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
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