Sunday, June 30, 2024

MoU format for Public Private partnership in education and practice

Memorandum of Understanding (MOU)


Between


Public Institute of Education and Research  


And

Private Medical College and Research Centre, 

This Memorandum of Agreement (MOA) is entered into this _____day of ___________, 2014 BETWEEN Public Institute of Education and Research (IISER) located at By-pass Road, Madhya Pradesh, India (hereinafter called ‘PIER’ which expression shall where the context so admits, include its successors, permitted assigns and will include its Constituents) of the one part.

AND

Medical College and Research Centre, a private hospital and research centre, having its Registered Office at L. N. Medical College and Research Centre (NCH), 

Town, C-Sector,Road, Madhya Pradesh India  ‘(hereinafter called ‘PMCRC’ which expression shall include its successors in interest/business and permitted assigns) of the other part; 




Preamble

‘IISER Bhopal’ has been established in 2008 by the Ministry of Human Resource Development (MHRD), Government of India.  Ever since its inception, IISER Bhopal engaged in providing a platform for the faculty to engage in high quality cutting edge research in frontier areas of basic sciences. The institute offers Integrated Masters (M.S.) and Ph.D. degree programs in Biology, Chemistry, Mathematics, Physics, and Environmental Sciences etc. IISER Bhopal is dedicated to imparting high quality science education in a research oriented environment to young and academically motivated undergraduate and postgraduate students.

LNMC is a comprehensive Tertiary care hospital which provides specialized services to make the life of ill patients comfortable as per the guidelines of WHO. LNMC has therapeutic and diagnostic facilities, at par with national level hospitals. LNMC is also actively involved in biomedical research.

To synergize R&D and academic efforts in the field of biomedical education and research, IISER Bhopal and LNMC Bhopal are interested in establishing interaction in collaborative research and academic activities primarily toward building a vital bridge between basic and clinical science professionals that may translate bedside patient needs to solutions from the bench. This collaboration eventually hopes to propagate 'Personalized Medicine and patient centred learning’ such that students, Scientists and health professionals take pride in their teamwork toward making a positive change in patients' lives.


The MOU will broadly cover the following areas and modalities.

IISER Bhopal and LNMC will identify research opportunities to conduct cooperative research and experimental programmes for the mutual benefits. Areas of mutual interest include, but are not limited to, Global health, Personalized Medicine and Patient centred learning, Infectious disease, Immunology, Oncology including Cancer metastasis, cancer epidemiology, chemoprevention, carcinogenesis, tumor immunology, palliative care, chemotherapy and radiation oncology.

IISER Bhopal and LNMC will encourage respective physicians, faculty members and scientists to explore and prepare joint research proposals on some thrust areas for funding by government agencies.

Joint research projects will be submitted to funding agencies after obtaining explicit clearance from both the institutions. The technical activities and grant sharing between two parties shall be defined and mutually agreed while submitting such proposals. Existing/stipulated guidelines of the funding agencies with regard to research publications and patents will be followed. Else such matters will be mutually decided. 

The samples from patients and healthy individuals (if required) will be collected from LNMC following the guidelines laid by the Indian Council of Medical Research (ICMR) New Delhi. The clinical research projects will be thoroughly examined and approved by the ethical committee of the IISER Bhopal and LNMC before collection of clinical samples from LNMC. In the absence of ethical committee at the LNMC, the clinical research projects will be examined and approved by the ethical committee of IISER Bhopal as per the guidelines of ICMR New Delhi. The clinical samples required for the project will be exchanged free of cost and will be purely used for academic research only. The confidential information of the patient/healthy individuals will not be disclosed under any circumstances. 

All patent applications will be made through IISER Bhopal directly or through some federal or private agency appointed/approved by IISER Bhopal. The interests of LNMC while filing the patent applications will be respected as per the mutual agreement made prior to the beginning of the project on case to case basis. 

IISER Bhopal and LNMC shall consult each other for research publications and acknowledge the same for research publications resulting from collaborative research. The role in research and authorships of contributors in publications from each institute should be clearly defined prior to the beginning of the project.

IISER Bhopal and LNMC will explore possibility to organize seminars, workshops, conference and various scientific activities of mutual interest under auspices of learned professional societies at mutually convenient venues to promote R&D/academia/industry interactions. The resources for such activity will be shared.

Duration of MOU will be initially for FIVE years, which can be renewed upon mutual understanding. 

Either party may terminate this MOU by giving thirty (30) days notice in writing to the other party provided that such termination shall not affect the rights of the parties to MOU which have been accrued prior to such termination.

If any dispute or difference arises between the parties hereto as to the construction, interpretation, effect and implementation of any provision of this MOU including the rights and liabilities or any claim or demand of any party against other or in regard to any other matter under this MOU but excluding any matters, decisions or determinations of which is expressly provided for in this MOU, such disputes or differences shall be resolved by mutual consultation and if it fails, the dispute shall be referred to the Bench of Arbitrators. Each party would appoint one Arbitrator and the two Arbitrators would appoint the third Arbitrator as the Presiding Arbitrator. A reference to the Arbitration shall be deemed to be submission within the meaning of the Arbitration and Conciliation Act, 1996 and the rules framed there under for the time being in force.

If however, ‘IISER Bhopal’ or ‘LNMC’ does not make any claim or demand or raise any dispute or difference within one year from the date on which such demand or claim arises, IISER Bhopal’ or ‘LNMC’ shall be deemed to have waived and abandoned such claim or demand or the right to raise such dispute or difference against the other party.

The venue of the Arbitration shall be at Bhopal.

Each party shall bear and pay its own cost of the arbitration proceedings unless the Arbitrator otherwise decides in the Award.

This MoU shall not be construed as financial and legal binding, nor are any legal consequences intended to flow as a result of this MoU.

This MOA shall become effective on and from the date it is signed.



IN WITNESS WHEREOF, both the parties herein set their respective hands on the day, month and year first above written in the presence of following witnesses.



On behalf of IISER Bhopal                                 On behalf of LNMC




WITNESSES




Thursday, June 27, 2024

PaJR case report of 27M Diabetes on insulin 15 years, hypoglycemic seizures, retinopathy Telangana

 DEPARTMENT OF GENERAL-MEDICINE

DISCHARGE SUMMARY ***
Pay Type : Paying
Age/Gender : 27 Years/Male
Address : 
Discharge Type: Relieved
Admission Date: 10/06/2024 09:46 AM

Diagnosis
HYPOGLYCEMIC SEIZURES 
TYPE 1 DM SINCE 15 YRS
SEIZURE DISORDER 15 YRS AGO
ANEMIA [IDA-NUTRITIONAL]
HYPOTHYROIDISM SINCE 2 YRS

Case History and Clinical Findings

C/O SEIZURES 1 EPISODE ONE HOUR AGO

HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC 1 HR AGO THEN HE DEVELOPED
SEIZURES 1 EPISODE OF VOMITING ,NON PROJECTILE ,NON BILIOUS FOOD AS CONTENT

NO H/O FEVER/COLD/COUGH
NO H/O POST ICTAL CONFUSION N
NO H/O GIDDINESS
NO H/O ABDOMINAL PAIN
NO H/O CHEST PAIN CHEST TIGHTNESS
NO H/O SOB,ORTHOPNEA ,PND
NO H/O BOWEL AND BLADDER ABNORMALITIES
NO H/O BLEEDING MANIFESTATIONS
PAST HISTORY

K/C/O DM ON MIXTARD 20 IU 15 years 
K/C/O SEIZURES 10 YRS BACK
K/C/O Hypothyroidism ON THYRONORM 100 MG
Page-2

PERSONAL HISTORY :
DIET - MIXED
APPETITE - NORMAL
SLEEP - ADEQUATE
BOWEL& BLADDER MOVEMENTS - REGULAR
ADDICTIONS - NIL


GENERAL PHYSICAL EXAMINATION :
PATIENT IS CONSCIOUS , COHERENT &COOPERATIVE , WELL ORIENTED TO TIME AND
PLACE .
NO PALLOR/ ICTERUS / CYANOSIS / CLUBBING / LYMPHADENOPATHY / OEDEMA.




VITALS :
BP ; 110/80MM HG
PR : 90 BPM
RR : 22 CPM
TEMP ; 98F
SPO2 : 98 @ RA
GEBS- 205 MG/ DL

SYSTEMIC EXAMINATION :
CNS : NFND
REFLEXES :
B T S K A
R +2 +2 + 1 +2 +
L +2 +2 +1 +2 +
CVS :
S1, S2 HEARD , NO MURMURS
RS :
BAE + , NVBS
Page-3

P/A :
SOFT , NON TENDER

COURSE IN THE HOSPITAL : 

A 27 YR OLD MALE PATIENT CAME WITH C/O INVOLUNTARY
MOVEMENTS AND CONFUSION WITH GRBS OF 23 MG/DL AND WAS DIAGNOSED AS
HYPOGLYCEMIC SEIZURES .PATIENT IS A K/C/O DM I AND SEIZURE DISORDER SINCE 15
YRS FOR SEIZURES HE USED ANTIEPILEPTICS FOR 3 YES AND STOPPED MEDICATION FOR
DM I HE WASON MIXTARD 20U-X-20U BD FOR GLYCEMIC CONTROL HE WAS PUT ON HAI TID
OPTHALMOLOGY OPINION WAS TAKEN AND PATIENT HAS DIABETIC RETINOPATHIC
CHANGES [ MILD NPDR] PATIENT HAS HYPOTHYROIDISM SINCE 3 YRS WAS ON 100 MCG
CHANGES TO 75 MCG BUT PATIENT HAD FLUCTUATING SUGARS AND . ENDOCRINE
OPINION WAS TAKEN IN VIEW OF ?BRITTLE DIABETES ?HYPOPITUTARISM AND SIR HAS
ADVICED INJ.LANTUS 8U AT NIGHT WITH 4U HAI TID BUT PATIENT HAS HYPOGLYCEMIA AT
NIGHT.

SO PT IS BEING Discharged UNDER OCTREOTIDE 100 MG STAT AND LOW DOSE
STEROID TO MAINTAIN EUGLYCEMIA

PATIENT IS BEING Discharged UNDER
HEMODYNAMICALLY STABLE CONDITION

Investigation

Name Value Range
Name Value Range

COMPLETE URINE EXAMINATION (CUE) 10-06-2024 10:38:AM

COLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR TraceBILE
SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
HBsAg-RAPID 10-06-2024 10:38:AM NegativePOST LUNCH BLOOD SUGAR 10-06-2024 10:40:AM
101 mg/dl 140-0 mg/dl
BLOOD UREA 10-06-2024 10:40:AM 25 mg/dl 42-12 mg/dlSERUM CREATININE 10-06-2024
10:40:AM 1.4 mg/dl 1.3-0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 10-06-2024 10:40:AMSODIUM 141 mmol/L 145-136
mmol/LPOTASSIUM 3.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 104 mmol/L 98-107 mmol/LLIVER
FUNCTION TEST (LFT) 10-06-2024 10:40:AMTotal Bilurubin 0.44 mg/dl 1-0 mg/dlDirect Bilurubin
0.14 mg/dl 0.2-0.0 mg/dlSGOT(AST) 30 IU/L 35-0 IU/LSGPT(ALT) 33 IU/L 45-0 IU/LALKALINE
PHOSPHATASE 180 IU/L 128-53 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4 gm/dlALBUMIN 3.8
gm/dl 5.2-3.5 gm/dlA/G RATIO 1.48
Page-4
4
T3, T4, TSH 11-06-2024 05:50:AMT3 0.85 ng/ml 1.87-0.87 ng/mlT4 6.67 micro g/dl 12.23-6.32 micro
g/dlTSH 0.37 micro Iu/ml 5.36-0.34 micro Iu/mlPERIPHERAL SMEAR 11-06-2024 03:50:PM RBC :
Microcytic hypoochromic WBC : With in normal limits PLATELET : Adequate
STOOL FOR OCCULT BLOOD 11-06-2024 03:50:PM Negative (-ve)ABG 12-06-2024 07:40:AMPH
7.342PCO2 33.8PO2 73.3HCO3 17.8St.HCO3 18.9BEB -6.6BEecf -6.8TCO2 37.2O2 Sat 94.3O2
Count 14.1
SERUM CREATININE 12-06-2024 10:41:PM 1.6 mg/dl 1.3-0.9 mg/dlSERUM ELECTROLYTES (Na,
K, C l) 12-06-2024 10:41:PMSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5
mmol/LCHLORIDE 102 mmol/L 98-107 mmol/L
PHOSPHOROUS 3.0 mg/dl 4.5-2.5 mg/dl
FBS : 287 MG/DL
PLBS : 101 MG/DL
HBA1C 8.2%


Treatment Given(Enter only Generic Name)
INJ.LEVITIRECETAM 1GM IV/OD
INJ. GLARGINE SC/OD 8 UNITS 8 PM
INJ.HAI SC/TID ACCORDING TO GRBS
INJ.OCTREOTIDE 100 MG IV/ STAT
TAB.THYRONORM 100 MICRO GRAMS PO/OD
Advice at Discharge
INJ.GLARGINE S/C OD [8 UNITS ]
TAB.LEVITIRACETAM 500 MG PO/OD
TAB. THYRONORM 75 MCG PO/OD 1-0-0 8 AM
INJ.HAI S/C TID [6-6-6]
TAB .DEFOCORT 6 MG 0-1-0 2PM
Follow Up

REVIEW TO GENERAL MEDICINE OPD AFTER 2 WEEKS ON MONDAYS.

When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
Page-5

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: hospital phone helpline For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:15/6/24
Ward:AMC
Unit: I

Wednesday, June 26, 2024

Altered sensorium outcomes ProJR Case report form 2

Current Project PI: Dr Haripriya


Project details from her portfolio:



Similar project quantitative analysis with question to PI and project team:

Check out the quantitative thematic analysis in the form of various demographic and disease related themes (as quantitative associations with patients of altered sensorium) from a past similar project from Osmania shared full text here ๐Ÿ‘‡


Share if you can answer the following questions quickly after reading the above quantitative thematic analysis:


What was already known to you around altered sensorium outcomes before your study?

What was already known to the world around altered sensorium outcomes before your study although you didn't know it?

What was not known to the world around altered sensorium outcomes before your study?

Current Project qualitative analysis:

1) First case case report form and thematic analysis:


2) Second case report form and thematic analysis:


2nd case report form rough draft of "altered sensorium ProJ" patient for thematic analysis in the ProJR as shared by the PI Dr Haripriya:


Data below retrieved from the hospital 

Diagnosis? NEUROTOXOPLASMOSIS.? NEUROTUBERCULOSIS.

Case History and Clinical Findings

PRIMARY SURVEY:PR:108 BPMBP:130/90 MM/HG

RR:22CPM
TEMP: 103F.

SPO2:98% AT RBS:113MG/DL

CHIEF COMPLAINTS:Patient has complaints of generalised weakness since 1 week.h/o loss of speech and deviation of mouth since 3 days

HOPI: PATIENT WAS BROUGHT TO CASUALITY WITH COMPLAINTS OF GENERALIZED WEAKNESS OF BOTH UPPER AND LOWER LIMBS SINCE 1 WEEK, COMPLAINTS OF UNABLE TO SPEAK SINCE 3 DAYS , COMPLAINTS OF DEVIATION OF MOUTH TO RIGHT SIDE SINCE 3DAYS , COMPLAINTS OF FEVER SINCE 1 DAY.NO HISTORY OF SEIZURES,HEADACHE, GIDDINESS,SHORTNESS OF BREATH,FEVER,RASHES,PAIN ABDOMEN AND BURNING MICTURATION.

SECONDARY SURVEY:

GENERAL:PATIENT IS DROWSY, NON COHERENT , NOT ORIENTED TO TIME, PLACE AND PERSON.
HEAD: ATRAUMATIC, NORMOCEPHALIC ,

GCS: E2V2M4[8/15]EYES: ATRAUMATIC, NO DISCHARGE, B/L PUPILS EQUAL REACTING TO LIGHT,

RT EYECATARACT.EARS:ATRAUMATIC, NO DISCHARGE.NOSE:ATRAUMATIC, NO DISCHARGE.NECK:NO NECK SWELLINGS,NO JVP DISTENSION,B/L CAROTIDS FELT, NO STRIDOR CHEST: B/L CHEST RISE EQUAL.HEART: S1 S2 HEARD, NO MURMURS.LUNGS: BAE+ No added breath sounds.ABDOMEN: SOFT,NON TENDER,NO DISTENSION,BOWEL SOUNDS PRESENT




PAST MEDICAL HISTORY: nil significant

PAST SURGICAL HISTORY : no past surgical history
NO SIGNIFICANT FAMILY HISTORY
NO KNOWN DRUG OR FOOD ALLERGIES NO KNOWN

COMORBIDITIES.

Investigation MRI BRAIN PLAIN AND CONTRAST:Multiple ring enhancing lesions in pons mid brain bilateral straito capsular regions,left frontal lobe andright cerebellar hemisphere with extensive edema in the above areas.F/S/O Neurotoxoplasmosis/NeurotuberculosisDD-cryptococcal meningitis

CSF ANALYSIS:

CSF CULTURE:zn stain-no acid fast bacilli seen. gram stain:few disintegrated pus cells,occasional gram positive cocci in pairs seen.CSF CYTOLOGY:few lymophocytes and few monocytes are seen.

Treatment Given(Enter only Generic Name)1)INJ NEOMOL 1GM IV/TID

2)INJ PANTAPRAZOLE 4OMG IV/STAT

3).INJ.ONDENSETRON 4MG IV/OD

4)OPTINEURON 4AMP IN 500ML NS IV/OD

5)TAB ECOSPORIN 75MG/RT/OD

6)TAB ROSUVASTATIN 40MG/RT/OD


7)INJ CLEXANE 60MG/SC/OD

8)INJ MANNITOL 100 /IV/TID

9)INJ LEVETIRACETAM 500MG /IV/BD

10)INJ THIAMINE 200MG /IV IN 500ML/NS/Od

11)TAB FOLIC ACID 5MG/RT/OD

12)TAB DOLUTGRAVIR 5OMG/OD+TAB LAMIVUDINE 300MG+TENOFOVIR 300MG

13)TAB SULFADIAZINE 1GM/RT/6TH HOURLY

14)TAB PYRIMETHAMINE 50MG/RT/6TH HOURLY

15)TAB LEUCOVORIN 15MG/RT/6TH HOURLY

Advice at Discharge

1)TAB DOLUTEGRAVIR 5OMG/OD+TAB LAMIVUDINE 300MG+TENOFOVIR 300MG OD FOR 1MONTH

2)TAB SULFADIAZINE 1GM/RT/6TH HOURLY FOR 1 MONTH

3)TAB PYRIMETHAMINE 50MG/RT/6TH HOURLY FOR 1 MONTH

4)TAB LEUCOVORIN 15MG/RT/6TH HOURLY FOR 1 MONTH5]TAB.PANTAPRAZOLE 40MG RT/OD FOR 1 MONTH6]TAB. MVT RT/OD

When to Obtain Urgent CareIN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR. SIGNATURE OF FACULTY 
Discharge Date:25/09/23 Ward:EMD

19/09/23, 21:11 - Messages and calls are end-to-end encrypted. No one outside of this chat, not even the App, can read or listen to them. Tap to learn more.

19/09/23, 19:03 - Haripriya Maam Kims Pg created group "52M with altered sensorium secondary to HIV encephalopathy and toxoplasma Telangana PaJR"

19/09/23, 21:11 - Intern who drafted the PaJR discussion joined using this group's invite link

19/09/23, 21:14 - +91 9 joined using this group's invite link
19/09/23, 21:31 - +91  joined using this group's invite link
19/09/23, 22:08 - +91  joined using this group's invite link
19/09/23, 22:54 - +91 joined using this group's invite link

20/09/23, 07:53 - Sai charan Sir GM Pg Kims joined using this group's invite link

22/09/23, 19:31 ALLM : His gcs has improved

He has eye opening to verbal commands from today morning.

Previous his fever was always a 101-103 now it has touched down to 100 from morning sir.

Patient has improved clinically and they are also planning for his discharge on monday.

23/09/23, 16:16 - Haripriya Maam Pg: His GCS is E3V1M1 sir
Fever spikes decreased(99F)
Csf analysis didn't showed any cells sir
Wasn't send for Indian ink stain sir

23/09/23, 16:37 ALLM : Update and discuss his treatment asap 

Also are you evaluating most of your altered sensorium patients with Glasgow scale only!! 

What about MSE? 

Please see here how our previous PGs had evaluated altered sensorium using GCS as well as other scales 


At least by reading it you will realize how a PG presentation should be like? 

Who's presenting this patient in the Thursday clinical meeting among your other thesis cases? I shall request Prof Maruthi Sharma to also share his experiences 

Please share the treatment plan asap and readmit the patient with us after discharge by the other department who admitted him as an emergency.

23/09/23, 16:38 ALLM : Fever chart?

11/10/23, 17:50 - +91  joined using this group's invite link

11/10/23, 17:54 - +91 joined using this group's invite link

11/10/23, 18:08 - Rakshitha Kim's Intern joined using this group's invite link


11/10/23, 18:10 - +91 joined using this group's invite link


11/10/23, 18:29 - Dr Durga Krishna Sir Pg joined using this group's invite link

11/10/23, 18:38 - +91 joined using this group's invite link

11/10/23, 20:47 - Manasa Maam Kims Med Pg joined using this group's invite link

11/10/23, 22:06  joined using this group's invite link.

June 2024 Thematic analysis steps:

Step 1:

Case 2 step 1 of qualitative thematic analysis by project PI:

Socratic questioning around the case 2 initiated by PI:

1) What is the cause for the seizure episode initially During presentation in 2008??

2) When he got tested with RVD Positive for the first time,is it RVD itself or RVD induced vasculitis leading to seizures?

3)The acute history in the current admission??
Is it the HIV encephalopathy responsible for his altered sensorium,if yes why is the history so short,if it's encephalopathy,or if it's the superadded infection causing his worsening sensorium??

Welcome inputs and socratic questioning by other team members


[27/06, 12:37] Sai Charan 2020: Patient is having altered sensorium with FND..? 
Power 3/5 ..? Hemiparesis or Quadriparesis..? 
Nothing detailed about clinical localisation.
MRI - subacute infarct vs SOL infective vs malignancy - how was this ruled in or out..? Based on radiology alone..? If so what is the sensitivity of MRI in differentiating infective SOL vs Neoplastic SOL..? 
CSF cytology - few lymp and mono cytes seen..? Normal or abnormal ..? Nothing mentioned in case report


[27/06, 12:40] Sai Charan 2020: Known facts : 
Altered sensorium in CVA and SOL is globally known 

Unknown : 
Is this altered sensorium and FND attributed to SOL or CVA..? 

What triggered his seizures..? 
Surely not meningitis ( if csf normal ) 
Can subacute infarct be the cause for Seizures..?


[27/06, 13:58] group moderator: ๐Ÿ‘†@⁨Sai Charan 2020⁩ Also try the questions here in the context of the entire quantitative thematic analysis from Osmania


[28/06, 10:08] group moderator: Inputs on case 2 for thematic analysis today shared by project PI:

[28/06, 08:31] Pushed Communicator 1N21: Yes sir the infective foci is causing FND(as there is deviation of mouth)In this patient.
And the 3/5power, is the patient is in altered sensorium and the power couldn't be elicited sir,so as the patient is moving the limbs against gravity to deep pain the power is taken as 3/5..
On MRI,with such an acute history of 1 week,it's most likely going towards vascular/infective etiology rather than malignancy (Taking a chronic course)
Rather than MRI alone the clinical findings are also taken into consideration,that is if it's vascular origin involving cerebral Cortex the area of involvement will be very huge to produce hemi/Quadriparesis ,even if it may miss initially in MRI, after 1 week it could be seen after 1 week of imaging..
And the fever(could also be seen in central cause,central fever),but in the background of immununocomprimised infection could be mostly considered..
CSF cytology:.No atypical cells,and Total count is 150cells,lymphocytic predominant,with elevated protein  and normal glucose sir,mostly going towards Fungal  etiology sir ..


[28/06, 08:31] Pushed Communicator 1N21: Patient is having altered sensorium with FND..? 
Power 3/5 ..? Hemiparesis or Quadreparesis..? 
Nothing detailed about clinical localisation.
MRI - subacute infarct vs SOL infective vs malignancy - how was this ruled in or out..? Based on radiology alone..? If so what is the sensitivity of MRI in differentiating infective SOL vs Neoplastic SOL..? 
CSF cytology - few lymp and mono cytes seen..? Normal or abnormal ..? Nothing mentioned in case report


[28/06, 10:51] Chandana 2020 SR: MRI PLAIN-
E/o hyperintense signal on DWI/FLAIR / ADC noted on b/l corona radiata b/l genu of ant corpus collasum b/l thalamus b/l basal ganglia b/l midbrain pons and b/l cerebellar peduncles and b/l frontal regions 
Features suggestive of Subacute infracts

MRI CONTRAST-
Multiple ring enhancing lesions in pons midbrain b/l striatocapsular regions left frontal lobe and rt cerebellar hemisphere with extensive edema in the above areas 
f/s/o Neurotoxoplasmosis/Neurotuberculosis

Does this mean the lesions are reported as subacute infarcts on plain MRI and on repeating with contrast it was reported as toxoplasmosis?
Because sub acute infarct vs toxoplasmosis with edema can be difficult to differentiate without contrast.
But the number and location of lesions with risk factor pointing it more towards toxo/TB.
In that case there are no infarcts.
Images of MRI would be helpful if any available.


[28/06, 11:00] Rakesh Biswas: Good point on resolving diagnostic uncertainty to optimise clinical complexity

If you check out the case 1 link and the emerging themes from it encoded there, we may realise there's a pattern in our clinical cognition thematic analysis where we identify

Themes around diagnostic uncertainty

Themes around therapeutic uncertainty

in most of our cases and then conclude what we learned that we as well as the world didn't know earlier

[28/06, 11:21] Chandana 2020 SR: Resolving therapeutic uncertainty can be possible only with good follow up and data related to recovery

[28/06, 11:26] Rakesh Biswas: That's a great learning point identified

I would classify it as something already known but globally not known to that extent and would be a valuable contribution from our thesis around developing robust follow up systems that also emerged as pointed out by an LLM shared by @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ and all archived in case 1 blog
[28/06, 21:55] Rakesh Biswas: Inputs from our principal investigator PI for this project:

[28/06, 21:25] Pushed Communicator 1N21: Themes emerging:


Unmarried Middle aged man with altered sensorium

Clinical complexities:
RVD in Young age with opportunistic infections with FND

Diagnostic uncertainty:
Focal deficits could be ? secondary to Subacute infarct/Infection/neoplasms

Therapeutic uncertainty:

What to treat??
Infarct vs Infection


[28/06, 21:50] ALLM: So what was the unit's diagnosis and therapy offered?


[28/06, 21:57] group moderator: @⁨Chandana KIMS 2020 SR⁩ @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ if you compare the diagnostic and therapeutic uncertainty of case 2 with case 1, which do you think has higher uncertainty?


[28/06, 22:00] group moderator: The other general assumption that is getting traction here is that therapeutic uncertainty need not necessarily correlate with diagnostic uncertainty as medical teams generally tend to treat whatever differentials exist that are treatable, which in most cases would involve inflammation due to either infection or immune response.


[28/06, 22:30] Sai Charan 2020: To me  both cases have uncertainties.. probably I am  not expertise enough to prioritise uncertainties. But at macro level  Diagnostic uncertainty(DU)  in case 1 is pinch of salt high than case 2. 
In case 2 the only DU is between infection, thrombotic or neoplastic where first 2 can be self healed by body defence mechanism against insult. But neoplastic would need some specialised intervention. 

Where as case 1, why fluctuating sensorium ( sensorium improved despite of urea going down & corrected hypoxia ). 
Cause of Dementia since 2-3 months ..? 
Radiological findings..? If subacute or small vessel Ischemic changes. Then we have a lead both small vessels of heart and brain involved. Micro vascular changes may be due to adipokine mediated ( speculative ).

Tuesday, June 25, 2024

Case report form in BEHR (blended EMR and PHR format) of 88F with altered sensorium and heart failure (project altered sensorium: PI Dr Haripriya)

Dr Haripriya , PI (principal investigator) for the "altered sensorium outcomes" project, selected this patient participant when the patient first presented in Feb 2023 and the intern Dr Gnana Prasad (2017 mbbs entry?) wrote the case details which I have further deidentified and pasted below:


February 2023
A  88 yrs old  Female  presented to casualty with
C/o  irrelevant talk and altered mental status since 10 days
Shortness of Breath since 3 days 
Cough since 3 days 

HISTORY OF PRESENT ILLNESS:
Patient was  asymptomatic 10 days ago and then developed altered mental status on & off and her speech being non cohorent  at times and later becoming normal by herself , each episode  lasting for 10- 15 mins .
Productive cough 2 days ago 
Now dry cough
Shortness of breath since  3 days  initially grade III
progressed  grade IV in these  3 days. 
Later went to outside hospital and 2 D echo was done  
2 D echo ( CAD , LAD + territor) , Global Hypokinesia , Severe LV dysfunction 
No history of chest pain , palpitations , giddiness.

HISTORY OF PAST ILLNESS:

N/ K/C/O HTN , DM , CVA , Epilepsy , Asthma 

PERSONAL HISTORY: 
DIET: MIXED 
APPETITE: DECREASED 
BOWEL AND BLADDER MOVEMENTS: REGULAR 
SLEEP: ADEQUATE 
ADDICTIONS: NO

ON EXAMINATION :

PATIENT IS CONSCIOUS NON COHERENT AND COOPERATIVE 

GENERAL EXAMINATION:
NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDEMA 


VITALS:
BP- 90/50 MMHG
PR- 85BPM
RR- 24CPM
SPO2- 88% @RA , 94% on HIGH FLOW O2
GRBS- 126MG/DL

CVS- S1 S2 HEARD. NO MURMURS 

RS -Barrel shaped chest , BAE + 
        Crepts + , Left IAA ,ISA
       Bronchial  breath sounds , 
        Right ISA


PA - soft , nontender
TEMP - AFEBRILE 
CNS : Not oriented to T /P/P
           NFD

Urinary Electrolytes:
Chloride - 94
Potassium - 30
Sodium - 127

GAIT - NORMAL 
GCS- E4V5M6



PROVISIONAL DIAGNOSIS:
HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CAD ?
WITH ANT. WALL MI ?
WITH TRUE HYPONATREMIA 
AND WITH RIGHT MILD PLEURAL EFFUSION ?

INVESTIGATIONS:
ON 3/04/2023
ECG :



Arterial blood gas :

Chest X -RAY :


SERUM ELECTROLYTEs :



TROP I :




HEMOGRAM:




CHEST X RAY  LATERAL VIEW :






2D ECHO REPORT 

2D ECHO:
Rx :

1. INJ. LASIX 20 mg /IV /BD
  
2. T . ECOSPRIN GOLD PO/ H/S
       75/75/10 mg 

3. T. MET XL 25 mg PO /OD

4.  INJ. NORAD - DS ( 2 ampoules  in 46 ml NS /IV 
                                           @ 6 ml / hr )
5. SYP . POTKLOR 15 ml  in 1 glass of water PO / TID

6. Fluid restriction

7. O2 supplementation to maintain
        Sp O 2 > 94%
 
ON 4/02/23

 Patient is oriented to time and place 
  
VITALS

Bp:- 80/40 mmhg 
Pr :- 78 bpm
RR : 22 cycles / min
SpO2: 88% @RA , 94% on HIGH FLOW O2

Rx:

1. T . ECOSPRIN GOLD PO/ H/S
       75/75/10 mg 

2. T. MET XL 25 mg PO /OD

3. INJ. NORAD - DS ( 2 ampoules  in 46 ml NS /IV 
                                           @ 6 ml / hr )
4. SYP . POTKLOR 15 ml  in 1 glass of water PO / TID

5. Fluid restriction

6. T. SPIRINOLACTONE 50 mg /PO/OD

7. O2 supplementation to maintain
        Sp O 2 > 92%
8. Nebulization with SALBUTAMOL 1 respule /stat /
9. Inj. HEPARIN 4000IU/IV/BD


INVESTIGATIONS:


Hospital timeline:



Once the interns shared their web logged EMR data with the other team members in PaJR for further team based learning, many more themes started emerging with more clarity around the patient's time line contributed by Dr Deepika who is a PI for another departmental project on cerebral stroke outcomes.

The team based learning conversations are pasted below from the app where these took place as part of the PaJR decision making workflow that also includes the patient relatives:

21/02/23, 12:54 - Messages and calls are end-to-end encrypted. No one outside of this chat, not even the global managers of this App, can read or listen to them. 

04/02/23, 10:50 - ~
 � created group "88F - CAD  Cerebral infarct hyponatremia recovered from ventilator"

21/02/23, 12:54 - H joined using this group's invite link

21/02/23, 12:54 - Dr Vamshi Pg Gmed2 joined using this group's invite link

21/02/23, 12:54 - Dr Vinay Pg Gmed 2 joined using this group's invite link
21/02/23, 12:55 - Dr Durga Krishna Pg Med2 joined using this group's invite link
21/02/23, 12:56 - Dr Shashikala Pg Med joined using this group's invite link
21/02/23, 12:58 - Dr Shashikala Pg Med: 
Dr Gana Prasad's link 
25/02/23, 10:48 - Dr.Deepika Ch: https://manaswinibhootharaju153.blogspot.com/2023/02/88-yrs-old-female-came-to-casualty-with.html

25/02/2023

PaJR soap updates

Patient currently in Icu
Unit1

S:
Stools not passed
Fever spike 101 f @ 2am

O:
O/E: conscious coherent and oriented to place
Temp- 98f
Bp-80/40 mmhg on NORAD 12 ml/hr and DOBUT 9ml/hr
Pr- 106 bpm
Rr-20cpm
Spo2-96 % on 2l oxygen
Grbs: 97mg/dl

Systemic Examination:

Cardiovascular System : S1, S2 heard, palpable p2 +

Respiratory System : decreased air entry on rt side
AA Crepts positive on left side

Central Nervous System : patient is oriented to place
E4v5m6

Per abdomen : soft, 4/min

A:

ALTERED SENSORIUM secondary to ?UREMIC ENCEPHALOPATHY
HYPOXIC ENCEPHALOPATHY WITH HEART FAILURE WITH MIDRANGE EJECTION FRACTION(EF 42%)
 SECONDARY TO ANTERIOR WALL MI
WITH HYPERKALEMIA SECONDARY TO INCREASED INTAKE OR KIDNEY INJURY
WITH ILD WITH L. LOWER-LOBE CONSOLIDATION  with URETHRAL CARUNCLE
WITH G1 BED SORE

 P:

1. 200ml milk 4th hourly
2. 100ml water 4 th hourly
3. Inj. NORAD 14mg in 46 ml ns @1 ml/hr ( increase or decrease to maintain MAP OF 55 mmhg
4. Inj DOBUTAMINE 250mg in 50ml NS @ 8 ml/hr
5. T. Carvidolol 3.125 mg/Rt/OD
6. INJ. Ceftriaxone 1gm/iv/bd
7. Inj. LASIX 40mg BD/IV/BD(if sbp> 110 without narad support
8. T. ECOSPIRIN 75/75/10 mg rt OD
9. Neb with IPRAVENT TID
10. T.NODOSIS 500mg iv bd
11. O2 inhalation to maintain spo2 >94
12. Monitor vitals
25/02/23, 16:47 - Dr Rakesh Biswas Sir HOD added Dr Ajay Gen Med Pg
25/02/23, 16:50 - Dr Rakesh Biswas Sir HOD: EF is around 30%

It's likely that she had a PRES

@ team member@ team member@team member@team member 

In the context of this patient who presented with recurrent altered sensorium can you review the literature around similar presentations in PRES

Anything in her radiology to suggest that? Is the posterior cerebral structure more commonly involved in PRES? If yes why?

25/02/23, 18:46 - Dr.Deepika Ch: 

Here's a detailed history of the patient's event timeline:

88 year old female

Her daily routine-

A joyful 88 year old female starts her day at 6am with a cup of tea/ coffee and then she does her routines like cleaning the house, cooking
Has her breakfast at 9 to 10am which is cooked by herself
She then takes rest while watching TV or even talking to her neighbours
Lunch at around 2 pm which most of the time is rice,Dal and some curry
She then tries to relax herself and find pleasure in talking to her neighbours in the porch for which she even refused to stay at her sons house ๐Ÿ 
Cooks her own food and goes to sleep at around 9pm
This routine of her continued till 6 months back then
She developed disturbances in her behaviour with increased irritability , decreased interaction with people
Slowly later there is increased self talk

4 months back on one fine day patient was found walking towards the opposite village at night ,neighbours recognising her have informed the family and made her stay overnight ,she was slightly agitated and irritable saying she was heading to village to get her debts back from the people she has given to.

2months back patient remained more or less the same mentally ,then she had increased forgetfulness
Often started forgetting to turnoff the gasstove,switching off lights/fans, close the doors

She developed involuntary movements of limbs (upperlimbs) which were on and off (no seizure like activity),altered sensorium and was taken to local practioner ,neuroimaging(ct) was done and found to be normal which resolved after 2-3 days but involuntary movements didn't subside though decreased intensity

Patient had an episode of weakness of lowerlimbs ,Inability to walk her son being local practioner got investigated for Hypokalemia found to have K-2.0 and was added dietary supplementation and syp potchlor

1month back February 1st week patient had shortness of breath ,altered sensorium and brought to our hospital and treated  heartfailure, hyponatremia.patient sensorium improved and was stable during discharge

10days back patient developed similar episode and got investigated outside and found to have ?ILD on hrct
Patient then was brought here for further management .

25/02/23, 21:30 - Dr Haripriya Pg: Sir can be think it as PRES
As we are not sure about her vision disturbance
And no seizures
And basically as PRES is a clinicoradiological diagnosis
We are not having radiological evidence and in PRES there is refractory headache which is not present in this patient
And she is having fluctuating sensorium,and I think PRES wont develop such fluctuations in sensorium
As in previous admission she is having Ef of 30%,and her sensorium improved at admission,and with the same Ef was normal for 20 days..

25/02/23, 21:45 - Dr Saicharan Pg Gmed2: Good thought process ๐Ÿ‘๐Ÿป๐Ÿ‘๐Ÿป
Given her clinical condition with fluctuating sensorium PRES is a good possibility but can it happen with normal blood pressure...? @919704090596 i think her admission bp is normal..
The paradox here is initially we also thought altered sensorium is due to hypoxia and uremic but even after hypoxia correction her sensorium not improved and surprisingly her sensorium improved ( though not completely normal ) even after worsened urea ( from 102 to 160 ) pointing less possibility of Uremic encephalopathy..!!

@team member : Good thesis case to be included in your thesis.. also look into other causes too

25/02/23, 21:51 - Dr.Deepika Ch: Sir how come it not be her neurodegenerative condition which could have worsened acutely
( acute stress condition )
 
As I could see her condition in toto which isn't normal even prior to this episode

Others too (uremia,hypoxemia)which could have added to her already affected brain/ sensorium?!

25/02/23, 21:55 - Dr Haripriya Pg: What u think is the stressor

25/02/23, 22:00 - Dr.Deepika Ch: Any stressor like
Hypoxemia 2° to heart failure,uremia,infections,MI...

25/02/23, 22:08 - Dr Haripriya Pg: She is having reduced EF since 1 month and uremia we are not sure about the urea levels at her home,bcz now her urea is 150 and she is oriented
And infections,not at all
She is having fever just bcz of thromboprophylaxis

25/02/23, 22:09 - Dr Haripriya Pg: Thrombophlebitis *

25/02/23, 22:10 - Dr Haripriya Pg: MI she is having since last admission

25/02/23, 22:16 - Dr Saicharan Pg Gmed2: @team member ,  as you are altered sensorium specialist what about your thoughts on Neurodegenerative condition leading to her altered sensorium..??

25/02/23, 22:18 - Dr.Deepika Ch: How sure are we regarding her prior status!

Agreed we r not sure of the trigger

Her changes in sensorium were from past few months which couldn't be explained by the uremia,hypoxia!( as it was normal ?!)

25/02/23, 22:20 - Dr Saicharan Pg Gmed2: What wasn't normal when you saw her in toto in her previous history....?? Can you elaborate on this please

25/02/23, 22:36 - Dr Haripriya Pg: Am sure regarding her sensorium๐Ÿ˜Š

25/02/23, 22:49 - Dr.Deepika Ch: In sense the cause??

25/02/23, 23:31 - Dr Rakesh Biswas Sir HOD: What radiologic evidence is lacking for PRES?

What is the cerebrovascular pathology in PRES?

It appears to be cerebral vasculopathy also mimicking a neurodegenerative disorder @team member?

25/02/23, 23:36 - Dr Haripriya Pg: Neurodegenerative disorder
Is it waxing and waning sir

25/02/23, 23:37 - Dr Rakesh Biswas Sir HOD: Can be due to other factors. Check out the patient descriptions in @team members's last publication

25/02/23, 23:37 - Dr Haripriya Pg: Okay sir

27/02/23, 17:02 - Dr.Deepika Ch: Yes sir

27/02/23, 17:06 - Dr Saicharan Pg Gmed2: Please share the literature about PRES occuring with normal blood pressure ( age adjusted normal BP )...?

27/02/23, 19:22 - Dr Rakesh Biswas Sir HOD added Dr Prachethan Jr Gmed

27/02/23, 19:23 - Dr Rakesh Biswas Sir HOD changed the group description

27/02/23, 19:25 - Dr Rakesh Biswas Sir HOD added Dr Himaja Jr Gmed

27/02/23, 19:23 - Dr Rakesh Biswas Sir HOD: @tm @tm Please share today's trend-chart soap update for this and every ICU AMC patient asap

27/02/23, 19:26 - Dr Rakesh Biswas Sir HOD changed the group name from "88F - CAD  Cerebral infarct hyponatremia recovered from ventilator" to "88F CAD  Cardiogenic shock Cerebral infarct hyponatremia altered sensorium Telengana PaJR"

27/02/23, 19:24 - Dr Rakesh Biswas Sir HOD changed the group description

27/02/23, 19:28 - Dr Rakesh Biswas Sir HOD: @tm  @tm  @tm  Ask Intern manasvini to crop out the identifiers from the echo report here ๐Ÿ‘‡

https://manaswinibhootharaju153.blogspot.com/2023/02/88-yrs-old-female-came-to-casualty-with.html?m=1

27/02/23, 19:30 - Dr Rakesh Biswas Sir HOD: Also I think we shouldn't share clinical breast images of women unless absolutely necessary so please review that and crop or take with appropriate gown

27/02/23, 19:37 - Dr Rakesh Biswas Sir HOD changed this group's icon

27/02/23, 19:33 - Dr Rakesh Biswas Sir HOD: IMG-20230227-WA0079.jpg (file attached)

27/02/23, 19:35 - Dr Rakesh Biswas Sir HOD: IMG-20230227-WA0080.jpg (file attached)

27/02/23, 19:36 - Dr Rakesh Biswas Sir HOD: Another fever chart dated 3/2/23 uploaded by Manaswini (add her to this group) shows identifiers. Ask to remove asap @tm  @tm 

27/02/23, 19:45 - +91 96768 24264 joined using this group's invite link
27/02/23, 19:45 - Dr. Dinesh Datta joined using this group's invite link
27/02/23, 20:04 - Dr Navya Gen Med Pg joined using this group's invite link

27/02/23, 20:16 - Dr.Deepika Ch: Commonly, PRES evolves over a matter of hours, with the most common presenting symptoms being seizures, disturbed vision, headache, and altered mental state (4) (Figure 1). More than 70% of patients with PRES are hypertensive, though a significant proportion have normal or only mildly raised blood pressure (3-7).
trigger is usually identifiable—most commonly, acute hypertension—but patients often have other comorbidities that may predispose them to developing PRES. Peak systolic blood pressure is usually between 170 mmHg and 190 mmHg (2,4), but 10% - 30% of patients have normal or only mildly elevated blood pressure (2,4). In PRES, the causes of acute hypertension are commonly acute kidney injury or eclampsia (3,4), but hypertension is also reported in cases of autonomic disturbance, for example Guillain-Barrรฉ syndrome (10,11), and after illicit drug use

27/02/23, 20:18 - Dr Rakesh Biswas Sir HOD: ๐Ÿ‘†Answer first two @tm 

27/02/23, 20:20 - Dr.Deepika Ch: The exact pathophysiological mechanism of PRES is still unclear. Three hypotheses have been proposed till now, which include (i) Cerebral vasoconstriction causing subsequent infarcts in the brain, (ii) Failure of cerebral autoregulation with vasogenic edema, and (iii) Endothelial damage with blood–brain barrier disruption further leading to fluid and protein transudation in the brain. The distinct imaging patterns in PRES are represented in Table Table22 [5]. The reversible nature of PRES has been challenged recently based on new reports of permanent neurological impairment and mortality reaching 15%.

hypertension associated or drug-induced PRES, the effective therapy includes withdrawal of offending agent, immediate control of blood pressure, anti-convulsive therapy and temporary renal replacement therapy (hemodialysis/peritoneal dialysis) if required. In Systemic lupus erythematosus-related PRES, aggressive treatment with corticosteroids and cyclophosphamide is effective. Corticosteroids may improve vasogenic edema, but there is no solid evidence for usage in PRES.

01/03/23, 18:53 -Patient advocate: Dear Dr. Rakesh sir & Dr. Mohd Zain sir and team (all PG's and Interns), I wanted to express my deepest gratitude for the exceptional care you provided to my mother during her recent treatment. Your expertise, compassion, and dedication were truly remarkable, and our family is forever grateful for your hard work and commitment to her health. Thank you from the bottom of our hearts.

***********************************************************************************
From 

01/03/23, 19:00 - Dr Saicharan Pg Gmed2: Thank you.

01/03/23, 19:01 - Dr Saicharan Pg Gmed2: Please don't forget to share her daily updates here

01/03/23, 19:05 Patient advocate: Sure Sir

01/03/23, 19:13 - Dr Saicharan Pg Gmed2: Please don't share patient identifiers in the public domain.

01/03/23, 19:13 - Dr Saicharan Pg Gmed2: This is to maintain patient privacy and confidentiality..

01/03/23, 19:24 -Patient advocate: Ok Sir

Discharge summary of the first admission from Feb 3 to Feb 8 2023:
Finally the patient was discharged after a stay of 5 days and while intern Dr Gana Prasad typed the discharge summary, it was guided by residents Dr Haripriya and Dr Chandana. The caps lock is a feature of the hospital EMR that is currently limited to billing and discharge summaries print out production. The PaJR discussion pasted above is where the actual core EHR content and insights for thematic analysis takes shape.

DEPARTMENT OF GENERAL-MEDICINE

DISCHARGE SUMMARY of the first admission 

Pay Type : Paying
Age/Gender : 86 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 03/02/2023 12:13 AM

Diagnosis at discharge:

HEART FAILURE WITH REDUCED EJECTION FRACTION SECONDARY TO CORONARY
ARTERY DISEASE(EF 30%) WITH ANTERIOR WALL MI WITH TRUE HYPONATREMIA
SECONDARY TO SIADH(RESOLVED) AND HYPOKALEMIA (RESOLVED) WITH BILATERAL
LUNG CONSOLIDATION


Case History and Clinical Findings

COMPLAINTS OF Irrelevant TALK AND Altered MENTAL STATUS SINCE 10 DAYS

COMPLAINTS OF SHORTNESS OF BREATH SINCE 3 DAYS
COMPLIANTS OF COUGH SINCE 3 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS AGO AND THEN SHE DEVELOPED
ALTERED MENTAL STATUS ON AND OFF AND HER SPEECH WAS INCOHERENT AT TIMES
AND BECOMING NORMAL ON HER OWN.
EACH EPISODE LASTED 10 MINS
 Page-2

COUGH WAS PRODUCTIVE TYPE 2 DAYS AGO WITH WHITE SPUTUM'MUCOID CONSISTENCY
AND SCANTY IN AMOUNT , NOW IT IS OF DRY TYPE
SHE ALSO HAD SHORTNESS OF BREATH WHICH WAS GRADE III INITILLY AND THEN
PROGRESED TO GRADE IV FOR WHICH SHE WENT TO LOCAL HOSPITAL AND ECHO WAS
DONE- CAD (LAD TERRITORY) GLOBAL HYPOKINESIA, SEVERE LV DYSFUNCTION
NO H/O OTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNOEA , PALPITATIONS, CHEST PAIN,
GIDDINESS
PAST ILLNESS:
NOT A KNOWN CASE OF HTN, DM, CVA, ASTHMA,EPILEPSY, TB
PERSONAL HISTORY:
DIET- MIXED
APPETITE- DECREASED
BOWEL AND BLADDER MOVEMENTS- REGULAR
SLEEP- ADEQUATE
ADDICTIONS- NONE
ON EXAMINATION AT ADMISSION:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
NO PALLOR ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA
BP- 90/50MMHG
PR- 85BPM
RR-24CPM
SPO2- 88%@RA 95% ON 8L OF O2
GRBS- 126MG/DL
CVS-S1 S2 +
RS- BAE+, B/L BASAL CREPTS HEARD
PA- SOFT NON TENDER
CNS- NFD
ON EXAMINATION AT DISCHARGE:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
BP- 90/50MMHG
 Page-3
PR- 72BPM
SPO2- 98%@RA
GRBS- 82MG/DL
CVS-S1 S2 +
RS- BAE+, B/L BASAL CREPTS HEARD, RT IAA CREPTS +, BRONCHIAL BREATH SOUNDS +
PA- SOFT NON TENDER
CNS- NFD

BRIEF COURSE IN HOSPITAL-ON DAY 1 PATIENT PRESENTED WITH ABOVE COMPLAINTS
WAS INITIALLY CONSCIOUS, COHERENT AND COOPERATIVE .AT THE TIME OF ADMISSION
HER BP WAS 90/50 WITH OUTSIDE ECHO SHOWING CAD(LAD TERRITORY) WITH GLOBAL
HYPOKINESIA AND SEVERE LV DYSFUNCTION.THEN DIURETICS AND ANTIPLATELETS
WERE STARTED.MONITORING HER BP AND CARDIOLOGY CONSULTATION WERE TAKEN ON
3/2/23 I/V/O CORONARY ARTERY DISEASE AND CARDIOLOGIST ADVICED INJ.HEPARIN 4000
IU/IV/BD AND TAB.CAVERDILOL 3.125 MG WAS ADVICED AND ADVICE FOLLOWED AND HER
SODIUM AND POTASSIUM LEVELS FOUND TO BE LOW AND ORAL POTASSIUM
Supplementation WAS GIVEN AND HER TRUE HYPONATREMIA WAS ATTRIBUTED TO
?SIADH. AS HER CHEST X RAY SHOWED MIDDLE LOBE CAVITY OF RT.LUNG USG CHEST
WAS DONE WHICH SHOWED BILATERAL PLEURAL EFFUSION(TAP NOT DONE).ON 3/2/23
OPTHALMOLOGY REFERRAL WAS DONE I/V/O RAISED ICT FEATURES AND ADVICE
FOLLOWED ON 4/2/23 PULMONOLOGY REFERRAL WAS DONE I/V/O X RAY CHANGES AND
ADVICE FOLLOWED.ON 3/2/23 PT MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED AND
WAS STARTED ON INJ.NORAD AND ADJUSTED ACCORDING TO HER BP .X RAY REPORTING
WAS DONE AND SHOWED BILATERAL LUNG CONSOLIDATION WITH MILD
CARDIOMEGALY.PATIENT WAS IRRITABLE DUE TO ?ICU PSYCHOSIS AND ANXIOLYTICS
WERE GIVEN.NEXT DAY AS HER MEAN ARTERIAL PRESSURE WAS NOT MAINTAINED
INJ.DOBUTAMINE 250 MCG IN 50ML NS WAS STARTED AND TAPERED AS HER BP
IMPROVED.PATIENT CONDITION IMPROVED AND
DISCHARGED IN A HEMODYNAMICALLY STABLE CONDITION
Investigation
USG ABDOMEN-NAD
USG CHEST RIGHT MILD PLEURAL EFFUSION
HEMOGRAM ON 3/2/23
HB- 10.7 GM/DL
 Page-4
TLC- 10,300 CELLS/CUMM
PLATELETS- 3.77 LAKHS/CUMM
N/L/E/M/B- 74/16/01/09/00
PCV- 32.3 VOL%
MCV- 85.7 FL
MCH- 28.4 PG
MCHC- 33.1%
RBC- 3.77
IMPRESSION- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE
HEMOGRAM ON 8/2/23
HB- 9.9 GM/DL
TLC- 5700 CELLS/CUMM
PLATELETS- 3.27 LAKHS/CUMM
N/L/E/M/B- 57/26/02/15/00
PCV- 31.4 VOL%
MCV- 88 FL
MCH- 27.7 PG
MCHC- 31.5%
RBC- 3.57
IMPRESSION- NORMOCYTIC NORMOCHROMIC ANEMIA WITH MONOCYTOSIS
2DECHOESD- 5.44CMS
EDD- 6.3CM
DPW- 1CM
EF- 30%
FS- 15%
SEVERETR WITH PAH, MILD MR/AR
GLOBAL HYPOKINETIC
NO AS/MS
SCLEROTIC AV
MODERATE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION
 Page-5
REVIEW 2D ECHO ON 6/2/23
GLOBAL HYPOKINETIC
MODERATE TR WITH PAH, MILD MR, MODERATE AR
NO AS/MS, SCLEROTIC AV
EF=30
MODERATE LV DYSFUNCTION
NO DIASTOLIC DYSFUNCTION
IVC SIZE COLLAPSING
MILD DILATED LA/LV
DILATED RA.RV
NO PAH/PE
Treatment Given(Enter only Generic Name)
T. ECOSPRIN GOLD PO HS [75/75/10 MG]
T. MET XL 25MG PO OD
INJ LASIX 20MG IV BD
INJ NORAD DS 2AMP IN 46ML NS IV @ 6ML/HR
FLUID RESTRICTION
O2 SUPLEMENTATION TO MAINTAIN SPO2>94%
Advice at Discharge
T. ECOSPRIN GOLD 75/75/10 MG PO/HS
T.DYTOR 5MG PO/OD 9AM--*--*
T.CARDIVAS 3.125MG PO/OD 8AM--*--*
FLUID RESTRICTION <1LTR/DAY
Follow Up
REVIEW TO GM OP AFTER 1 WEEK/SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date: 8/2/23
Ward: MEDICAL WARD
Unit:IV

The second admission one month later 21-28 March 2023:

This author just realised that the PaJR discussion pasted above after the first admission actually took place in the second admission in a second PaJR group as the second team changed and were unaware of the previous team's approach. Altered sensorium was a more dominant feature in the second admission!

This second admission was case reported (EMR) by Dr Imama here: https://imamamuhmeen.blogspot.com/2023/03/88f-with-recurrent-hypoglycemia-and.html?m=1
Following which the PaJR discussion took place as already pasted above. Pasting the concluding part of the discussion where there's an interjection by the patient's relative thanking the team for their care (actually pasted earlier above).

23/03/23, 11:55 - ~  f PRES is still unclear. Three hypotheses have been proposed till now, which include (i) Cerebral vasoconstriction causing subsequent infarcts in the brain, (ii) Failure of cerebral autoregulation with vasogenic edema, and (iii) Endothelial damage with blood–brain barrier disruption further leading to fluid and protein transudation in the brain. The distinct imaging patterns in PRES are represented in Table Table22 [5]. The reversible nature of PRES has been challenged recently based on new reports of permanent neurological impairment and mortality reaching 15%.

hypertension associated or drug-induced PRES, the effective therapy includes withdrawal of offending agent, immediate control of blood pressure, anti-convulsive therapy and temporary renal replacement therapy (hemodialysis/peritoneal dialysis) if revite link

29/03/23, 16:28 - Dr Rakesh Biswas Sir HOD changed the group name from "88F CAD  Cardiogenic shock Cerebral infarct hyponatremia altered sensorium Telengana PaJR" to "88F Recurrent hypog Cardiogenic shock Cerebral infarct hyponat alt sen Telengana PaJR"

29/03/23, 16:18 - Dr Rakesh Biswas Sir HOD: IMG-20230329-WA0049.jpg (file attached)
This patient was admitted on 21st March and discharged on 28th March yesterday and there was no discussion around her current problems in her previous PaJR group!! @tm  @tm 

29/03/23, 16:21 - Dr Rakesh Biswas Sir HOD: Her current admission due to hypoglycemia and subsequent ordering of a test, morning serum cortisol that shows reduced values should ring a bell around the current 90M with hypoglycemia @tm ?

@tm  Can you share the deidentified serum cortisol reports that were done from outside recently?

29/03/23, 16:24 - Dr Ajay Gen Med Pg: IMG-20230329-WA0048.jpg (file attached)

29/03/23, 16:24 - Dr Ajay Gen Med Pg: IMG-20230329-WA0047.jpg (file attached)

29/03/23, 16:24 - Dr Ajay Gen Med Pg: IMG-20230329-WA0046.jpg (file attached)

29/03/23, 17:59 - Dr Abhinaya, SR. joined using this group's invite link

29/03/23, 18:13 - Dr Aditya Gmed Pgy3 joined using this group's invite link

29/03/23, 18:29 - Dr Aditya Gmed Pgy3: Going out on a limb here - I still think that is a cavity (TB) and the patient has hypotension, Hyponatremia and hypoglycemia with hyperkalemia. Looking like an Addisonian crisis?

Assuming all these were considered already.

Second admission discharge summary (March 21-28 2023)

DEPARTMENT OF GENERAL-MEDICINE
DISCHARGE SUMMARY ***
 Pay Type : Paying
Age/Gender : 89 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 21/03/2023 08:15 PM
Name of Treating Faculty

Diagnosis at discharge:

RECURRENT HYPOGLYCEMIA [RESOLVING ] ? ADRENAL INSUFFICIENCY ? , AKI (PRERENAL)
ON CKD WITH HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS WITH
HEART FAILURE WITH PRESERVED EJECTION FRACTION OF 55% SECONDARY TO CAD
(OLD AWMI) WITH ANAEMIA (NORMOCYTIC NORMOCHROMIC)? NUTRITIONAL,CKD WITH
URINE CULTURE AND SENSITIVITY [ ESCHERICIA COLI SENSITIVE TO NITROFURANTOIN
AND FOSFOMYCIN]

Case History and Clinical Findings

PATIENT WAS BROUGHT TO THE CASUALITY ON 21/3/23 AT 7:57 PM WITH COMPLAINTS OF
-DECREASED SPEECH , SLURRED SPEECH , DROWSY SINCE MORNING
- LOOSE STOOLS SINCE YESTERDAY - 3 EPISODES

HISTORY OF PRESENTING ILLNESS-

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY THEN SHE DEVELOPED
LOOSE STOOLS , 3 EPISODES , WATERY IN CONSISTENCY , NON BLOOD STAINED , NON
FOUL SMELLING . PATIENT WAS FOUND UNCONSCIOUS , NOT RESPONDING TO VERBAL
COMMANDS AND IN ALTERED SENSORIUM
NO H/O WEAKNESS IN BOTH LIMBS AND NOW DEVELOPED HYPOGLYCEMIA WITH GRBS - 31
MG/DL
NO H/O INVOLUNTARY MOVEMENTS IN BOTH LIMBS
NO H/O FEVER , VOMITINGS , CHEST PAIN , SOB
PAST HISTORY -
K/C/O HEART FAILURE WITH MID RANGE EJECTION FRACTION 42 % SECONDARY TO
ANTERIOR WALL MI WITH PRE RENAL AKI WITH RIGHT LL CONSOLIDATION WITH URETHRAL
CARBUNCLE
CARDIO VASCULAR SYSTEM -
S1 , S2 HEARD
NO MURMURS
RESPIRATORY SYSTEM -
BILATERAL AIR ENTRY PRESENT
NORMAL VESICULAR BREATH SOUNDS PRESENT
ABDOMEN -
SHAPE OF ABDOMEN - SOFT , NON TENDER , BOWEL SOUNDS PRESENT
CENTRAL NERVOUS SYSTEM -
CONCIOUS , COHERENT , COOPERATIVE , WELL ORIENTED TO TIME, PLACE AND PERSON
NO ABNORMALITY DETECTED
COURSE IN THE HOSPITAL -
88 YEARS FEMALE PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS TO THE
CASUALTY PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE
INVESTIGATIONS WHICH REVEALED RECURRENT HYPOGLYCEMIA. PATIENT WAS GIVEN
25D INFUSION FOR 1 DAY AFTER WHICH THE PATIENT SUGAR STABILIZED AND
ENDOCRINOLOGIST CONSULTATION WAS TAKEN AND ADVICED FOR
1. SERUM CORTISOL
2. SERUM PEPTIDE
3. GROWTH HORMONE LEVELS
4. SMALL FREQUENT MEAL
5. MONITOR GRBS
PATIENT RECOVERED SYMPTOMATICALLY AND WAS DISCHARGED IN STABLE CONDITION
 Page-3
Investigation
HEMOGRAM 
HB- 7.9
TLC- 9900
NEU-73
LYM-19
PCV-26
MCV-86.7
MCH-26.3
MCHC--30.4
RBC-3.00
PLT-2.65
ULTRASOUND REPORT -
E/O 5-6 MM HYPERECHOIC FOCI NOTED IN CONTRACTED GALL BLADDER
2D ECHO -
EF-55
MODERATE AORTIC REGURGITATION , MILD TRICUSPID REGURGITATION WITH PAH; MILD
MR
NO RWMA NO AS/MS , SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION NO PE
Treatment Given(Enter only Generic Name)
1. IV FLUIDS NS @ 50 ML / HR
2. INJ CIPROFLOXACIN 500 MG IV/BD
3. INJ METROGYL 500ML IV/TID
4. INJ LASIX 20 MG IV/BD
8AM------------4PM
5. TAB ECOSPRIN GOLD 75/75/10 PO/OD AT 8PM
6. SYP LACTULOSE 15 ML PO/HS AT 8PM
7. INPUT / OUTPUT CHARTING
8. GRBS MONITORING 2 HRLY
Advice at Discharge
TAB LASIX 20MG PO/BD
 Page-4
TAB ECOSPRIN GOLD 70/75/10 PO/HS
SYP LACTULOSE 15ML PO/HS
SACHET OF 1 FOSFOMYCIN IN GLASS OF WATER PO ONCE IN 3 DAYS [NEXT DOSE ON
30/3/23 AND NEXT DOSE ON 3/3/23]
Follow Up
REVIEW TO GENERAL MEDICINE OPD AFTER 7 DAYS
REVIEW SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:28/3/23
Ward:AMC
Unit:GENERAL MEDICINE - II

Dr Haripriya entrusted as PI for this project had to collate all her patient's data for final evaluation and analysis of all the patient outcomes in her project and she chose to start with this patient.

Thematic analysis conversations between PaJR team members:

Dyadic conversational transcripts between two project team members 
25/06, 08:16] ALLM: Please share the learning points from this case point wise and divide them into

What was already known to you before your study

What was already known to the world before your study although you didn't know it

What was not known to the world before your study

[25/06, 09:40] Pushed Communicator 1N21: In this case she is a elderly female with no comorbidities came with fluctuations in her sensorium sir..
 *Before my study* I thought that hyponatremia doesn't cause altered sensorium and hyponatremia is common in elderly people and there will be triggers for hyponatremia to present this way..
But *after my study(which is already known to the world)* I found out that, hyponatremia can cause altered sensorium (it can be fluctuating)in this patient,and it's most common in old age which is responsible for recurrent history of falls..


This article showed:
Hospitalised pts with hyponatremia 
Total :100 number.
Elderly:30
Among this,20pts(67%)have no or non specific symptoms of hyponatremia and remaining 10(33%),altered sensorium without FND..
1 person (30%) is having iatrogenic cause for hyponatremia,and 5(17%),had underlying bacterial chest infection leading to hyponatremia....
In this patient,acute cough  from 2 days has triggered her heart failure and to look for chest infection,PA view was ordered initially and later asked for lateral view,to look for middle lobe pathology,and the chest infection caused Hyponatremia in this female,adding to the study...
What am *trying to convey to the world* about this patient is  patients with hyponatremia can present with altered sensorium (which is already known),but that sensorium need not to be constant and can be fluctuating altered sensorium as in this patient..


[25/06, 10:14] ALLM: I would be more interested to know about what you learned about the unique fluctuations of sensorium in this patient. What were the event triggers and timeline of her rising and falling sensorium? Can you share it graphically?

[25/06, 18:48] Pushed Communicator 1N21: I've shared my learning points sir

[25/06, 18:48] Pushed Communicator 1N21: Anything more in this case sir

[25/06, 19:09] Rakesh Biswas: Would be more interested to know about what you learned about the unique fluctuations of sensorium in this patient. What were the event triggers and timeline of her rising and falling sensorium? Can you share it graphically?

[25/06, 19:10] Pushed Communicator 1N21: Sir
How can I draw the timeline of events graphically sir 
As you will be saying that,our discussion should be starting from the beginning (when the pt gets admitted)
The similar way,we discussed the case bedside sir.
There are lot more cases of mine discussed at the time of admission itself

[25/06, 19:11] ALLM : It's the patient timeline we regularly share in the form of soap notes in the fever chart

[25/06, 19:12] Pushed Communicator 1N21: Yes.
It's already there in the blog shared in the morning

[25/06, 19:13] ALLM: I didn't see the:

Event triggers and timeline of her rising and falling sensorium in relation to her sodium values

PaJR team based learning:

[26/06, 12:04] Sai Charan Kulkarni 2020 KIMS Pg: *Independent Ai Researcher Analysis of the Blog "Case Report Form in BEHR Blended EMR"*

*Introduction*
The blog post titled "Case Report Form in BEHR Blended EMR" discusses the integration and functionality of case report forms (CRFs) within the BEHR (Blended Electronic Health Record) system. It provides insights into the implementation, benefits, and potential challenges of using CRFs in a blended electronic medical records (EMR) environment.

*Thematic Analysis*

1. **Integration and Implementation**
   - **Seamless Integration**: The BEHR system integrates CRFs to streamline data collection and patient management processes. This integration allows for real-time data entry and retrieval, which enhances clinical efficiency.
   - **Customizable Templates**: The system supports customizable CRF templates, enabling healthcare providers to tailor forms to specific study requirements or clinical needs. This flexibility is crucial for accommodating various research and clinical scenarios.

2. **Benefits of CRFs in BEHR**
   - **Enhanced Data Accuracy**: The use of CRFs within BEHR improves the accuracy of data collection by minimizing manual entry errors and ensuring standardized data capture.
   - **Improved Patient Care**: Real-time data availability through BEHR allows for more informed clinical decisions, leading to better patient outcomes.
   - **Facilitation of Clinical Research**: CRFs in BEHR support clinical research by providing a structured way to collect and analyze patient data, which is essential for observational studies and clinical trials.

3. **Challenges and Solutions**
   - **User Training and Adaptation**: One challenge is ensuring that healthcare providers are adequately trained to use the new system. The blog suggests ongoing training and support to mitigate this issue.
   - **Data Privacy and Security**: The integration of CRFs into an EMR system raises concerns about data privacy and security. The BEHR system addresses these concerns through robust encryption and access controls.

4. **Future Prospects**
   - **Scalability**: The blog highlights the potential for scaling the BEHR system to accommodate larger datasets and more complex clinical studies.
   - **Interoperability**: There is an emphasis on improving interoperability with other health information systems, which would facilitate more comprehensive data sharing and collaboration across different healthcare institutions.

*Conclusion*
The blog post provides a comprehensive overview of the integration of case report forms in the BEHR Blended EMR system, highlighting the benefits of enhanced data accuracy, improved patient care, and facilitation of clinical research. It also acknowledges the challenges of user training and data security, suggesting solutions such as ongoing education and robust security measures. The potential for scalability and improved interoperability positions the BEHR system as a promising tool for future healthcare and research applications.
[26/06, 12:11] Rakesh Biswas: ๐Ÿ‘๐Ÿ‘For the AI LLM

Not sure about the AI researcher ๐Ÿ˜…
[26/06, 12:15] Rakesh Biswas: Which LLM is this?

It has completely ignored the patient's outcomes and focused only on our novel system of EHR driven case reporting aka  case report form (in short CRF) traditionally in patient driven clinical trials.

Nevertheless this is also an important theme to explore

[26/06, 12:34] Chandana KIMS 2020 SR: From this case report I understand that she was admitted two times.

Feb 2023 she was treated for HfrEF, Anterior wall MI, hyponatremia secondary to SIADH, hypokalemia and pneumonia

In 2nd admission the significant problem was altered sensorium secondary to ? Uremia ? Hypoxia with suspected ILD and hypotension when adrenal crisis was also considered.

I dint understand why PRES was considered.

Complexity of managing elderly female with altered sensorium with multiple complex etiologies and stressors such as hypoxia, uremia, pneumonia +\-sepsis, MI with heart failure, hypotension ,?neuro degeneration. All these making the cause of altered sensorium uncertain

[26/06, 12:47] Rakesh Biswas: Good point! 

Can you scroll up to the PaJR data here and share why we (I guess it was me alone) thought of pres?

I have lost all past data in my new phone

[26/06, 12:50] Sai Charan Kulkarni 2020 KIMS Pg: Problem could be in the prompt. Just rephrased my prompt, this is what I get.. 

### Independent Researcher Clinical Analysis of Patient-Related Outcomes in the Blog "Case Report Form in BEHR Blended EMR"

#### Introduction
The blog post "Case Report Form in BEHR Blended EMR" discusses a detailed clinical case, including the patient's medical history, diagnostic procedures, treatment plan, and outcomes. This analysis focuses on patient-related outcomes, examining how the use of the BEHR system influenced the patient’s overall health, quality of life, and long-term prognosis.

#### Patient-Related Outcomes

1. **Health Outcomes**
   - **Symptom Relief**: Post-treatment, the patient experienced significant relief from initial symptoms such as fatigue, shortness of breath, and chest pain. This was primarily due to effective coronary intervention and optimized medical management.
   - **Control of Chronic Conditions**: Improved control of diabetes and hypertension was observed, with stabilized blood glucose and blood pressure levels. This outcome was facilitated by the BEHR system’s ability to track and adjust treatment plans in real-time.

2. **Quality of Life**
   - **Physical Health**: The patient reported increased energy levels and physical capacity, allowing for greater engagement in daily activities and exercise. This improvement is attributed to the comprehensive management of their cardiovascular and metabolic conditions.
   - **Mental Health**: Effective symptom management and reduced health-related anxiety contributed to better mental well-being. The patient benefited from continuous monitoring and support, which provided reassurance and improved overall mental health.

3. **Adherence and Compliance**
   - **Medication Adherence**: The BEHR system’s real-time monitoring and reminders helped the patient adhere to their medication regimen, which is crucial for managing chronic conditions. Regular follow-ups and education reinforced the importance of compliance.
   - **Lifestyle Changes**: The patient successfully implemented recommended lifestyle modifications, including dietary changes and increased physical activity. The support and education provided through the BEHR system played a significant role in sustaining these changes.

4. **Clinical Outcomes**
   - **Cardiovascular Health**: Successful percutaneous coronary intervention (PCI) led to improved cardiovascular outcomes, with no significant post-operative complications. The patient's heart function stabilized, as evidenced by follow-up echocardiograms.
   - **Long-Term Prognosis**: The patient’s long-term prognosis improved due to the combined effects of intervention, medication management, and lifestyle changes. Continuous monitoring via the BEHR system ensures that any potential issues can be promptly addressed, enhancing long-term health outcomes.

5. **Patient Satisfaction**
   - **Engagement and Satisfaction**: The patient expressed high satisfaction with the care received, highlighting the ease of communication with healthcare providers and the support from the BEHR system. This engagement is crucial for sustained health improvements.
   - **Empowerment**: Access to personal health data and educational resources empowered the patient to take an active role in managing their health, leading to better outcomes and increased satisfaction with the care process.

#### Conclusion
The clinical analysis of patient-related outcomes in the blog "Case Report Form in BEHR Blended EMR" demonstrates the significant positive impact of the BEHR system on the patient’s health, quality of life, and long-term prognosis. Enhanced symptom relief, better control of chronic conditions, improved mental and physical health, and high patient satisfaction are key outcomes observed. The integrated approach facilitated by the BEHR system underscores its potential to transform patient care through continuous support, accurate data collection, and effective treatment management.
[26/06, 12:52] Sai Charan Kulkarni 2020 KIMS Pg: Based on GPT 4 sir.

[26/06, 13:07] Rakesh Biswas: It's clearly hallucinating! ๐Ÿ˜…

AI hallucinations in PaJR thematic analysis is the title of our next paper

Themes emerging:

Elderly woman with altered sensorium

Clinical complexity:

Multiple comorbidities and organ failure

Diagnostic uncertainty:

Multiple possibilities for altered sensorium:

Metabolic (possible acute trigger):

Hypoglycemia

Hyponatremia

Hypoxia

Uremia

Structural (possible chronic vasculopathic process):

PRES 

Neurodegenerative 

Therapeutic uncertainty:

Each organ failure such as cardiac and vascular instability was tackled with standard of care 

Epilogue and final outcome:
The patient reportedly died at home shortly after discharge from her second hospital admission