2 hours

4 PM- 9.30 PM- system work

9.45- dinner ( 2 cups rice + sambar + beans curry)

[07/12/23, 22:10:53] Rakesh Biswas Sir: The food appears to have been substantial today?

[07/12/23, 22:10:54] ~ A: Note- he started taking the previous medicine *chitrakadi Vati* yesterday and today, and says feeling more hungry and also seems his appetite increased than previous days

[07/12/23, 22:11:08] ~ A: Yes sir

[07/12/23, 22:12:49] ~ A: He took half tablet twice a day, yesterday and today

[07/12/23, 22:16:39] RB: Of?

[07/12/23, 22:19:19] ~ A: Sir same ayurvedic medicine which I have shared earlier - *chitrakadi Vati*

[08/12/23, 23:11:07] ~ A: 08.12.2023 Update

9.00AM- wake up time

9-9.30 AM- fresh up

9.30AM- 11.30 AM- temple visit

12. 30 pm- lunch (2 cups khichdi + sambar )

1-6 PM- system work

6.15- cup of tea

6.30-8- temple visit again

9 pm- dinner ( 3 piece idly + one dosa)

[09/12/23, 10:30:10] RB: Any detail sharing possible about the system work taking care to deidentify the patient

[09/12/23, 14:13:24] H: Sir i hope we can find some clue if we have his psychosocial history for his loss of appetite

[09/12/23, 14:14:07] ~ A: Yes sir. It's reading, editing work most of the times.

[09/12/23, 23:19:14] ~ A: 09.12.2023 Update

8.30AM- wake up time

8.30-9 AM- fresh up

9.45 AM- breakfast (2 Vada + chutney), cup of black coffee

10-12. 30 pm- travelling on work

12.30-2 - work meeting

2-2.30 PM- lunch (chicken biryani approximately 4 cups rice + 4-5 pieces of chicken )

2.30-3.30- journey back home

3.45-7.00 PM sleeping

7.30 PM- 10.30 PM- reading novels

Dinner skipped

[10/12/23, 12:15:22] RB: Which novel? Novels?

[10/12/23, 16:55:06] ~ A: He have a habit of reading different Telugu and English novels sir mostly thriller type. So randomly he keeps reading interesting ones. There's an app named *pratilipi* which has Telugu novels.

[11/12/23, 10:33:52] ~ A: 10.12.2023 Update

6.30AM- wake up time

6.30-7 AM- fresh up

7.15-10 AM- travelling to our or station for temple visit

10-1 PM- at temple

1.30-2.30 PM- lunch (pulihora 2 cups + 2 Vada + 2 cups sweet/kheer)

3.00-5.00 PM- journey back home

5.15-7- sleeping

7.30-8.00 PM-dinner (rice 3 cups + coccinea curry aka *dondakaya* in Telugu, dal)

[11/12/23, 10:34:01] ~ A: This was yesterday update

[11/12/23, 14:25:05] ‪+91 93917 64257‬: ‎‪+91 93917 64257‬ left

[11/12/23, 23:58:18] ~ A: 11.12.2023 Update

8.30AM- wake up time

8.30-9 AM- fresh up

9.30 AM- breakfast (3 cups of Bambino upma)

9.45-10.30PM- journey to workplace

10.30-3.30 PM- office work

3.30-4 PM - lunch (rice + dal + 6 pieces chicken )

4.30-5.30- journey back home

6.30- 8.30 pm - playing games on PC

9 PM - dinner (2 cups rice + palak dal + one omlette)

[11/12/23, 23:58:52] ~ A: He's having cold and cough since yesterday. Nasal congestion and running nose. Cough is dry, mostly starts in evening and bothers often till night and subsides on self. Not disturbing sleep. Yesterday there was some green sputum while he coughed in the morning which he missed to tell. And today also morning once little green sputum came.

[12/12/23, 00:00:29] ~ A: This green sputum comes atleast once an year when he have this seasonal cough/cold, and subsides in a week on self

[12/12/23, 00:01:19] ~ A: He just manages with steam inhalation and some home remedies.

[13/12/23, 22:23:30] ~ A: 13.12.2023 Update

6.00AM- wake up time

6.00-7 AM- fresh up and casual walk for 15minutes

7.30- 9.30AM- at temple

10 AM- breakfast (4 dosa + chutney)

10.30-2PM- client calls .

2.00-5 PM - sleep

5.30 PM- taken cup of milk

6.- 8.30 pm - system work

9.30 PM - dinner (2 cups rice + tomato dal )

[13/12/23, 22:24:13] ~ A: Sorry for not sharing yesterday's update as he failed to send me

[13/12/23, 22:24:49] ~ A: Weight consistent at 47-48 kgs

[14/12/23, 23:55:52] ~ A: 14.12.2023 Update

8.00AM- wake up time

8.00-8.30 AM- fresh up

9.30AM- breakfast (3 piece idli )

10 AM - 1 PM- household cleaning work

1.30- Lunch (2 cups rice + potato curry)

2.00-4 PM - sleep

4 PM - 9 PM- office work/client calls

9.30 pm - journey back home

9.45PM - dinner (3 cups poha )

[15/12/23, 22:39:33] ~ A: 15.12.2023 Update

7.00AM- wake up time

7.00-7.15 AM- fresh up

7.30AM- breakfast (one dosa + one cup upma + one idli)

8 AM - 11 AM- car journey

11-3 PM - mostly sitting idle (3 hours waiting for a 15 minute work at a government office)

3.30-7 PM - journey back home

8 PM- dinner (2 roti + moongdal-palak curry)

Note- as advised he had been avoiding gluten items for many days. Today he ate roti at night, and upma in the morning. Noticed that mild stomach disturbance was there (gurgling sounds, mild pain like discomfort for a while, later resolved).

[15/12/23, 22:40:59] ~ A: Previously also noticed that upma (made with sooji/rawa) is causing mild discomfort hence stopped for many days.

[15/12/23, 23:11:15] Rakesh Biswas Sir: Good points about the gluten

[16/12/23, 08:09:39] ~ A: Another point to note ... Next day his stool consistency used to be altered and the same happened today itseems

[16/12/23, 08:10:22] ~ A: Whenever he take roti or upma, stool comes unformed, loose. And the same happened today also .

[16/12/23, 08:11:56] RB: Can you get him to share his stool images? Can he weigh his 24 hours daily stools?

[16/12/23, 08:18:07] ~ A: Image only when stool is loose sir? Because all the other days normally it's well formed and with proper evacuation. Only when this roti/upma is taken it becomes loose.

[16/12/23, 08:54:32] RB: Well the normal day stools can serve as a comparator

[16/12/23, 08:54:55] ~ A: Ok sir

[17/12/23, 23:47:39] ~ A: 17.12.2023 Update

6.00AM- wake up time

6.00-6.45 AM- fresh up

7.30AM- breakfast (one dosa + one vada + one idli)

8 AM - 9 AM- travel to work place

10AM-4PM - work with clients/sitting work/paper work

4.30-5.30 PM - journey back home

6 PM- had food again (1 cup rice + dal + potato chips)

6.30- 10 PM- system work

Dinner skipped as lunch was delayed.

[18/12/23, 13:28:18] Rakesh Biswas Sir: Sunday working day?

[18/12/23, 13:29:37] ~ A: Yes sir .. based on the client requirements every Sunday mostly remains working

[18/12/23, 23:26:26] ~ A: 18.12.2023 Update

7.30AM- wake up time

7.30-8 AM- fresh up

8AM- 12 noon - at temple

12-1 PM - lunch at temple (2 cups pulihora , one cup sweet Pongal, 2 vada )

1.30-4 PM- sleeping

6-9 PM- client calls

Ate only once today due to the ritual at temple

[20/12/23, 08:39:23] ~ A: 19.12.2023 Update

6.00AM- wake up time

6.00-6.30 AM- fresh up

6.30AM- 8.30 AM noon - journey to temple at Medak

8.30-10 - at temple

10-12- journey back home

1 PM - lunch (2 cups rice+ dal + potato curry+papad)

2-9 PM- client work on system

9.30 PM - dinner (4 dosas + potato curry)

[20/12/23, 23:17:37] ~ A: 20.12.2023 Update

8.00AM- wake up time

8.00-8.30 AM- fresh up

8.45 AM- cup of coffee

8.45-9.30 - watching TV news

9.30- breakfast (3 cups poha)

10 AM- 2 PM - client work on system

2.30 PM- lunch (2 cups rice + ladyfinger curry+ sambar )

3 PM- 5PM- sleeping

5.30 PM- had a cup of tea

6-9 PM - client work on system

10 PM- dinner (4 roti + mixed vegetable curry)

Note- as there was no option available had to eat roti for dinner and again mild stomach discomfort with gurgling sounds noticed

[21/12/23, 08:38:07] RB: Nice causal correlation toward gluten enteropathy! Although more complex factors are possibly at play here

[21/12/23, 09:35:17] ~ A: Ok sir

[22/12/23, 10:17:35] ~ A: 21.12.2023 Update

8.00AM- wake up time

8.00-8.30 AM- fresh up

9.15 AM- breakfast (3 idli )

9.30-12.30 - system work at home

1 PM- lunch (chicken biryani 4 cups + 5 pieces )

2-4 PM - sleeping

4pm-4.30 PM- journey to office

5 pm - 9.30 pm- client work

9.30-10 PM - journey back home

10.15 PM - dinner (same chicken biryani again)

[23/12/23, 10:04:01] ~ A: 22.12.2023 Update

8.30AM- wake up time

8.30-9.00 AM- fresh up

9.45 AM- breakfast ( poha 2 cups)

10-2.30 PM - system work at home

3 PM- lunch (3 cups rice + mutton curry around 200 gm )

3.30-5 PM - sleeping

5.30 PM- one cup coffee taken

5.45 pm - 9 pm- client work

9.30 PM - dinner ( 4 dosa + mutton curry)

[23/12/23, 10:04:13] ~ A: Note- weight stable at 48.5 kg

[24/12/23, 19:22:25] RB: https://medicinedepartment.blogspot.com/2023/12/pajr-daily-activities-energy-outputs.html?m=1

[24/12/23, 22:49:08] ~ A: 24.12.2023 Update

7.30AM- wake up time

7.30-8.00 AM- fresh up

8.15 AM- breakfast ( 6 dosa + peanut powder + chutney)

8.45-9.30 - travelling to work place

9.45-5 PM - client work at office

5 PM - 5.30 PM - travelling back home

5.45 PM - had delayed lunch ( 3 cups rice + chicken curry approximately 250 grams + rasam)

6-9 PM - watching movies

9.30 PM - dinner ( 2 cups rice + chicken curry approximately 150 grams )

[24/12/23, 22:50:22] ~ A: Note - as he was feeling good hunger with this, he have been using it regularly, and may be he thinks his food intake have increased because of that... Moreover no significant gain in weight happened

[26/12/23, 22:30:17] ~ A: 26.12.2023 Update

7.30AM- wake up time

7.30-8.00 AM- fresh up

8.15 AM- one cup coffee

8.45-12.30 - at temple in a ritual

1 PM - lunch (3 cups rice + one cup capsicum curry + dal + 3 pieces kaju katli sweet)

2 PM - 4.30 PM - sleeping

4.30-5 PM- journey to office

5.00- 9 PM - client work at office

9-9.30 PM - journey back home

9.45 PM - dinner ( 5 dosa + capsicum curry)

[27/12/23, 07:57:00] RB: Observations on diet :

I'm noticing from the start of this group that the patient is having only two substantial meals in a day!

I can see a few images of a more or less substantial breakfast and dinner in the group but not lunch although in text such as yesterday, the patient did have a substantial lunch although again the overall substantial meals remained at two in 24 hours?

[27/12/23, 09:21:36] ~ A: Yes sir that's the issue.... Like previously ir was hardly once a day... But later on after he takes that ayurvedic medicine it comes to twice daily or rarely thrice daily. But rarely he feels that proper thrice a day hunger. Also the digestion seems little slow hence he skips meals during that times

[28/12/23, 11:39:58] ~ A: 27.12.2023 Update

8.30AM- wake up time

8.30-9.00 AM- fresh up

9.15 AM- breakfast (8 idli + chutney + one cup coffee)

9.45-2 PM - system work

2.45 PM - lunch (3 cups rice + chicken curry approximately 250 grams )

3 PM - 5.30 PM - sleeping

6-9 PM - client work

9.45 PM - dinner (2 vada + chicken curry approximately 150gm)

[28/12/23, 11:40:45] ~ A: Curious to know if anything can be done to improve hunger and intake ?

[28/12/23, 12:17:07] Rakesh Biswas Sir: What are the patient's favorite foods since childhood?

What is his ancestral diet?

[28/12/23, 12:21:27] ~ A: Sir typical South Indian food.... Rice dal curries .. occasionally rotis and weekly non-vegetarian food.

[28/12/23, 12:23:26] Rakesh Biswas Sir: That's the same which he's eating and sharing in images now right?

[28/12/23, 12:23:55] ~ A: Yes sir

[29/12/23, 09:40:28] ~ A: 28.12.2023 Update

7.30AM- wake up time

7.30-8.00 AM- fresh up

8.30 AM- breakfast (4 idli + 2 dosa + chutney)

9-12 PM - system work

12.45 PM - lunch (vegetable pulav approximately 200grams with chicken curry approximately 250 grams)

1 PM - 3.30 PM - sleeping

4 PM - had a cup of tea

4.30-5.30 PM - travel to work place

5.30-9 PM - client work

9-10- journey back home

10.15 PM dinner - 2 cups vegetable pulav + 150 grams of fish

[30/12/23, 08:04:25] ~ A: 29.12.2023 Update

9 AM- wake up time

9-9.30 AM- fresh up

10 AM- breakfast (4 idli + chutney)

11 AM - 1 PM - cleaning work at home

1.45 PM - lunch (3 cups rice + 2 cups dal + Apollo fish approximately 200 grams)

2 PM - 4.30 PM - sleeping

4.45-9 PM - client work in system

9.30 PM dinner - only fish pieces approximately 200 gm

[30/12/23, 20:16:13] RB: 👍

[30/12/23, 20:16:32] RB: The appetite and intake appears to be improving?

[30/12/23, 20:30:23] ~ A: Sir ups and downs... Not consistently maintained

[31/12/23, 22:04:55] ~ A: 31.12.2023 Update

7 AM- wake up time

7-7.30 AM- fresh up

7.45 AM- one cup coffee

8.45 AM - breakfast (one masala dosa + 2 idli)

9-9.30- journey to work place

10 AM- 4.30 PM - client work

4.45-5.30 PM - journey back home

6 PM - late lunch (3 cups rice + tomato dal + one cup beans curry + 200 grams boneless chicken fry)

7PM- 9PM- watching TV

No dinner

[31/12/23, 23:28:37] RB: No appetite for dinner?

[31/12/23, 23:34:00] ~ A: Yes sir no appetite

[02/01/24, 08:06:40] ~ A: 01.01.2024 Update

7.45 AM- wake up time

7.45-8.30 AM- fresh up

8.45 AM- one cup milk with complan

9.45 AM - breakfast (5 dosa + peanut powder)

10-1.30 PM- system work

2 pM- lunch (rice 3 cups + dal + 300 grams chicken curry

2.30-4.30- sleeping

5PM-8 PM - client work

8.45 PM - dinner (chicken fried rice around 250 grams)

[02/01/24, 08:10:14] ~ A: In the past doctor used to ask him to update his stool consistency with a image scale

‎[02/01/24, 08:10:19] ~ A: ‎image omitted

[02/01/24, 08:10:38] ~ A: So it's always type 3/4

[02/01/24, 08:11:21] ~ A: Whenever he takes roti or upma and the day when little stomach upset happens, it will be type 6/7

[02/01/24, 08:11:34] RB: Except the times when he inadvertently consumes gluten? Does it become type 7 at that time?

[02/01/24, 08:12:05] ~ A: Yes sir ... Mostly 6 that time. Type 7 happens during stomach pain episode which later follows with vomiting or diarrhea

[02/01/24, 08:14:35] RB: How frequent are the type 7 episodes?

[02/01/24, 08:18:26] ~ A: Sir after stopping gluten as per your advise nil sir.. only when he unavoidably took roti or upma recently it happened twice in type 6. Type 7 never happened since long, last in July or August I think he had it. It was specially during stomach pain episode only.

[02/01/24, 08:20:43] RB: Let's hope the diagnosis is coeliac disease and he recovers soon off gluten

[02/01/24, 08:21:44] ~ A: Ok sir 🙏🏻

[02/01/24, 08:22:24] ~ A: Sir he got tested for celiac disease (Ttg test). It was negative. Still is there a chance that it is coeliac disease ?

[02/01/24, 09:02:34] RB: Off course!

The TTG-IgA test can have a sensitivity as low as 78%

So there's always a 22% chance of missing it

[02/01/24, 11:14:08] ~ A: Ok sir

[03/01/24, 09:45:03] ~ A: 02.01.2024 Update

7. AM- wake up time

7.00- 7.45 AM- fresh up

7.45-8.30 AM- walking for almost 30 mins

8.45 AM - breakfast (4 dosa + peanut powder)

9.30 AM - 12.30 PM - client work on system

1.15 PM- lunch (rice 3 cups + rasam + 1 cup beans curry + papads)

2.00-5.00- sleeping

5.30PM-6.45 PM - played shuttle

7 PM- cup of tea

7 PM - 9 PM - client calls on phone

9.45 PM - dinner ( 3 cups rice + 1 cup dal + papads + pickle)

[03/01/24, 09:46:14] ~ A: Note- he had stool of type 6/7 today. He was thinking if *complan* is the culprit. He took it yesterday and also was eating little little throughout the day. When ingredients checked... It contains Maltodextrin

[03/01/24, 09:47:00] ~ A: ‎This message was deleted.

[03/01/24, 09:48:25] ~ A: Though Google says it doesn't contains gluten... It says sometimes source is wheat

[03/01/24, 11:16:17] RB: Complan does contain wheat unless they specify it's gluten free

[03/01/24, 11:18:46] ~ A: Ok sir will ask him to avoid

[04/01/24, 09:46:23] ~ A: 03.01.2024 Update

8. AM- wake up time

8.00- 8.30 AM- fresh up

8.45 AM - breakfast (6 idli + sambar + chutney)

9.15 AM - 1.30 PM - client work on system

1.45 PM- lunch (4 cups mutton biryani with approximately 300 gm meat)

2.00-4.00- sleeping

4.30-9.30 PM- in journey up and down to airport to pickup someone

9.45 PM - dinner ( 200 gm apollo fish + 100 gm fried corn seeds + 100 grams prawns + 2 cups chicken biryani )

[04/01/24, 22:03:31] RB: Looks like a good substantial diet!

[05/01/24, 09:09:10] ~ A: 04.01.2024 Update

8. AM- wake up time

8.00- 8.30 AM- fresh up

9 AM - breakfast (2 vada+ sambar + chutney)

9.20 AM - 2.30 PM - client work on system

2.45 PM- lunch (3 cups rice + dal + papad)

3-4.00- sleeping

4.30-9.30 PM- client work at office

9.45 PM - dinner ( 2 cups rice + dal + papad)

[05/01/24, 09:09:19] ~ A: Yes sir once a while he eats more

[06/01/24, 09:40:37] ~ A: 05.01.2024 Update

10. AM- wake up time

10.00- 10.30 AM- fresh up

11 AM - breakfast (2 vada+ 2 idli+ sambar + chutney)

11.15 AM - 12.45 PM - journey to work place

1 PM- 4 PM- client work on system

4.30 PM - lunch (chicken pulao around 250 grams + 2 piece tandoori roti + mutton curry around 200 grams)

5-7 - travelling

7-9.30 PM- visit to Numaish Exhibition

10. PM - dinner ( 2 cups vegetable pulao + grilled chicken + grilled lamb meat around 400 grams )

[06/01/24, 09:42:04] ~ A: Note- Had loose stools today (type 7)... Likely because of the roti he ate yesterday. He said whole night mild discomfort was there like gurgling sounds and bloating and in the morning he had loose stools

[06/01/24, 11:15:52] RB: Can't have a better case report to support clinically diagnosed gluten emteropathy that could make the world think "labs" are overated!!

[07/01/24, 09:13:49] ~ A: 06.01.2024 Update

7. AM- wake up time

7.00- 7.30 AM- fresh up

8 AM - breakfast ( 2 cups khichdi made with rice + moongdal)

8.30 AM - 12 PM - client calls

12.15 PM- 1 PM- travelling

1.30-5 PM - spent time at Salarjung museum

5.30 PM - lunch (2 cup vegetable biryani)

6 - 7 PM - travelling back home

Dinner skipped

[07/01/24, 09:14:27] ~ A: Note- was having mild dry cough once a while since 2 days. But since yesterday morning it is getting significant. He also has pain in the right lower part of chest. And when he stretches the body (like full body stretch as in yawning), he can feel more pain in the chest/lung area. He said one time, very little brown sputum have come yesterday afternoon. But not again. Also feels feverish since yesterday with pulse rate around 100-120

‎[07/01/24, 09:15:52] ~ A: ‎image omitted

‎[07/01/24, 09:16:43] ~ A: ‎image omitted

‎[07/01/24, 09:21:22] ~ A: ‎image omitted

[07/01/24, 13:17:13] RB: Appears to be a pleuritic pain secondary to the viral lung infection he may have picked up possibly. Can someone keep checking his respiratory rate?

[07/01/24, 14:20:40] ~ A: I shall update the respiratory rate sir. I'll ask him to note down

[07/01/24, 14:20:50] ~ A: How frequently is it to be checked

[07/01/24, 14:33:19] RB: Depends on if it's increased

If not increased then every 4 hours

[07/01/24, 14:39:21] ~ A: Noted sir

[07/01/24, 15:46:21] ~ A: It's 18/min sir

[07/01/24, 15:46:30] ~ A: Will update every 4 hourly

[07/01/24, 20:58:34] ~ A: RR- 16/min

[08/01/24, 09:37:35] ~ A: 07.01.2024 Update

8 AM- wake up time

8.00- 8.30 AM- fresh up

8.45 AM -12 noon - at temple in a ritual

12.45- lunch ( 2 cups vegetable biryani + one cup dal)

1. 30 PM - 4 PM- sleep

4.30-8 PM - client calls

9 PM - dinner (one cup brown rice + one cup dal)

[08/01/24, 09:39:49] ~ A: Note- he had some fever in the night again upto 101-102°. With little body pains, though he didn't take any medicine as he slept. RR was around same range 16-18/min and SPO2 was 98-99. Now currently SPO2 is 99 and RR-17/min. Pulse rate is 90. No fever or body pains now.

[08/01/24, 19:31:11] ~ A: Good Evening. From morning had been checking Respiratory rate and SpO2 every 3 -4 hourly once. RR is same around 15-18/min. And SpO2 is 98-100. Pulse rate around 80-90

[09/01/24, 09:09:30] ~ A: 08.01.2024 Update

9 AM- wake up time

9.00- 9.30 AM- fresh up

9.45 AM - breakfast (cup of oats)

10 AM - 2 PM - client work on system

2.30 - lunch ( 2 idly + peanut powder)

3-5 PM - sleeping

5-8 PM - system work or clients

8.45 PM - dinner (one rice + tomato pickle)

Note - his respiratory rate and SpO2 have been in the range of 15-18/min and SPO2 was 98-100 whole day yesterday. But in the night almost for couple of hours he felt pricking pain in the chest region in the affected area, as if pricked with needles.

[09/01/24, 10:53:16] RB: Your patient has been fortunate with his virus

Another patient not so fortunate (blame it on his acquired comorbidities) discussed below 👇

[1/9, 10:15 AM] +91 : HRCT CHEST

[1/9, 10:21 AM] +91 : Yesterday night he was expired sir

[1/9, 10:46 AM] RB: What is the evidence of dengue in this patient?

Dengue mortality is very rare

His pneumonia could have been due to other viruses with multiorgan failure? Even bacteria like Leptospira?

https://chat.whatsapp.com/HqWjiLrpFguKSTUZpqZbEy

A 40 yr old came to the causality with complaints of.

fever since 10 days ,cough ,shortness of breath since 3 days fever is low grade assosiated with chills and rigours subsided with medication

cough is insidious and dry cough ,increased on lying down

sob since 3 days progressed form garde I to III

n/k/c/o dm ,thyroid ,htn, cad

previous h/o he had a attack of fits 5 yr back.

HE IS A CHRONIC ALCHOLIC SINCE 20 YR HE WILL DRINK 1 QUATER TO FULL IN EVER DAY

[10/01/24, 08:31:50] ~ A: 09.01.2024 Update

8 AM- wake up time

8.00- 8.20 AM- fresh up

8.30 AM - had a cup of black coffee

9 AM- breakfast (4 dosa oil less + peanut powder)

9.30- 12 noon - client work on system

12.15-4 PM - was feeling exhausted so slept

4.30 PM - lunch (one cup rice + one cup dal)

5 PM - 9 PM - client work on system

9.30 PM - just had half cup of rice + dal

Note - his respiratory rate/SpO2 have been normal (15-18/98-100) whole day yesterday. Pricking pain in chest was there for sometime in night. And no fever. But the pain like a band on the chest area on stretching the body is still there

[10/01/24, 08:51:40] RB: So far so good

Sounds like a recovering viral producing pleural pain and costochondritis

[10/01/24, 08:57:02] ~ A: Ok sir

[11/01/24, 09:04:32] ~ A: 10.01.2024 Update

8.30 AM- wake up time

8.45- 9.20 AM- fresh up

9.40 AM- breakfast (5 dosa oil less + karampodi)

10 AM- 12 noon - reading novels

12.15-1.45 PM- travelling

2-5 PM - visit to Charminar, Mecca Masjid, Chowmohalla palace

5.45 - late lunch ( today's lunch was in a buffet system where he had different items like chicken biryani, grilled prawns/fish/tandoori chicken, mutton curry, gulab jamun etc) so exact portion he couldn't keep a track of)

6.45-8 PM - journey back home

Dinner skipped

Note -he said his chest complaints reduced significantly by more than 80%. He didn't feel the pricking pain today nor the tenderness. Only some very mild discomfort which he thinks will resolve shortly. Last time also same way it bothered for a while and reduced on its own. SpO2 and Respiratory Rate and pulse are normal today (99-100/15-18/70-80)

[11/01/24, 09:32:02] ~ A: Though the band like pain on stretching is still there

[12/01/24, 08:59:16] ~ A: 11.01.2024 Update

9.30 AM- wake up time

9.30-10 AM- fresh up

10.30- 11.30 AM- at temple

11.45- breakfast (2 cups Pongal )

12.30-4.30 - client work on system

4.45- cup of coffee

5 PM- 7 PM- playing PC games

7.30 PM - dinner (3 cups rice + one cup dal + one cup rasam + one cup potato fry + papad + one cup mixed vegetable curry)

8-10 PM - watching TV

Note - he says the band like pain on stretching body changed its location. Now it's more towards the centre. Apart from this other discomfort seems almost resolved. His SpO2 and Respiratory Rate and pulse were normal throughput the day.

‎[12/01/24, 09:00:02] ~ A: ‎image omitted

[12/01/24, 09:05:57] RB: Yes it's shifting location as in going away

[12/01/24, 09:08:06] ~ A: Ok sir

[14/01/24, 08:13:34] ~ A: 13.01.2024 Update

9.00 AM- wake up time

9.00-9.45 AM- fresh up

10 AM- breakfast (2 dosa + one cup tea )

10.30-1.30 - client work on system

1.45- lunch (chicken biryani approximately 200 grams rice + 200 grams chicken)

2.30-5 - sleeping

5-7 PM - client work on system

7.30 PM - coffee one cup

9.30- dinner (poha upma around 200 grams)

Note - respiratory issue seems almost resolved except for some 10-15%, and occasional dry cough few times a day. The pain now is strange he says... Like till yesterday it was clearly in the chest/lung region. But now the pain like discomfort is below the lung. He's unable to differentiate if it's lung/chest related or abdomen related. He feels discomfort on bending forward, stretching back, or while walking or changing position. Not very severe discomfort... But it's bothering little. Respiratory rate, oxygen saturation had been normal.

[14/01/24, 08:59:10] RB: The pain is due to the residual pleural inflammation and fibrosis that was a result of the viral.

Excellent description by the patient that enables such an easy interpretation. Please convey our regards to him. 👏👏

[14/01/24, 09:28:21] ~ A: 🙏🏻🙏🏻

[15/01/24, 08:53:40] ~ A: 14.01.2024 Update

7.00 AM- wake up time

7.00-7.30 AM- fresh up

8 AM- breakfast (one masala dosa + one cup coffee )

8.30-9.30- journey to workplace

10.-1.30 - client work on system

1.45-2.30- journey back home

2.45- lunch ( 3 cups rice + 300 gm mixed vegetable curry)

3.30-5 PM - sleeping

5.30-8.30 pm- watching OTT series

Dinner skipped as wasn't feeling hungry

Note - he ate 2 pieces of an Arabian chocolate yesterday which has cocoa+ dates+ almond as ingredient. And in the evening he felt little stomach discomfort like gurgling/bloating. And today morning the stool was not well formed and the consistency was like Type 6 in the Bristol Stool Scale. He now recollect that along with wheat products, he had similiar discomfort in the past with eating dates also. May be dates also is causing issue.

[15/01/24, 09:23:35] RB: It's the gluten in the Arabian chocolate that is often used as a non specific binder in all confectionaries unless they specifically mention gluten free

[15/01/24, 09:27:01] ~ A: Ok sir

[15/01/24, 15:25:38] RB: Pending project for this PaJR :

Creating something similar to this :

https://medicinedepartment.blogspot.com/2023/12/pajr-daily-activities-energy-outputs.html?m=1

[16/01/24, 10:01:44] ~ A: 15.01.2024 Update

7.30 AM- wake up time

7.30-8.20 AM- fresh up

9-11 AM- temple visit

11.30 AM- breakfast (3 dosa + one cup tea )

12-3 PM - system work

3.30 pm - lunch ( 3 cups bagara rice + mixed vegetable curry)

4-5 PM - sleeping

5.15 PM - cup of tea

5.30-9PM- system work

9.30 PM - dinner (chicken biryani approximately 250grams rice + 200 grams chicken)

[17/01/24, 08:44:17] ~ A: 16.01.2024 Update

6.30 AM- wake up time

6.30-7 AM- fresh up

7-10.45 AM- temple visit

11.15 AM- breakfast (2 idly + 2 vada + one cup coffee )

11.45-12.30- journey to work place

12.45-3 PM - client work on system

3.30 pm - lunch ( 2 cups poha + peanut powder)

4-8 PM - system work continues

8.15-9 PM - journey back home

9.40 PM- dinner (2 cups poha again)

Note: at temple he mistakenly ate 4 appams ( made of wheat/jaggery) and today morning he had loose stools like type 7 as per Bristol stool scale. He's consciously trying to avoid wheat all times but missing it few times like this.

[17/01/24, 09:41:22] ~ A: One very interesting point he just shared is that he checked his weight and it's 49.3 today. Since August 2023 it was always fluctuating between 47-48. This is first time it touched 49.

[17/01/24, 12:39:56] RB: 👏👏

[18/01/24, 08:35:17] ~ A: 17.01.2024 Update

8.30 AM- wake up time

8.30-9.15 AM- fresh up

9.45 AM- breakfast (4 dosa + karampodi)

10.15-1.30 PM - system work

1.45 pm - lunch ( 4 cups rice + mutton curry approximately 300 grams)

2.30-5 PM - system work continues

5.30 PM - one cup tea + half cup poha flakes

6-7 PM - playing shuttle

8 PM - dinner ( 4 dosa + mutton curry approximately 250gm)

[18/01/24, 08:39:05] RB: Wow! Looks like remarkable progress in the patient's appetite as well as activities 👏👏

[18/01/24, 08:42:48] ~ A: Yes sir

[20/01/24, 08:33:58] ~ A: 19.01.2024 Update

7.30 AM- wake up time

7.30-7.45 AM- fresh up

7.45- 10 AM- household chores (cleaning, washing)

10.30 AM - breakfast ( 2 banana + one cup milk)

11 AM-1 PM- Puja at home

1.30 PM - lunch (3 cups khichdi + 1 cup vegetable curry)

2-5 PM- sleeping

5.15 PM- one cup tea

5.30-8.30 PM - client work on system

9 PM - dinner ( 4 cups rice + 1 cup dal + 1 cup mixed vegetable curry + 2 papads + 1 cup deep fried potato fry)

[20/01/24, 08:35:30] ~ A: He says chest discomfort seems resolved. But the pain is persistent on stretching, like a band as shared. Only when stretching back. Otherwise he's fine.

[21/01/24, 09:19:51] ~ A: 20.01.2024 Update

7.30 AM- wake up time

7.30-8 AM- fresh up

8.30 AM - breakfast ( 5 idly + chutney )

9-10 AM - journey to work place

10.30 AM -3 PM - system work

3.30 PM - lunch (3 cups rice + 2 cup beans curry + one cup dal )

4 PM - 7 PM - system work again

7-8 PM - journey back home

9 PM - one cup tea + poha

[22/01/24, 09:27:50] ~ A: 21.01.2024 Update

6.30 AM- wake up time

6.30-7 AM- fresh up

7.30 AM - breakfast ( 2 idly + 2 vada + chutney )

8-9 AM - journey to work place

9.30 AM -3 PM - client work

3.15-4 PM - journey back home

4-4.30 PM - fresh up

5 PM - lunch (2 cups rice + 1 cup beans curry + one cup dal + 200 gm roasted fish + 200 gm chicken curry )

5.45- 7 PM - watching OTT series

8.45 PM - took 4 pieces of Kaju katli sweet + 4 pieces dhokla

[23/01/24, 08:52:52] ~ A: 22.01.2024 Update

8.30 AM- wake up time

8.30-9 AM- fresh up

9.15 AM - one cup tea

10 AM - breakfast (4 Vada + peanut chutney )

10.45 AM - 2 PM - system work

2.15 PM - lunch (3 cups rice + 1 cup dal + one cup ladyfinger curry + one cup beans curry + little ghee )

3- 5 PM - sleeping

5.30 PM - 8.30 PM - system work again

9 PM - dinner ( 2 cups upma made with poha)

Note- last 1-2 days he's noticing unformed/loose stool like type 5-6 as per Bristol stool scale, inspite of no gluten items. Though there are no gut complaints ‎<This message was edited>

[23/01/24, 08:54:26] RB: 👆5-6 doesn't appear that bad

[23/01/24, 08:55:24] ~ A: Ok sir... Usually 3-4 is the type always. Hence was little curious what made it type 5-6.

[25/01/24, 07:20:46] ~ A: 24.01.2024 Update

7.00 AM- wake up time

7.00-7.45 AM- fresh up

8 AM - one cup tea

9 AM - breakfast (4 dosa + peanut chutney )

9.45 AM - 12 PM - system work

12.15 PM - lunch (3 cups rice + chicken curry approximately 300 grams)

1-5 PM - system work

5.30 PM - one cup coffee

6-9 PM - went out for shopping

9.30 PM - dinner ( mutton biryani approximately 250 grams + 150 grams grilled chicken )

[26/01/24, 09:09:18] ~ A: 25.01.2024 Update

8.00 AM- wake up time

8.00-8.20 AM- fresh up

9 AM - breakfast (2 dosa + 4 Vada + chutney )

9.30-10.30 AM- travel to workplace

11 AM - 4 PM - system work

4-5 PM - journey back home

5.15 PM - lunch (3 cups rice + 2 cups tomato dal + fried chicken pakodi approximately 200 grams)

6 PM - 9 PM - watching films on YouTube

Note- since he had food after 5 PM, he was having mild discomfort which eventually became some significant discomfort with diffuse pain, gurgling sounds in stomach which lasted till he slept. And in the early morning around 3 AM he had loose stools episode of Type 7, after which the discomfort was relieved. Surprised what must have caused this, as usually gluten was believed to be the culprit but yesterday he didn't take anything such.

[26/01/24, 11:29:14] RB: What was the coating used for the pakodi?

‎[26/01/24, 11:33:37] ~ A: ‎image omitted

[26/01/24, 11:59:30] RB: What is the food color made of? Also are corn flour always pure corn?

[26/01/24, 12:02:18] ~ A: Not sure sir. They say pure corn flour extract.

‎[26/01/24, 12:03:08] ~ A: ‎image omitted

‎[26/01/24, 12:03:09] ~ A: ‎image omitted

[26/01/24, 12:03:09] RB: "16% of corn flour samples contained over 20 parts per million (ppm) of gluten, ranging anywhere from 8 ppm to 731 ppm. Manufacturing processes have remained relatively unchanged since this study was completed."

https://www.celiac.ca/corn-statement/

[26/01/24, 12:04:02] ~ A: Omgg

[27/01/24, 08:28:57] RB: An important lead to a probable etiology in this patient from our global patient advocate :

[1/27, 7:17 AM] Global patient advocate US-India : Is celiac or gluten common in India or becoming more common? It’s quite prevalent in states and glyphosate is suspected as having created leaky gut in most

[1/27, 7:42 AM] RB: Thanks! Glyphosphate is an interesting angle to explore to explain it's current emergence in India!

[1/27, 8:08 AM] global patient advocate US-india : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945755/

[27/01/24, 08:34:46] ~ A: Would checking the deficiencies help us to understand if there's an exposure to this chemical sir ?

[27/01/24, 08:34:55] ~ A: 26.01.2024 Update

7.00 AM- wake up time

7.00-7.30 AM- fresh up

7.45 AM - one cup tea

9 AM- breakfast ( 3 idli with ghee + podi)

9.30 AM - 12 noon - watching republic day parade

12.30-3 PM - travelling on real estate work

3.45 PM - lunch (mutton biryani approximately 300 gm)

4-6 PM - travelling on real estate work

7 PM - had cup of tea + some poha

[27/01/24, 08:47:38] Rakesh Biswas Sir: Probably not.

Perhaps drug or toxicology assay for glyphosphate detection may help. Let me ask globally

[27/01/24, 08:48:09] ~ A: Because in the past doctor said that if it's gluten , there has to be some gross minerals and micronutrient deficiency. But he didn't check it ever sir

[27/01/24, 08:48:11] ~ A: Ok sir

[27/01/24, 08:50:45] RB: No that can't be feasibly checked! Also we are not debating the diagnosis of gluten which appears clear through the bioclinical medical cognition markers generated here.

We are thinking about why this patient developed gluten sensitivity and the probable role of glyphosphate exposure in his food due to pesticides

[27/01/24, 08:51:12] ~ A: Okay sir

[28/01/24, 09:06:33] ~ A: 27.01.2024 Update

7.00 AM- wake up time

7.00-7.30 AM- fresh up

8 AM- breakfast ( 4 Vada + chutney )

8.30- 5 PM- journey to/fro warangal

5.45 PM - delayed lunch (2 cups rice + 1 cup dal + 1 cup brinjal curry + 1 cup alu fry)

6.30-8 PM - client work on system

8.30 PM - one cup tea

[29/01/24, 07:55:52] ~ A: 28.01.2024 Update

7.30 AM- wake up time

7.30 AM- 8 AM fresh up

8.15-8.45 AM- reading news paper/had cup of tea

9-9.40 AM- journey to work place

10-2 PM - client work at office

2.15-3 PM - journey back home

3.45 PM - lunch (2 cups rice + sambar + 6 pieces of grilled chicken approximately 150 grams)

4.30-7.30 PM- watching movies on OTT

8.30 PM - had a glass of milk + poha + few roasted cashews

Note- due to some reason he wasn't hungry the whole day. In the afternoon after reaching home he was little hungry and had meal. Morning he didn't eat anything and so in night. ‎<This message was edited>

‎[29/01/24, 07:56:30] ~ A: ‎image omitted

‎[29/01/24, 07:56:31] ~ A: ‎image omitted

[29/01/24, 07:57:23] ~ A: And randomly he got his blood routine checked as it's been more than a month. As always, CRP is elevated (26) and ESR also mildly elevated (30).

[29/01/24, 08:06:28] RB: It's because of his recent inflammatory intestinal stool 7 episode due to the corn flour gluten!

Need to check CRP after he is absolutely alright for a few weeks

[29/01/24, 08:07:36] ~ A: Noted sir !

[30/01/24, 08:22:28] ~ A: 29.01.2024 Update

8.30 AM- wake up time

8.30 AM- 9 AM fresh up

9.15 AM- reading news paper/had cup of coffee

10.30 AM- breakfast (2 dosa + karampodi)

11 AM - 3 PM - client calls

3.45 PM - lunch (2 cups veg fried rice home-made)

4-6 PM - sleeping

6.30 PM - had cup of tea

6.45- 9 PM - client calls

9.45 PM - dinner (3 idly + chutney)

[30/01/24, 10:31:25] RB: Bristol grade of 8:30-9:00?

[30/01/24, 10:32:24] ~ A: Sir type 5-6

[31/01/24, 07:06:14] ~ A: 30.01.2024 Update

8. AM- wake up time

8-8.30 AM fresh up

9 AM- had cup of tea

10 AM - breakfast (4 dosa + karampodi)

10.30-11 AM - watching news

11- 11.45 PM - went out to market to buy some stuff

12-1 PM - was doing some basic electrical maintenance repair works at home

1.30 PM - lunch (2 cups rice + sambar + one cup brinjal curry + one cup cabbage fry)

2-3 PM - just lying on bed

3-4 PM - travel to work place

4-9.30 PM - client work

9.30-10 PM - back home

10.30 PM - dinner (2 cups rice + sambar + brinjal curry + redchilli pickle) + 3 pieces rasmalai sweet

Note- stool was of Bristol scale type 4-5

[01/02/24, 07:27:41] ~ A: 31.01.2024 Update

6.30 AM - wakeup time

6.40-7 AM - freshup

7.15 AM - had a cup of tea

7.30-11 AM - at temple

11.30 AM - breakfast (3 idli + ghee + chutney)

12-2 PM - client calls

2.30 PM - lunch (3 cups rice + 250 gm mutton curry )

3.15-8 PM - client calls

8.30 PM - dinner (1 cup rice + 100gm mutton curry )

‎[01/02/24, 07:30:21] ~ A: ‎image omitted

[01/02/24, 07:36:54] ~ A: Stool is type 4-5 of Bristol scale

[01/02/24, 11:54:15] RB: Appears to be sacroileitis which is an inflammation often associated with intestinal inflammation

[01/02/24, 12:58:59] ~ P: since the pain increases on taking deep breaths, need to clarify the pain location. Is it closer to the chest or lower back. The pain character and severity on a scale from 1 to 10…

[01/02/24, 13:02:12] ~ A: Sir I have googled this term. So the pain is not in bones/joint sir.. in between space

‎[01/02/24, 13:02:33] ~ A: ‎image omitted

[01/02/24, 13:02:42] ~ A: Can say 2-3

[01/02/24, 13:03:00] ~ A: In the morning it was more while waking up... After going to washroom and as time passes feel better now

[01/02/24, 13:04:10] ~ A: Like a band/stretch it pains in that area with every deep breath. Not significant but discomfort can be felt

[01/02/24, 13:04:52] ~ A: He says he's almost fine now compared to the morning time....

‎[01/02/24, 13:07:06] ~ A: ‎image omitted

[02/02/24, 00:46:27] RB: Likely to be a muscle pain then

[02/02/24, 07:40:31] ~ A: 01.02.2024 Update

7. AM - wakeup time

7 -7.40 AM - freshup

8 AM - breakfast (3 Vada + chutney + one cup tea)

8.15- 9 AM - watching news

9-9.35 AM - journey to work place

10 AM- 4 PM- client work on system

4.30 PM - lunch (3 cups rice + 2 cups tomato dal + grilled chicken approximately 200 grams)

5-6 PM - journey back home

6.30 PM- had a cup of coffee

7-9.30 pm- watching OTT

10.00 PM - dinner (2 cups vegetable fried rice + 2 chocolate muffins - gluten free made of ragi+jowar )

Note - the pain he complained in the lower back was almost negligible by evening/night. Only some 5-10 % discomfort was there.

[03/02/24, 07:45:47] ~ A: 02.02.2024 Update

7.30 AM - wakeup time

7.30 - 8AM - freshup

8.15 AM - had a cup of tea

8.30- 9.30 AM - temple

10 AM - breakfast (2 cups rice + 2 cups palak dal+ one cup bhendi fry)

10 AM- 2 PM- client calls

3.00 PM - lunch (2 rice + 1 cup palak dal + tandoori chicken approximately 200 grams)

4.30 PM- next day morning 6-7 AM- journey (going out of station)

9 PM - dinner in bus (veg fried rice+ egg bhurji made with 3 eggs)

Note- stool is well formed like type 3-4 in Bristol scale.

[04/02/24, 07:55:21] ~ A: 03.02.2024 Update

6.00 AM - wakeup time

6-6.30 AM - freshup

6.30-8 AM - morning walk

8-8.30 AM - took shower

9 AM - breakfast (3 idly + 2 vada + chutney + sambar)

9.30 AM- 2 PM- meeting

2.30 PM - lunch (2 cups rice + 2 cups dal + 1 cup paneer curry + 1 cup bhindi fry)

3-6 PM - meeting continues

6.30 PM - one cup coffee

7-9 PM - watching TV

9.30 PM - dinner (6 pieces chicken tikka + 2 jowar roti)

Note- stool is well formed like type 3-4 in Bristol scale. And yesterday he had no pain as the previous days.

[07/02/24, 10:27:49] ~ A: 06.02.2024 Update

7.00 AM - wakeup time

10 AM - back to home

10-11 AM - freshup

11.30 AM - breakfast (4 dosa + peanut powder)+ coffee

12-2 PM - resting

3 PM- lunch ( 2 cups rice + 2 cups sambar + one cup beans curry) + 2 muffins (gluten free made of ragi)

3.30- 5 PM - sleeping

5.30 PM - went out to market on walk for 30 mins

6.30 PM- 9 PM - system work

9.30 PM - dinner (2 cups rice + 1 cup palak dal + papad)

Note- one important finding he said is that while out of station he had to join for a group dinner at a hotel where he had Gujrati Thali. Unknowingly he consumed few wheat based items , though he avoided roti. But he didn't have any stomach discomfort as in previous days and the next day stool was also well formed , almost type 3-4 in stool scale.

[07/02/24, 10:28:52] ~ A: And apologies for not updating the last 2 days as he was totally carried away in his work and wasn't able to keep a track.

[07/02/24, 11:08:56] RB: How did he realize they were wheat?

[07/02/24, 14:36:03] ~ A: Sir consciously he had been avoiding roti/Puri /sooji etc major gluten items. There also he avoided them clearly as gujrati thali have roti and Puri as main dish. Later he ate everything, but later when he checked with his gujrati friends and the servers it's said that they were made of wheat

[07/02/24, 14:36:28] DD: Explain 'consciously'

[07/02/24, 14:37:01] RB: What else did he eat?

[07/02/24, 14:37:42] ~ A: He doesn't know the name of dish sir but he said it looked like a small fried momo, and another item which looked like a kachori. I asked him to enquire those names.

[07/02/24, 14:39:24] ~ A: Like majorly as wheat item we take is roti Puri and sometimes sooji/semolina made of a wheat variant... He's avoiding those readily. But sometimes unknowingly he ate other items with gluten which he had no knowledge about

[07/02/24, 14:40:33] ~ A: Like sometimes he ate roti when he went out with a team... But later became more conscious to avoid it

‎[07/02/24, 17:49:00] ~ A: ‎image omitted

‎[07/02/24, 17:49:01] ~ A: ‎image omitted

‎[07/02/24, 17:49:02] ~ A: ‎image omitted

[07/02/24, 17:49:57] ~ A: These are 3 items he ate which had wheat/ semolina as ingredient. Another one not in list is *Bhakri* which is nothing but a small baked biscuit made of wheat

[07/02/24, 19:10:44] RB: And yet the intestine didn't react!

Perhaps it's healing completely 👏👏

[08/02/24, 12:21:22] ~ A: 07.02.2024 Update

8.00 AM - wakeup time

8-8.30 AM - freshup

9.00 AM - breakfast (2 idly + 2 vada + chutney)+ one cup tea

9.30 - 1 PM - client work on system

2 PM- lunch ( chicken biryani approximately 300 grams)

2.45-4.30 PM - sleeping

4.45-5.30 PM - went out on a casual walk of approximately 1.5 km

5.45 PM - 2 muffins + one cup coffee

6. PM- 9 PM - system work

9.20 PM - dinner (chicken biryani approximately 200 gm)

Note- the pain he had in the lower back on the left side area seems to have returned and is bothering in the same way like it did a week ago . Faces pain / discomfort in that area on deep breath and also when stretching body.

[08/02/24, 12:21:33] ~ A: Hopefully sir 🤞

‎[08/02/24, 13:07:16] ~ A: ‎image omitted

[08/02/24, 13:08:05] ~ A: From that spots till down as a band it's paining on deep breath or on stretching body

[08/02/24, 14:30:09] RB: He's more prone to muscle sprain perhaps due to reduced muscle mass @919604701505?

[08/02/24, 14:33:06] ~ G: Did we look at any correctable causes such deficiency of Vit D , calcium , magnesium ?

[08/02/24, 14:41:08] RB: I guess he may have had some of those tests earlier that came normal? @918247756704?

[08/02/24, 14:54:53] ~ A: These tests were not checked sir

‎[08/02/24, 14:57:27] ~ A: ‎image omitted

[08/02/24, 15:27:40] RB: Not sure if there would be any correlation as for most Indians the vitamin D comes out to be deficient but for this patient serum calcium, serum phosphorus, serum alkaline phosphatase may provide better clues.

I'm reminded of this last patient here : https://rishik37.blogspot.com/2021/08/gm-elog-case-7.html?m=1 as classic osteomalacia is rarely confirmed

[09/02/24, 08:53:27] ~ A: 08.02.2024 Update

8.30 AM - wakeup time

8.30-9 AM - freshup

9.30 AM - breakfast (6 vada + chutney)+ one cup coffee

10 AM - 1 PM - client calls

1.45 PM- lunch (3 cups rice + chicken curry approximately 300gm)

2.15-5.30 PM - client work continues

6 PM - 2 muffins + one cup tea

6. PM- 9PM- client work on system

9.30 PM - dinner (2 cups rice + chicken curry approximately 200gm)

Note- the pain on the lower left was significant throughout the day. He tried doing local heat application with a hot water bag at frequent intervals. This morning after waking up he says it's a little better, maybe because of the heat application yesterday.

[09/02/24, 08:53:45] ~ A: Sir shall I ask him to get these done ?

[09/02/24, 08:55:13] RB: Can

[09/02/24, 08:56:01] ~ A: Okay sir

[10/02/24, 09:34:18] ~ A: 09.02.2024 Update

7.30 AM - wakeup time

7.30-8 AM - freshup

8.30 AM - breakfast (4 vada + chutney)+ one cup tea

9 AM - 10 AM - went out to market

10.30-2 PM - client calls

2.30 PM - lunch (mutton biryani approximately 300 grams) + rasmalai sweet 3 pieces

3.00-5.30 PM - client calls

6.15 PM - fistful or cashews + one cup tea

6. 30PM- 9PM- playing games on PC

9.30 PM - dinner ( one masala dosa + 2 idli)

Note- the pain in lower back on left side below the rib was there throughout the day. He says it seems like it's little better than last days as he's doing heat application, though it's bothering while breathing. Unable to take proper deep breaths because of the pain.

[10/02/24, 09:39:30] RB: Muscle pains can be very unsettling especially with all the diagnostic and therapeutic uncertainty! @919604701505 @918790889907 ?

[10/02/24, 09:48:06] RK: Personal experience - D, Vit B12, folic acid are important to check.

Just a crazy hunch.. is this related to auto immune disorders? Should immunoglobulin indicators IgE, IgA, IgM be checked?

[10/02/24, 09:50:33] ~ A: And just now he messaged me that he feels very negligible pain now as he woke up and moving around

[10/02/24, 09:50:57] ~ A: It's like becoming severe sometimes and then reducing on its own later

[10/02/24, 09:51:36] RB: My review of literature suggests that all of these tests have poor specificity if not sensitivity.

It's off course immune mediated. Again immunoglobulin testing wouldn't help as immunity here could be largely T cell mediated while immunoglobulins are mostly from B cells

[10/02/24, 09:53:00] H: Can he pinpoint the pain

[10/02/24, 09:54:26] RB: 👆@H

[10/02/24, 09:54:30] RK: Thank you for the explanation.

Then should tests be done for t-cell immune response to try and narrow it down?

[10/02/24, 09:54:37] ~ A: Same location the pain is sir

[10/02/24, 09:54:40] RB: 👆

[10/02/24, 09:55:15] ~ A: This was the pain area he was feeling but later realised it's starting from a tender point in the lower edge of left rib bone

[10/02/24, 09:55:22] ~ A: As in here

[10/02/24, 09:56:41] RB: There aren't any tests in the peripheral blood for that as the action is localized to the intestine! Intestinal biopsy perhaps but again no macro indicator to which would be the most appropriate site for biopsy. Also downside is that it would involve undergoing an unpleasant colonoscopy

[10/02/24, 10:04:53] RK: Ouch!

1mg app has some flow cytometry based diagnostic tests for CD19 and HLA B-27. Those are relevant to check autoimmune?

[10/02/24, 10:12:20] RB: Again it's all a question of sensitivity and specificity!

We need to always find out the expected sensitivity specificity of our proposed tool before using it to find out our expected diagnosis

[10/02/24, 11:22:43] RB: Some more feedback outside this box:

[2/10, 10:14 AM] Human systems engineer: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3764583/

" tTG was found to have a higher positive predictive value for celiac disease than AGA, however AGA identified 5 patients (19% of biopsy confirmed celiac disease) that had a negative tTG and would not have been identified by tTG screening alone. Using AGA in combination with tTG should be considered if the goal of screening is to identify all patients with celiac disease, with the understanding that this strategy will generate more false positive tests and result in additional patients undergoing small bowel biopsy"

[2/10, 10:15 AM] Human systems specialist : Sir would Gliadin antibodies give any hint towards confirming Gluten sensitivity

[2/10, 11:20 AM] RB: Question is : is it going to change our management of this patient ?

[11/02/24, 09:15:09] ~ A: 10.02.2024 Update

9 AM - wakeup time

9-9.30 AM - freshup

10am-1pm - at temple

1.45 PM - lunch (2 cups rice + dal + 2 papad)

2.30-5 PM - system work

5.30 PM - one cup tea

6-8.30 PM - system work

9.15 PM - dinner (2 cups vegetable fried rice)+ 3 piece rasmalai sweet

Note-his lower back pain almost subsided, may be around 10% remaining he said. He's just managing with local heat application

[11/02/24, 19:21:25] RB: Made these Telugu guidelines with the help of the content in this PaJR

https://userdrivenhealthcare.blogspot.com/2024/02/pajr-telugu-guidelines-for-sharing.html?m=1

[11/02/24, 19:25:10] RB: Also translated it to different languages for the benefit of our other patient advocates👇

https://userdrivenhealthcare.blogspot.com/2024/02/pajr-daily-activities-sharing-guide-in.html?m=1

Huge thanks to the patient advocate @918247756704 here for his amazing participation

[12/02/24, 09:16:34] ~ A: 11.02.2024 Update

6.30 AM - wakeup time

6.30 -7 AM - freshup

7-7.30 AM- morning walk

8 AM PM - breakfast (one masala dosa+ 2 idli + 2 vada)

8.30-9.15 AM - journey to work place

9.30-4 PM - system work of clients

4-5 PM - journey back home

5.45 pm- delayed lunch (2 cups rice + chicken curry approximately 300gm) + rasmalai sweet 3 pieces

6.30-9 PM - watching movie on OTT

9.30 PM- glass of milk

[13/02/24, 09:29:08] ~ A: 12.02.2024 Update

7.30 AM - wakeup time

7.30 -8 AM - freshup

8.15 AM- cup of tea, few cashews

9.30 AM - breakfast (4 dosa + chutney )

10 AM - 2 PM - client calls

2.30 PM - lunch (2 cups rice + chicken curry approximately 250gm) + rasmalai sweet 4 pieces

3.15-5 PM - system work

5.30 PM - one cup tea + one gluten free muffin

6-9 PM - watching movies

9.30 PM - fried chicken pieces approximately 150 gm + one bowl tomato soup

[13/02/24, 09:30:18] ~ A: An update - the back pain is gone but he started to get pain in the front part of chest on left side. On sitting or standing there's no complaint. On sleeping posture he feels pain in inspiration. He pressed the whole area of the chest and could identify one tender point from where the pain seems radiating like a band ‎<This message was edited>

‎[13/02/24, 09:34:08] ~ A: ‎image omitted

[13/02/24, 09:34:32] ~ A: Though the pain is not severe or bothering.... It's a little discomfort whenever he lies down

[13/02/24, 09:41:17] RB: Possibility of enthesitis which is often known to happen as an accompaniment to immune spondyloarthropathy due to molecular mimicry and this patient of intestinal inflammation appears perfectly predisposed!

‎[13/02/24, 11:31:27] ~ A: ‎image omitted

[13/02/24, 11:32:42] H: Ask him to Try using moisturiser regularly

[13/02/24, 11:33:35] ~ A: Noted

[14/02/24, 09:50:08] ~ A: 13.02.2024 Update

6.45 AM - wakeup time

6.45 - 7.15 AM - freshup

7.15-8.15 AM- temple visit

8.30 AM - cup of tea

9 AM - breakfast (4 dosa + peanut powder)

9.45 AM-2 PM- system work

2.30 PM - Lunch (2 cups rice + dal + sambar + 2 vegetable curries)

3.15 PM- 4 PM - journey to work place

4.15-8 PM - client work on system

8-9 PM - journey back home

9.30 PM - 2 muffins + one glass milk

‎[14/02/24, 19:58:35] ~ A: ‎image omitted

‎[14/02/24, 19:58:44] ~ A: ‎image omitted

[14/02/24, 19:59:09] ~ A: Sir hereby sharing calcium and phosphorus reports as advised

[14/02/24, 20:52:43] RB: Alkaline phosphatase?

[14/02/24, 21:08:08] ~ A: Sir missed it .

[14/02/24, 21:08:22] ~ A: I'll ask him that also to get done

‎[14/02/24, 21:12:11] ~ A: ‎image omitted

[14/02/24, 21:13:34] ~ A: CRP was also done today sir just to check it. Last time it was 26

‎[14/02/24, 21:14:45] ~ A: ‎image omitted

[14/02/24, 21:34:35] RB: No then we can accept it as normal and it's likely he may not have significantly overt vitamin D deficiency

[14/02/24, 21:42:57] ~ A: Ok sir

[14/02/24, 21:51:30] DD: Any pain during eating?

How are the stools?

Alcohol intake history? ‎<This message was edited>

[14/02/24, 21:54:00] ~ A: No pain. Stools are fine passing once or twice daily well formed. No alcohol or any addiction is there

[14/02/24, 21:54:25] ~ A: He gets loose stools when something is wrong in food like wheat item . Otherwise it is well formed

[14/02/24, 21:55:39] ~ A: And also when he over eats in quantity

[14/02/24, 22:01:52] DD: Suspecting any other alternative diagnosis apart from Celiac?

Any dizziness?tachycardia? ‎<This message was edited>

[14/02/24, 22:04:12] DD: If possible,ask him to share the pics of oral cavity/gums and tongue.

@919121046928 Is that hyperpigmentation on elbow a normal finding? ‎<This message was edited>

[14/02/24, 22:37:59] DD: Palms and knuckles too

[15/02/24, 13:34:53] ~ A: Yes will ask him to share

‎[16/02/24, 09:01:27] ~ A: ‎image omitted

‎[16/02/24, 09:02:00] ~ A: ‎image omitted

‎[16/02/24, 09:02:36] ~ A: ‎image omitted

[16/02/24, 09:05:27] ~ A: 15.02.2024 Update

8.15 AM - wakeup time

8.15-9 AM - freshup

9.30 AM - breakfast (2 uthappam + peanut powder)

10 AM-1 PM- system work

1.30 PM - Lunch (2 cups rice + chicken curry approximately 200 grams)

2-4 PM - sleeping

4 PM - 4.40 PM - journey to work place

5-8 PM - client work on system

8-8.45 PM - journey back home

9.30 PM - dinner (one cup rice + chicken curry approximately 100 grams ) + kaju katli sweet 4 pieces

[17/02/24, 09:22:30] ~ A: 16.02.2024 Update

9.15 AM - wakeup time

9.15-10 AM - freshup

10.30 AM - breakfast (poha approximately 200 gm) + one cup tea

10.45 AM-2 PM- system work

2.30 PM - Lunch (chicken biryani approximately 250gm)

3-5 PM - system work + drank half litre coconut water.

5.40 PM - one cup coffee

6-8.30 PM - playing games on PC

9 PM - rasmalai sweet (4 pieces)

Note- he experienced gurgling sensation and mild pain/discomfort in the stomach just like in the past, for few hours in the evening. He's Surprised because there was no gluten in diet in any form. And today morning he had loose stools like type 6. He feels it started after taking coconut water.

[17/02/24, 10:39:18] RB: What about the hidden ingredients in the biryani? The chef's secret recipe?

[17/02/24, 10:39:53] ~ A: Sir it was home made ...

[17/02/24, 10:40:06] ~ A: No gluten sir

[19/02/24, 09:58:36] ~ A: 18.02.2024 Update

6.30 AM - wakeup time

6.30-7 AM - freshup

7-7.45 AM- morning walk

8 AM- breakfast (2 idli + 2 vada )

8-8.45 AM- journey to work place

9 AM-2 PM- client work on system

2.15-3 PM - journey back home

3.45 PM - lunch (mutton biryani approximately 250gm)

4.30-6 PM - sleeping

6.30- 9PM- watching movie

9.30 PM - one glass milk + poha

[19/02/24, 10:01:15] ~ A: Good Morning Doctors. He just raised a doubt. In home cooking while making Tadka, we use asafoetida/hing. Just realised that the packing mentions it has 30% wheat flour. We just use a pinch. Can that minimal amount also serve as a gluten trigger. Should it be stopped?

[19/02/24, 10:06:10] DD: Better to avoid

[19/02/24, 10:20:04] ~ A: Ok

[19/02/24, 10:22:07] DD: Can replace it by making powder from garlic,ginger and onion(at home,store brought ones has wheat flour added as preservative) ‎<This message was edited>

[19/02/24, 10:23:14] ~ A: Sure Dr

[19/02/24, 10:55:00] RB: Good observation 👏👏

Great insights from this PaJR on managing gluten enteropathy that needs to be published asap. Have been meaning to do it myself for a while now.

[19/02/24, 10:57:00] DD: True..

Very valuable insights from pt advocate

[19/02/24, 11:06:28] RB: Let's hope I find the time to make this case report asap

[20/02/24, 09:02:44] ~ A: 19.02.2024 Update

8.30 AM - wakeup time

8.30-9 AM - freshup

9.25 AM- breakfast (2 idli + 2 vada + one ghee dosa)

10 AM-2 PM- client work on system

2.15-3 PM - lunch (2 cups rice + 2 cups palak dal + one cup potato curry)

4-6 PM - sleeping

6.30 PM - one cup tea + few potato chips

6.45- 8 PM- paper work / writing

Dinner skipped as he wasn't feeling hungry in the night

[20/02/24, 09:03:10] ~ A: His weight is 49.2 today, same as that of a month ago

[20/02/24, 09:04:19] RB: It's the muscle mass and the overall body shape that is also very important!

Can we have another follow up side profile in sequence?

[20/02/24, 09:05:02] ~ A: Sir I didn't get you.. didn't understand ‎<This message was edited>

[20/02/24, 09:07:53] RB: That the weight is static is surely good news 👏👏

It's the overall profile as in the DP that matters in the evaluation of his muscle mass.

Can another image be taken and shared in sequence with the previous two images in the DP to guage the progression of his muscle mass? ‎<This message was edited>

[20/02/24, 09:08:23] ~ A: Oh ok sir. I will ask him to get latest images

[21/02/24, 09:24:28] ~ A: 20.02.2024 Update

9 AM - wakeup time

9-9.30 AM - freshup

9.45-12 AM- temple visit

12.30 PM - lunch (3 cups vegetable fried rice)

1-3 PM - sleeping

3-3.45 PM - journey to work place

5- 9 PM- client work

9-9.40- journey back home

10 PM - one masala dosa

[21/02/24, 16:01:47] ~ A: Today he took latest pics like last time as per advise sir

[12/07/24, 21:33:14] ~ A: Namasthe. Patient's health issue started in November 2022, when he had an episode of severe abdominal pain and vomiting one day at home, thought it was due to the roadside food consumed . Later once a month the episode repeated. Severe abdominal pain, bloating, and then vomitings/loose stools. This continued till April 2023. Ever since this issue happened, he started to loose his appetite and wasn't feeling to eat anything.

On the advise of a doctor , a few investigations were done (abdominal scan, CBP, ESR, CRP, TTG antibody, LFT, RFT, Sputum for AFB, Chest Xray, Quantiferon Gold for TB, Montoux test). All the reports were normal, except for high CRP. First he consulted a Physician and a Gastroenterologist who said as the reports were normal, likely outside food is the culprit. Hence asked him to avoid outside food. He was advised with 2 medicines for improving his appetite and digestion (Aristozyme). He used it for a month or so , but the gut issues continued. Later he consulted an Ayurveda doctor who asked him to take a single medicine to improve appetite and gut health, after which his condition improved to certain extent. Didn't have any such pain/vomitings episode again after taking that medicine. After using it for some days it was stopped, and was advised to be taken as SOS basis whenever hunger and digestion is poor. But the weight issue was still there and he wasn't gaining weight, though his intake of food improved.

From November 2022 to April 2023, he approximately lost 10 kgs weight. CRP was the only test which was proportionate to his symptoms. Whenever he had stomach pain and vomitings/loose stools episode, next day his CRP increased upto the level of 60-100. But since April after starting treatment it's maintained at 10-20 range.

Later after receiving inputs from this PaJR group after a thorough follow up for few days, it was understood that he likely seems to have Gluten Sensitivity, and wheat/all gluten triggers was avoided from his diet. After which he improved his weight for the first time in this one year period of illness, from 47-48 to 50-51 and was stable there. Patient was happy and was hoping that things will improve soon.

Recently in May 2024, patient suddenly developed some strange sensation in lungs, like rub/vibration sensation in chest area with every breath. He thought it would resolve , but it didn't. A Chest Xray was taken (shared here in this group) which was apparently normal. Later after 15 days, he developed a high grade fever which wasn't responding to Paracetamol, and temperature was consistently high around 103-104. It lasted for around 5-7 days after which he developed difficulty in breathing. A Chest Xray was taken again and immediately he consulted a local Pulmonologist.

It was said that he developed Pleural Effusion and needs some tests. Next day the fluid from lungs was removed and sent for few tests, in which a test named *ADA* was elevated (51) than normal range. Doctor said that he likely have *Extra Pulmonary TB*. And he was advised to start a medicine named *Akurit-4*.

Patient started the medicine from June 1st. Once every 2 weeks a review chest xray was taken to see if effusion was resolving or not. But doctor said effusion was still there even after 4 weeks of using medicine. Then an Ultrasound Chest was done recently, which revealed that patient had *loculated/septated pleural effusion* and pleural thickening also, with fluid around 700ml. Initially when fluid was removed for tests, doctor said around 2 litres fluid is there (he checked with ultrasound machine but report was not given). He said much fluid was gone but remaining was stuck , and it likely needs surgery to clear it. Last week once again 300ml fluid was removed and a test was done. Doctor said to wait till month end to see if the fluid resolved, else he said surgery might be the option. Currently patient is continuing same medicine.