Evidence based date wise workflow logs collated by the intern with clickable and verifiable links

 Case 1 

https://modupallimamatharollno92.blogspot.com/2023/11/67-year-old-male-with-bl-knee-and-joint.html

 https://chat.whatsapp.com/IFVNWSn6nyeBhM8xjYmKKW

[11/21, 15:49] Rakesh Biswas Sir Hod Medicine: Please share the results of his tests done here asap @⁨Dr.Deepika Ch⁩ @⁨Dr. Manohith N V Gm Pg 1 St Yr⁩ @⁨Mamatha⁩ @⁨Manvi Sharma⁩

[11/21, 15:50] Mamatha: Sir didn't send any investigations

[11/21, 15:52] Rakesh Biswas Sir Hod Medicine: Chest X-ray?

[11/21, 15:52] Mamatha: These are his previous reports which were done long back

[11/21, 15:53] Mamatha: I will update   reports by tomorrow sir

[11/21, 15:53] Rakesh Biswas Sir Hod Medicine: Why? We asked in the OPD to send his CBC again yesterday! Also serum albumin? 

Why didn't you ask and confirm here?

[11/21, 15:53] Rakesh Biswas Sir Hod Medicine: Why not today?

[11/21, 15:56] Mamatha: Ok sir I will send them today

[11/21, 16:11] Rakesh Biswas Sir Hod Medicine: Confirm here again what you are supposed to send 

@⁨~A.Naga Sathvika⁩ From your readings what tests other than the above are necessary?

[11/21, 16:13] Rakesh Biswas Sir Hod Medicine: We may have to screen him for any internal malignancy as discussed in the opd yesterday 

Chest X-ray 

Ultrasound abdomen 

CBC with peripheral smear 

Serum creatinine 

Serum albumin 

Serum alkaline phosphatase 

Serum calcium and phosphorus

[11/21, 16:13] Rakesh Biswas Sir Hod Medicine: 👆@⁨Mamatha⁩

[11/21, 16:19] +91 96760 70013: I think these are enough sir..

[11/21, 16:22] Rakesh Biswas Sir Hod Medicine: But are these necessary?

[11/21, 17:17] +91 96760 70013: Peripheral smear is not required.. I think sir..

[11/21, 17:18] Rakesh Biswas Sir Hod Medicine: Why not? 😳

[11/21, 17:18] Rakesh Biswas Sir Hod Medicine: We need serum ferritin after we see his current CBC @⁨Mamatha⁩

[11/21, 17:20] +91 96760 70013: Because we already saw that his wbc is not increased.. and we weren't suspecting any infections... so I think.. it is not required..sir..

[11/21, 18:28] Rakesh Biswas Sir Hod Medicine: Peripheral is not for infection or WBC! 

It's for knowing the morphology of RBCs

[11/21, 18:29] Rakesh Biswas Sir Hod Medicine: What is the syndrome in the left hypochondrium?

[11/21, 18:30] +91 96760 70013: Sorry sir I thought we were doing it for DLC

[11/21, 20:36] Rakesh Biswas Sir Hod Medicine: @⁨~A.Naga Sathvika⁩ We have currently many many patients in our wards as well as follow up who have much lesser hemoglobin due to iron deficiency (wish we could have a mechanism to scrape those PaJR case report links from our dashboard @⁨~Dr. Avinash Kumar Gupta⁩ )

Why do you think this patient with mild iron deficiency anemia should have myalgia due to it? 

@⁨Mamatha⁩ Have you found out about sending his serum ferritin?

[11/21, 20:38] +91 96760 70013: Sir.. I thought it might be one of the reasons since.. I couldn't see any other deviations in CBP and other tests..

[11/21, 20:56] Rakesh Biswas Sir Hod Medicine: Yes 

Now think the other way! 

Why so many patients with iron deficiency anemia don't have muscle symptoms 

Let's review the iron deficiency and myalgia connection a bit more @⁨~Dr. Avinash Kumar Gupta⁩ Can LLM help?

[11/21, 21:29] Mamatha: Sir is retic count required for this patient  since he is having normocytic normochromic anemia with monocytosis

[11/21, 22:17] Rakesh Biswas Sir Hod Medicine: What is the sensitivity and specificity of Retic count and what diagnosis do you have in mind?

[11/22, 07:55] Mamatha: Normochromic, normocytic anemias are a consequence of other diseases; a minority reflects a primary disorder of the blood. This may be due to anemia of chronic disease (inflammation, neoplasia), renal failure, endocrine failure (hypothyroidism, hypopituitarism), marrow failure (pure red-cell aplasia, aplastic anemia, infiltration), acute blood loss, and polymyalgia rheumatica.[6]

The etiology of normocytic normochromic anemia depends on whether the anemia is hypoproliferative (i.e., corrected reticulocyte count <2%) or hyperproliferative (i.e., corrected reticulocyte count >2%).[7][8]

Normal/Decreased Reticulocyte Count

Normal Bone Marrow

Anemia of chronic disorders (neoplastic, infections)

Anemia of renal failure

Endocrinopathy (myxedema, Addison disease, hypothyroidism, panhypopituitarism)

Anemia of liver disease

Early iron-deficiency anemia

Abnormal Bone Marrow

Marrow infiltration (leukemia, myelofibrosis, metastasis)

Hypoplastic anemia

Aplastic anemia

Medication side effect

Increased Reticulocyte Count

Hemolysis

Intrinsic: Inherited defects of hemoglobin, RBC membrane, or enzyme; paroxysmal nocturnal hemoglobinuria

Extrinsic: Autoimmune hemolytic anemia, microangiopathic hemolytic anemia, disseminated intravascular coagulation (DIC). 

Hemorrhage

[11/22, 07:55] Mamatha: Normochromic Normocytic Anemia - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK565880/

[11/22, 07:59] Rakesh Biswas Sir Hod Medicine: The question was how is Retic count going to help! Not sure why you are sharing text book information about normocytic normochromic anemia here! Tell us how are you going to utilize this information for your patient

[11/22, 08:01] Mamatha: To evaluate the  causes of anemia

[11/22, 08:02] Rakesh Biswas Sir Hod Medicine: Does the sensitivity specificity of Retic count vary with our ability and competence to stain it properly? 

How do they stain the Retic count in our Institute and what's the sensitivity specificity of that method?

[11/22, 08:03] Rakesh Biswas Sir Hod Medicine: 👆Next step

[11/22, 08:03] Rakesh Biswas Sir Hod Medicine: What is the scientific evidence that this is a good approach?

[11/22, 16:37] Rakesh Biswas Sir Hod Medicine: Let's start him on tab Livogen 120 mg once daily

[11/22, 17:18] Mamatha: Ok sir

[11/22, 19:01] Rakesh Biswas Sir Hod Medicine: Share the medications he's currently on for pain

[11/22, 20:02] Mamatha: Tab ultracet  sir

[11/22, 20:39] Mamatha: TAB ULTRACET PO/ BD 

TAB PAN 40 MG PO /OD BBF

[11/22, 20:43] Rakesh Biswas Sir Hod Medicine: Since when? 

Is his pain any less?

[11/22, 21:14] Mamatha: Since the day of admission 

Sir

[11/22, 21:18] Mamatha: No sir

[11/22, 21:31] Rakesh Biswas Sir Hod Medicine: Who prescribed it?

[11/23, 08:11] Mamatha: Sir he is telling his pain decreased

[11/23, 08:14] Rakesh Biswas Sir Hod Medicine: After all the tests or the Ultracets

[11/23, 08:15] Mamatha: Don't know sir

[11/23, 08:22] Rakesh Biswas Sir Hod Medicine: @⁨Mamatha⁩ Share their discharge summary from and in the case report that you have linked in the description box

[11/23, 08:24] Mamatha: Ok sir

[11/23, 08:31] Mamatha: Sir please  tell what medications should I add at advice at discharge

[11/23, 08:52] Rakesh Biswas Sir Hod Medicine: Ultracet for two days only. Not more than that as it is an opiod that has addictive potential. In US people are jailed for prescribing such opiods long term

[11/23, 08:53] Rakesh Biswas Sir Hod Medicine: Continue Tablet Livogen and get his CBC repeated after a month

Case 2 : 

Blog link : 

https://modupallimamatharollno92.blogspot.com/2023/11/50-year-old-female-with-chief.html

Wats app link : 

[11/6, 16:43] Rakesh Biswas Sir Hod Medicine: Transferred to ward? 

Fever Chart update?

[11/6, 16:44] Mamatha: Went to dialysis

[11/6, 16:44] Mamatha: Sir

[11/6, 19:42] Rakesh Biswas Sir Hod Medicine: 👆Please indicate the date of dialysis in the charts and mention the daily intake output

[11/6, 19:51] Mamatha: Ok sir

[11/7, 10:01] Mamatha: S: no fever spikes , vomitings and loose stools subsided 

O : pt is conscious, coherent, cooperative 

Bp : 110/70 mm hg 

Pr : 78 bpm 

Rs : BAE + NVBS + ,NO added sounds 

Cvs : s 1, s2 + , no murmurs 

P/A : soft , NT 

CNS : NFND 

A : AKI on CKD Secondary to acute gastroenteritis with OHA INDUCED HYPOGLYCEMIA ( resolved)

K/c/o DM T2  and HTN 

with 2 sessions of hemodialysis done on 4/11/23 and 6/11/23  with 1 prbc transfusion done on 6/11/23 

P: 

INJ CEFTRIAXONE 1g IV/ BD 

INJ METROGYL 500 mg IV /TID 

INJ ZOFER 4 mg IV /SOS 

Tab LASIX 40 Mg PO /BD 

Tab CLINIDIPINE 10 mg PO/OD

[11/8, 09:57] Mamatha: S: no fever spikes , vomitings and loose stools subsided 

O : pt is conscious, coherent, cooperative 

Bp : 110/70 mm hg 

Pr : 88 bpm 

Rs : BAE + NVBS + ,NO added sounds 

Cvs : s 1, s2 + , no murmurs 

P/A : soft , NT 

CNS : NFND 

I/o : 900/1400 

A : AKI on CKD Secondary to acute gastroenteritis with OHA INDUCED HYPOGLYCEMIA ( resolved)

K/c/o DM T2  and HTN 

with 2 sessions of hemodialysis done on 4/11/23 and 6/11/23  with 1 prbc transfusion done on 6/11/23 

P: 

Tab ciprofloxacin 500 mg BD 

TAB .ECOSPRIN AV 75/10 OD 

Tab LASIX 40 Mg PO /BD 

Tab CLINIDIPINE 10 mg PO/OD

SYP POTCHLOR 10 ML IN 1 GLASS WATER TID

SYP ARISTOZYME 10 ML BD 

SYP CREMAFFIN PLUS 15  ML BD

[11/8, 14:13] Rakesh Biswas Sir Hod Medicine: Lateral view of biceps and abdomen?

[11/8, 14:18] Rakesh Biswas Sir Hod Medicine: Share questions about the patient in the group to stimulate learning inputs from the other group members

[11/8, 14:56] Rakesh Biswas Sir Hod Medicine: 👆

[11/8, 14:56] Mamatha: Sir why is the creatinine level still high even after 2 sessions of hemodialysis?

[11/8, 14:56] Mamatha: Ok sir

[11/8, 14:59] Rakesh Biswas Sir Hod Medicine: How much would be the expected fall in the creatinine levels with each dialysis? 

Can you share the trends of creatinine in this patient since admission and the volume of ultrafiltrate removed with each dialysis?

[11/8, 15:08] Rakesh Biswas Sir Hod Medicine: Okay what I was asking for was already shared in this fever chart. 

Now if you see the trends in creatinine especially after the dialysis days the first Day post dialysis creatinine reduction was from 7.1 to 6.4 and after the second dialysis the creatinine dropped from 6.4 to 3.1!!

Today without any dialysis done yesterday the creatinine has increased to 4

So what drives recovery of renal failure? Can dialysis induce renal recovery or it's just to reduce the serum creatinine and other toxins? Can the creatinine come down unless the kidneys recover on their own?

Case 3 : 

Blog link : https://modupallimamatharollno92.blogspot.com/2023/11/33-year-old-female-with-hematemesis.html

Case 4 : 

Blog link : https://modupallimamatharollno92.blogspot.com/2023/11/85-old-male-kco-hypertension-since-10.html

Case 5 : 

Blog link : 

https://modupallimamatharollno92.blogspot.com/2023/11/40-f-with-complaints-of-pedal-edema.html