Hand signed with background removed:
Original
Thursday, September 17, 2026
Wednesday, September 16, 2026
Current medicine department workflow
Patient centred OPD, Casualty, IPD, post discharge follow up:
Offline 9 AM to 4 PM:
Online 24x7:
Research:
University summative assessments:
Internal examiner's workflow:
Theory paper correction:
Practical bedsides:
External examiner's workflow:
Logistics:
Theory paper correction:
Practical bedsides:
Tuesday, September 15, 2026
Workflow illustration for an Indian medicine department faculty going as an external examiner from one state to another
Invitation from the university controller of exams from another state:
Emailed back interest to attend.
Applied through proper channel for leave from current working college as an external examiner on the dates invited
Received the permission from Principal
Taken exams
Obtained the attendance certificate after taking the exams
Monday, September 7, 2026
A pictorial sample from the Patient centred blended learning workflows in a de-identified teaching hospital and community settings
Simplified textual schematic for a quick TLDR workaround to understanding the workflow components:
1) Patient experiences symptoms events at home
2) Comes to hospital for a routine OPD or Casualty emergency clinical encounter depending on the symptoms and finally gets admitted in the in patient wards or returns home from OPD
3) Engages with a community outreach service of the same hospital who provides care either at home or hospital
Workflow illustration below , archived from a currently functioning , open access, real-patient centred , blended learning, home hospital integrative workflow since few decades with superficial alterations over time due to evolving technology
1) Home symptoms event:
50-year-old female from a rural village in Telangana presented to a local medical center on Day 0, approximately 40 minutes after being bitten on her right big toe by a small, approximately 10 cm long, snake identified as a juvenile Russell's viper (Daboia russelii). She presented with local swelling and fang marks.
Full text below:
For richer image based data can click into the patient diary at the above link
2) Comes to hospital Casualty
Day 0: Acute Presentation and Anaphylaxis Upon arrival, her initial vital signs included a heart rate of 110 bpm, unrecordable blood pressure, and SpO2 of 81% on 10L O2, with a "silent chest." A 20-minute whole blood clotting time (WBCT) test was performed, which was initially recorded as negative but later corrected to positive (incoagulable blood), confirming severe systemic envenomation with venom-induced consumptive coagulopathy (VICC). Initial management included wound cleaning, Betadine application, tetanus toxoid, intramuscular promethazine (Avil) 45.5mg, and intravenous hydrocortisone 100mg. Following protocol, an initial dose of 5 vials of polyvalent ASV in 500ml normal saline was initiated.
More:
Full text below:
For richer image based data can click into the patient diary at the above link
3) Inpatient wards:
Day 1: Persistent Coagulopathy and Stabilization On Day 1, the patient exhibited extensive subcutaneous ecchymosis, indicating active bleeding into the skin. Laboratory results confirmed coagulopathy with a prolonged Prothrombin Time (PT) of 20.6 seconds (control 13.5 seconds) and an International Normalized Ratio (INR) of 1.5. A subsequent PT/INR showed further prolongation to 22.5 seconds and INR 1.7, while Activated Partial Thromboplastin Time (APTT) was within normal limits (31.5 seconds). Despite the systemic coagulopathy, renal function tests (RBS 91 mg/dL, Urea 31 mg/dL, Creatinine 1.1 mg/dL) remained within normal limits.
More:
Full text below:
For richer image based data can click into the patient diary at the above link
Discharge:
Day 3: Discharge and Follow-up Challenges The patient was discharged on Day 3 against medical advice (LAMA) as she did not wish to wait for continuous observation. She was reported to have reduced systemic envenomation and no other features suggestive of progressive envenomation. However, the provided patient advocate's contact number was incorrect, hindering post-discharge follow-up.
Community outreach:
Day 6: Remote Follow-up Through an international phone call to the patient's husband, it was confirmed that the patient was doing well with no ongoing symptoms or health concerns.
More:
Full text below:
For richer image based data can click into the patient diary at the above link
Further learning and publications from the above real patient data:
The project team is addressing a fundamental flaw in how frontier Large Language Models (LLMs) are currently evaluated.
Static case reports are easily "cracked" by LLMs through training memorization. Conversely, dynamic, un-indexed PaJR pathways challenge models to exhibit genuine clinical cognition.
Quantum analogies in clinical decision making
Added to our snake bite project:
Friday, September 4, 2026
ProJR: Brick and mortar offline workflows optimisation in healthcare organisations in terms of learning and caring
A previous ProJR log on similar lines is found here:
Here is the text from the circular in the image:
---
*A MEDICAL COLLEGE & HOSPITAL*
No. /010
Date: 04-09-2026
*CIRCULAR*
*SPECIAL DRIVE- NATIONAL NUTRITION WEEK*
All HODs, Faculty, PGs and Nursing Staff are hereby informed that the following measures have been taken to support the patient's immediate effect until 15-09-2026.
*1. FREE SERVICES FOR PATIENTS (TILL 15-09-2026 ONLY)*
a) All Surgeries will be done free of cost.
b) All Investigations including CT scan, Ultrasound, X-ray, ECG and all Blood Investigations will be free for inpatients.
c) Food will be provided free of cost to all IP Patients.
*2. PHARMACY:*
Patients will be charged only for Pharmacy / Medicines at 20% discount
*3. IP CENSUS & STAY:*
All OP patients posted for surgery must be admitted and shall remain in the ward for a minimum of 5 days post-surgery for a better monitoring & care.
*4. EMERGENCY & CASUALTY:*
All 24 hours Emergency Departments, Casualty, Labour Room and OT shall be fully functional round the clock all Doctors and Staff posted as per duty roster.
All Heads of Departments are directed to ensure strict compliance
*Medical Superintendent*
[Signature dated 4/9/26]
Wednesday, September 2, 2026
Title: Narketpally syndrome: a triad of toxic etiological overlap addressed through a PaJR workflow
Introduction: The first case of Narketpally syndrome was published this year (reference 1 also shared as an image excerpt above). We present another case here who is an 82 year old man with prolonged exposure to a triad of toxic etiologies common in location Narketpally in Telangana and likely also in certain other parts of India hitherto undescribed.
Methods: (Identification data) The 82 year old man living 10 kms away was first admitted to our medical college in Narketpally in May 2024 and had been on regular "patient journey record" PaJR follow up since then along with two more admissions in November 2024 and April 2025 (PaJR reference 2,3,4).
Presenting complaints: He had a history of Diabetes since 30 years, hypertension and mild chronic kidney disease since 10 years and his chief complaints during first and second admission was for tingling of limbs and giddiness and in his third admission months later he had sudden giddiness with slurring of speech. He had a history of exposure to fluoride water for first 6 decades of his life, regular Alcohol consumption since age of 20 and a diet rich in simple sugars but low in complex carbohydrates and proteins.
Examination findings: On general examination he was found to have an invisible pillow sign due to ossified posterior longitudinal ligament that has been named Narketpally sign (reference 1) to distinguish it from the previously described invisible pillow sign aka imaginary pillow as it was commonly described in catatonic schizophrenia (reference 5). He also had a metabolic syndrome phenotype with trunkal obesity and sarcopenia. On CNS examination during first admission positive findings were a broad based gait with absent lower limb vibration senses along with loss of ankle reflexes. On second admission he had a cerebellar speech with marked gait ataxia that recovered within a day.
Investigations: His blood biochemistry confirmed mild azotemia of CKD and impaired blood sugars that were quickly controlled on insulin and a cervical spine x-ray confirmed his ossified posterior longitudinal ligament and cranial MRI revealed old cerebral lacunar infarcts and fazekas grade 2 leukoariosis suggestive of cerebral small vessel disease.
Differential diagnosis: OPLL due to immune spondyloarthropathy, CNS and peripheral neural vasculopathy due to causes other than alcohol and diabetes.(reference 6,7)
Treatment: His Diabetes, Hypertension, CKD was managed with standard care through regular PaJR follow up and his OPLL was managed with physiotherapy.
Patient is on regular follow up and the triad of toxin exposure to fluoride, alcohol and simple sugars have been minimised by ensuring filtered water, abstinence and balanced diet through PaJR monitoring.
Conclusion: Narketpally syndrome with musculoskeletal OPLL and neural vasculopathy is a result of a triad of toxic outcomes from exposure to Fluoride, C2H5OH and C6H12O6. While the link between metabolic syndrome, fluoride exposure and OPLL has been separately elucidated before, Narketpally syndrome describes the triad of exposure and defines a syndromic workflow through team based learning around a patient's journey record (1,2,6,7).
References:
1: Podder V, Kulkarni R, Samitinjay A, Salam A, Gade S, Agrawal M, Surendran AK, Biswas R. Narketpally Syndrome and the Embedding of Contextual Values in Real-Life Patient Pathways. J Eval Clin Pract. 2025 Aug;31(5)
2: Martin CM, Biswas, R., Joshi, A., & Sturmberg, J. P. (2011). Patient Journey Record Systems (PaJR): The Development of a Conceptual Framework for a Patient Journey System. In R. Biswas & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 75-92). IGI Global Scientific Publishing
3:Podder V, Dhakal B, Shaik GUS, Sundar K, Sivapuram MS, Chattu VK, Biswas R. Developing a Case-Based Blended Learning Ecosystem to Optimize Precision Medicine: Reducing Overdiagnosis and Overtreatment. Healthcare (Basel). 2018 Jul 10;6(3):78
4:Agrawal, Mansi & Bobba, Braahmani & Iftequar, Yousra & Lekhana, Macharla & Gade, Aditya & Podder, Vivek & Kulkarni, Rahul & Biswas, Rakesh. (2025). PaJR as the Foundation for Next Generation Telemedicine. 10.2991/978-94-6463-784-7_4. https://www.atlantis-press.
5: Shukla R, Ahsan M, Pal A, Shaan F. Unraveling the enigma of ‘Psychological Pillow’: A unique catatonicphenomenon. Industrial Psychiatry Journal. 2024 Aug 1;33(Suppl 1):S284-S286
6: Wang, J., Wei, Z., Kong, Q. et al. The relationship between OPLL and metabolic disorders. Bone Res 13, 90 (2025). https://doi.org/10.1038/
7: Ramos-Remus C, Russell AS, Gomez-Vargas A, Hernandez-Chavez A, Maksymowych WP, Gamez-Nava JI, Gonzalez-Lopez L, García-Hernández A, Meoño-Morales E, Burgos-Vargas R, Suarez-Almazor ME. Ossification of the posterior longitudinal ligament in three geographically and genetically different populations of ankylosing spondylitis and other spondyloarthropathies. Ann Rheum Dis. 1998 Jul;57(7):429-33.https://pmc.
Further references to past data on the same from Narketpally
Sunday, August 30, 2026
Diabetic foot and pulmonary embolism incidentalomas: Clinical decision making amidst diagnostic and therapeutic uncertainty
Global Health Case Report: Concurrent Pulmonary Embolism and Osteomyelitis in a Patient with Uncontrolled Diabetes
SUMMARY
This report details the case of a 53-year-old female from a rural setting in Bihar, India, with a 12-year history of poorly controlled diabetes mellitus. She presented with acute-on-chronic systemic hypoxia, initially attributed to sepsis from a chronic diabetic foot ulcer. However, a series of targeted investigations uncovered a more complex clinical picture involving at least two simultaneous life-threatening pathologies: a high probability of pulmonary embolism (PE) and definite, severe osteomyelitis of the foot. The case highlights the diagnostic and therapeutic challenges of managing patients with cascading comorbidities, particularly the need to resist premature diagnostic closure and act decisively in the face of uncertainty. The patient was successfully managed with therapeutic anticoagulation, broad-spectrum antibiotics, and surgical debridement (great toe disarticulation), leading to clinical stabilization. This case serves as a crucial example of the "domino effect" of chronic non-communicable diseases in global health settings.
KEYWORDS
Pulmonary Embolism, Diabetic Foot Ulcer, Osteomyelitis, Glycemic Variability, Diagnostic Uncertainty, Socratic Steelman, Global Health, Resource-Limited Setting.
***
INTRODUCTION
In global health, patients with long-standing, poorly managed non-communicable diseases (NCDs) like diabetes mellitus frequently present with multiple, intertwined complications. A common and dangerous clinical scenario is the patient with a diabetic foot ulcer who develops acute systemic symptoms. The most convenient diagnosis is often sepsis originating from the wound. But is this always the correct or complete picture? What if another, equally lethal process is occurring simultaneously?
This case report concerns a 53-year-old female whose presentation forced a direct confrontation with this diagnostic dilemma. The Socratic question at the heart of this case is: How should a clinician prioritize diagnostic and therapeutic pathways when a single patient presents with compelling evidence for two distinct, life-threatening conditions (thromboembolism and sepsis)? Using a "Steelman" approach, we will reconstruct the clinical reasoning not as a linear path to a single answer, but as a robust, parallel process that validates the initial uncertainty and demonstrates how to navigate it safely. The purpose is to illustrate a framework for managing high-stakes ambiguity in complex patients, a daily reality in many healthcare environments.
METHODS (CASE PRESENTATION)
A 53-year-old female with a 12-year history of diabetes mellitus, managed with an inconsistent insulin regimen, presented to a local clinic in Bihar.
Her chief complaint was a non-healing ulcer on her right great toe, present for over a month, which had progressed to expose bone. Acutely, she developed systemic hypoxia, requiring 3 liters of oxygen per hour to maintain an SpO2 of 95%.
Initial evaluation revealed tachycardia (100 bpm), tachypnea (24-26 breaths/min), and dangerously unstable blood glucose levels ranging from a low of 74 mg/dL to a hyperglycemic crisis peak of 514 mg/dL. The patient, however, paradoxically denied any subjective feeling of shortness of breath ("happy hyoxemia").
A diagnostic cascade was initiated to address the primary life-threat: hypoxia.
RESULTS
Laboratory Findings: A D-dimer test was grossly elevated ("in the thousands"), creating a high pre-test probability for thromboembolic disease. Blood glucose logs confirmed severe glycemic variability, reflecting a brittle diabetic state.
Radiological Findings:
Chest X-Ray: Was deceptively clear, showing no signs of pneumonia, fluid overload, or other parenchymal cause for the hypoxia.
Venous Doppler Ultrasound (Right Lower Limb): Was ordered to find the source of a potential PE. It was negative for deep vein thrombosis (DVT). However, the ultrasound serendipitously provided a definitive secondary diagnosis: a 3.6 cm abscess surrounding the great toe with clear signs of underlying osteomyelitis (bone infection).
Foot X-Ray & Clinical Images: Confirmed complete destruction of the proximal phalanx of the great toe, consistent with advanced, limb-threatening osteomyelitis.
Clinical Course & Interventions:
Based on the classic combination of unexplained hypoxia, a clear chest X-ray, and a massively elevated D-dimer, a working diagnosis of Pulmonary Embolism was established. Therapeutic anticoagulation with LMWH was initiated immediately, even before definitive imaging could be obtained.
Concurrently, based on the Doppler and X-ray findings, a diagnosis of severe diabetic foot osteomyelitis with sepsis was confirmed. The patient was placed on broad-spectrum IV antibiotics (Amoxicillin/Clavulanate and Clindamycin).
Source Control: The patient underwent a disarticulation of the right great toe at the metatarsophalangeal joint to remove the necrotic and infected tissue.
Post-operatively, the patient’s hypoxia resolved, and she was weaned off oxygen. Her glycemic control was stabilized on a revised insulin regimen, and she was transferred to the ward for continued monitoring before a planned discharge.
DISCUSSION (SOCRATIC STEELMAN)
This case is a masterclass in managing concurrent pathologies. Let us "Steelman" the clinical journey by asking the key Socratic questions the care team faced.
1. Was it correct to prioritize Pulmonary Embolism when a floridly infected foot provided an obvious source for sepsis-induced hypoxia?
Absolutely. The strongest argument for prioritizing PE is not that it's more likely, but that it is more immediately lethal if missed and requires a completely different treatment. The clinical triad of hypoxia, tachycardia, and a normal chest X-ray is a textbook PE presentation. To attribute these findings solely to "sepsis" from the foot without aggressively ruling out PE would be an example of premature diagnostic closure. The team correctly identified the pattern with the highest mortality risk and acted on it by starting anticoagulation, a decision that is difficult but necessary in the face of ambiguity.
2. Does a negative DVT scan rule out PE, and what was the hidden value of this "negative" test?
A common pitfall is to believe a negative peripheral DVT scan excludes a PE. This is false. Clots can originate from pelvic veins or have already fully embolized to the lungs. The true value of the Doppler scan here was its accidental discovery. It provided incontrovertible evidence of severe osteomyelitis, shifting the clinical picture from a "non-healing ulcer" to "limb-threatening bone infection with sepsis." This finding did not negate the PE diagnosis but rather added a second, equally critical diagnosis that demanded its own aggressive management (surgery and targeted antibiotics). This demonstrates the principle of diagnostic serendipity.
3. How does one manage the therapeutic conflict of anticoagulating a patient who needs urgent surgery?
This is the central challenge. The patient needed anticoagulation for the PE, which increases bleeding risk, and simultaneously needed surgery for the osteomyelitis, which carries its own bleeding risk. There is no perfect, risk-free answer. The clinical team correctly reasoned that the systemic, immediate threat of a fatal PE was greater than the manageable, local risk of bleeding from the foot surgery. The correct path, which they followed, is to:
Start anticoagulation immediately.
Inform the surgical team about the anticoagulation.
Proceed with the necessary surgery (source control) with meticulous hemostasis.
Monitor the patient closely post-operatively.
This balancing act is a high-level skill, particularly in settings where surgical and ICU support may be limited.
***
THEMATIC ANALYSIS
The Domino Effect of Chronic Disease: This case is a powerful illustration of how a single NCD, poorly managed over time, creates a cascade of catastrophic failures. Diabetes led to neuropathy and vascular disease, which led to a foot ulcer, which led to osteomyelitis, which created a hypercoagulable state that likely resulted in a PE, all while the underlying metabolic chaos (glycemic variability) worsened every aspect of the illness. This is the modern face of disease in many parts of the world.
Resisting Premature Diagnostic Closure: The most significant intellectual victory in this case was the refusal to accept "sepsis" as a simple, all-encompassing diagnosis for the patient's hypoxia. By maintaining a broad differential and recognizing the classic PE pattern, the team avoided a potentially fatal misstep.
Acting in the Face of “Therapeutic Uncertainty”:
The decision to start anticoagulation before a definitive CTPA scan was available represents a crucial lesson for resource-limited settings. When diagnostic tools are delayed or unavailable, treatment must often be initiated based on high clinical suspicion and a careful risk/benefit analysis. In this case, the risk of not treating a PE far outweighed the risk of treating it.
Follow up:
On Day 17, the patient was reviewed in the outpatient department, showing continued clinical stability.
This case was first reported here in real time even as she presented to the treating unit:
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