37M Snake bite
Following is the view of my case
37 year old male born in 1986 in Medak district by normal delivery.
Milestones achieved normal
Was born in lower socioeconomic status.
Father of four children.
Studied till 2nd standard and then joined his father for work to earn money from childhood.
Got married in 2008. Consagious wedding. In 2009 first child (daughter) was born.
He worked as a daily wage labourer till 2009 and moved to Hyderabad in 2010 and started working as garbage collector .
In 2010 second child was born (daughter).
Daily routine past : wakes up by 4am freshen up and go to work, have breakfast at work station provided for free. Come back home at 10.30 am have a cup of tea. Lunch at 11.30am. Relaxes for sometime and steps out of home to collect papers.
At 6.30pm comes back home and have one glass of beer and one glass toddy initially and later increased to two bottles of beer and quarter of alcohol. Have dinner and go to bed by 8.30pm.
Started consuming alcohol due to peer pressure after moving to city.
Social relations with family and friends were good.
In 2013 he had his third child (son).
He went to his village in Medak district to collect ration rice provided for free by the government. On one fine evening around 7pm he went to the fields to empty his bladder and stepped on a snake (?russel viper) which bit his leg. He lost consciousness and doesn’t remember anything. Bystanders told him that he vomited, passed urine and stools in his clothes, swelling of left lower limb and was taken him to the nearby herbal medicine doctor who gave him herbal medicines. Gained consciousness in the morning. He used herbal medicines for five months and his left lower limb swelling subsided gradually.
Patient borrowed money and celebrated his sons first tonsure.
After swelling subsided and patient started going back to workstation he noticed numbness and sensation loss in his right leg which worried him but did not get any aid and carried on his daily activities.
In 2017 he had insidious onset of urinary and stool incontinence, erectile dysfunction which was gradually progressive. Due to affordability issues he went back to his town and consulted a local mbbs doctor who took an X-ray and advised him medications(unknown) for 10 days. Patient had no relief and went for herbal medications which he trusted would cure him. But patient had no improvement with herbal medicines.
Patient stopped going for work outside since then and sits idle at home.
Daily routine at present: wakes up at 5am occasionally at 8am and lies ideally on bed watching walls and surroundings. Freshen up and have tea with bread. At 11.30pm have lunch with rice and curry. Takes nap from 2-4pm. Drinks tea after waking up. Stays isolated most of the time. Gets anger outbursts often when children irritates him.
He tried homeopathy medicine for one month. On advice of homeopathy doctor he stopped consuming alcohol since two months but because of cravings he still drinks on Sundays.
Bought a garbage van and hired a man to collect garbage through which he earns a little amount and runs the family.
Sometimes patient have anxiety and feels generalised weakness. Worried about his children future. At times he feels taking off his life would be better than to be bed ridden.
He also feels low and his pride hurt for not been able to perform sexual activities.
Hourly routine
Wakes up by 6am pass stools and urine occasional incontinence. Sometimes go to washroom, sometimes defecate in clothes.
Have tea (sugar and milk ) with bread at 7am
At 8am He drops children at school by bike (xl) and bring groceries for home. While riding bike on a bumpy road he feels abdominal discomfort followed by stool and urine incontinence
From 9am patient passes time sitting idle or watching tv
Have lunch at 11am usually rice and dal. Non veg weekly thrice.
At 12pm he brings back children from school and have nap till 4pm
Wakes up at 4pm drinks tea.
6-9pm he watch TV serials
Dinner at 9.30pm usually rice and go to bed by 10.30pm
Wakes up middle of night once for washroom.
His concern
* to be able to get back to normal and carryon his daily activities.
Clinical Videos:
Clinical images:
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CDSS (Conversational Decision Support System)
[3/23/23, 5:26:41 PM] Dr. Rakesh Biswas sir: Thanks. Yes. This current patient tells me that what we at that time (20 years back) thought to be due to antivenom may have been directly due to the snake bite too.
[3/23/23, 5:30:58 PM] Dr. Rakesh Biswas sir: Looked at other reports and it appears that snake bite induced myelopathy although uncommon is not unheard of.
[3/23/23, 5:32:32 PM] +91 87908 89907: How can we treat such cases sir?
[3/23/23, 5:36:19 PM] Dr. Rakesh Biswas sir: We can only provide solutions (aka treat) once we understand the patient's requirements in detail.
Tell us in detail about his incontinence.
Currently it's only this and to quote from the case report :
In 2017 he had insidious onset of urinary and stool incontinence.
Unquote
Tell us how in his current regular workflow what does he do hourly and what is the problem he experiences in those same hourly slots due to his disabilities so that we can have a grasp on his requirements that may enable us to design better solutions for him.
[3/23/23, 5:37:12 PM] +91 87908 89907: He had the sensation of passing stools and urine but unable to hold them till he reach washroom and pass in clothes.
[3/23/23, 5:39:02 PM] Dr. Rakesh Biswas sir: How many times did this happen yesterday?
What is his own current solution for it? Does he need to have to use diapers regularly?
[3/23/23, 5:39:11 PM] +91 87908 89907: Daily routine of past and present I have written in the blog. In brief he is sitting ideal at home eats and sleeps.
[3/23/23, 5:39:59 PM] +91 87908 89907: He pass urine after drinking water(in average after 10mins)
[3/23/23, 5:40:05 PM] Dr. Rakesh Biswas sir: We need a representative day to understand his hourly problems to be able to provide a more meaningful solution
[3/23/23, 5:40:14 PM] +91 87908 89907: Okay sir
[3/23/23, 5:40:37 PM] Dr. Rakesh Biswas sir: How does he manage to avoid passing it in the floor?
[3/23/23, 5:40:58 PM] +91 87908 89907: He does that sir.
[3/23/23, 5:41:04 PM] +91 87908 89907: That’s his main concern.
[3/23/23, 5:41:22 PM] Dr. Dinesh Datta: Does the patient here got bitten by a 'semipoisonous snake'? DP looks like Russels viper.
@919121046928 (RB Sir) Which snake bit your old patient which was mentioned in your 20yo case report?
[3/23/23, 5:43:03 PM] Dr. Rakesh Biswas sir: Ours was a semi poisonous green pit viper.
We really don't know which viper bit this man though. The picture appears to be one of our current assumptions (aka differential)
[3/23/23, 5:43:48 PM] Dr. Rakesh Biswas sir: How many times? We need to visualize his life like seeing a movie.
What are his other problems throughout the day?
[3/23/23, 5:49:48 PM] Dr. Dinesh Datta: @919966699473(AC) Do you have any biopolymers at your dispense which can help us make a custom made 'reusable diapers' for this patient at minimal or easily crowd funded cost?
[3/23/23, 5:51:42 PM] +91 99666 99473: No... Sorry. Bio compatibility issues will arise unless any material is siliconized enough. We may need to think / design a little out of the box
[3/23/23, 5:53:28 PM] Dr. Rakesh Biswas sir: Yes think beyond diapers which are already available.
By the way what is the solution the patient is currently using?
[3/23/23, 5:53:53 PM] Dr. Dinesh Datta: We can try asking Zahir,metapsych group fellow,more on this
[3/23/23, 5:54:32 PM] +91 99666 99473: Yes.
[3/23/23, 5:55:47 PM] Dr. Dinesh Datta: @918790889907(H) Can help us in capturing the exact patient requirement,and we can build further on it in the other group
[3/23/23, 5:57:51 PM] +91 87908 89907: I will find out and update
[3/23/23, 5:58:43 PM] +91 99666 99473: Curious, and should have referred to literature, but snake bite leading to myleopathy should be more diffused.
Also, the bite was in 2013, and version of history we could gather - the symptoms started 5 years back.
[3/23/23, 6:03:49 PM] Dr. Dinesh Datta: Recall bias?
Can we tackle it by taking history from patient as well as patient advocate?
[3/23/23, 6:04:07 PM] +91 87908 89907: Did that
[3/23/23, 6:04:20 PM] +91 99666 99473: https://www.mdpi.com/2072-6651/14/7/436
They have reviewed some good cases
From the article...
_Lastly, we also discuss several studies of therapeutic agents against snakebite-envenoming-induced complications, which could be potential adjuvants along with AV treatment_
[3/23/23, 6:06:36 PM] +91 99666 99473: Please correlate with other versions of the history.
10 years is a huge recall window in the target demography. Opinion: latest would be the most accurate, with the only risk of *scripting errors*
Will share some links on *scripting in recall*
[3/23/23, 6:11:41 PM] +91 99666 99473: https://link.springer.com/article/10.3758/bf03195836
Three classes of evidence demonstrate the existence oflife scripts, or culturally shared representations of the timing of major transitional life events.
[3/24/23, 4:44:10 PM] Dr. Rakesh Biswas sir: Just tell us what does he do hourly and how the illness intrudes upon his hourly activities
[3/24/23, 4:44:14 PM] Dr. Rakesh Biswas sir: The etiolopathogenesis may not be very important at this juncture but yes slow lesions can develop due to slowly progressive inflammatory demyelination similar to multiple sclerosis although here it would be labelled as secondary demyelination.
[3/24/23, 4:44:19 PM] +91 87908 89907: I will update shortly sir.
[3/29/23, 3:37:53 PM] +91 87908 89907: Wakes up by 6am pass stools and urine occasional incontinence. Sometimes go to washroom, sometimes defecate in clothes.
Have tea (sugar and milk ) with bread at 7am
At 8am He drops children at school by bike (xl) and bring groceries for home. While riding bike on a bumpy road he feels abdominal discomfort followed by stool and urine incontinence
From 9am patient passes time sitting idle or watching tv
Have lunch at 11am usually rice and dal. Non veg weekly thrice.
At 12pm he brings back children from school and have nap till 4pm
Wakes up at 4pm drinks tea.
6-9pm he watch TV serials
Dinner at 9.30pm usually rice and go to bed by 10.30pm
Wakes up middle of night once for washroom.
[3/29/23, 3:38:02 PM] +91 87908 89907: He says his urine and stool incontinence is occasional
[3/29/23, 3:38:19 PM] +91 87908 89907: And he has no idea when and what factors trigger it.
[3/29/23, 3:52:47 PM] Dr. Rakesh Biswas sir: Thanks. This is valuable input.
So is that his current requirement from us:
Occasional episodes of mild soiling of clothes due to urinary and fecal incontinence due to reflex neurogenic bladder aka UMN bladder due to his past spinal cord injury following snake bite?
What is his own current solution for this? Does he use diapers?
[3/29/23, 3:53:18 PM] +91 87908 89907: He is not using diapers sir.
[3/29/23, 3:53:58 PM] +91 87908 89907: Spoil his clothes whenever he has incontinence
[3/29/23, 3:54:04 PM] +91 87908 89907: Which is occasional.
[3/29/23, 3:54:06 PM] Dr. Rakesh Biswas sir: Well changing clothes during such very occasional accidents is also a good solution
[3/29/23, 3:55:36 PM] Dr. Rakesh Biswas sir: So what is his requirement that needs a robotic solution from us?
What about his daily motor movement requirements? Does he experience any difficulty with that?
[3/29/23, 3:56:08 PM] +91 87908 89907: Yes sir
[3/29/23, 3:56:55 PM] +91 87908 89907: His concern is to be able to get back to normal and carryon his daily activities.
[3/29/23, 3:58:11 PM] +91 87908 89907: He says his gait is staggering
[3/29/23, 3:58:45 PM] +91 87908 89907: Ataxia
[3/29/23, 4:02:41 PM] Dr. Rakesh Biswas sir: Tell us what normal activities is he sacrificing currently. According to you he appears to have a normal life
[3/29/23, 4:10:36 PM] +91 87908 89907: He stopped going for work and sitting idle due to his bladder and bowel irregularities, and patient had sensation loss in both lower limbs Due to which he occasionally injured himself
[3/29/23, 9:59:00 PM] Dr. Rakesh Biswas sir: Since when has he stopped work?
Is it due to his motor disability? What work did he do before he stopped work? What is his current income source?
[3/29/23, 10:17:22 PM] +91 87908 89907: Garbage collector sir
[3/29/23, 10:18:40 PM] +91 87908 89907: Bought a garbage van and hired a man to collect garbage through which he earns a little amount and runs the family
[3/29/23, 10:22:00 PM] Dr. Rakesh Biswas sir: So he hasn't stopped work?
Probably not doing the same kind of work as earlier?
Since when is he doing his current work?
[3/29/23, 10:27:46 PM] +91 87908 89907: He is not doing work sir
[3/29/23, 10:28:08 PM] +91 87908 89907: He bought a van and hired a man for doing his job and they both share the income
[3/29/23, 10:59:46 PM] +91 87908 89907: Since 4 years sir
[3/29/23, 10:59:57 PM] +91 87908 89907: He stopped going by himself for collecting garbage
[3/30/23, 7:04:37 AM] +91 87908 89907: @919885321401 Asha garu we welcome your inputs on the patient and his concerns.
[3/30/23, 8:32:12 AM] Dr. Rakesh Biswas sir: Handing over to the day duty PG?
[3/30/23, 8:33:36 AM] +91 87908 89907: No sir she is volunteer from 37M society whom @919966699473 has asked to involve her.
[3/30/23, 8:35:28 AM] Dr. Rakesh Biswas sir: Volunteers can't be addressed as PGs?
[3/30/23, 8:36:31 AM] Dr. Rakesh Biswas sir: You are a PG volunteer and she's a potential PJr volunteer?
[3/30/23, 8:36:57 AM] +91 87908 89907: 😄right
[3/30/23, 8:38:36 AM] Dr. Rakesh Biswas sir: You've handed over this particular biopsychosocial comorbidity patient to her entirely or just partially?
[3/30/23, 8:41:11 AM] +91 98853 21401: Good morning sir...I might not be able to explain it in medical terminology, however I can explain his problem in detail.
Srinu has been suffering with numbness in his left leg for over 4 years now, which has become chronic and now as per our(Abhisek and Myself) observation from different tests conducted here he has lost sensation in almost 60% of his whole body. He has for the last 1 year lost control over his nature calls too. Though he has sansation, he says he can't hold it long coz of which he has stopped coming to his regular duty of garbage collection. Having 4 kids keeps worrying him about their future. He can barely walk and it has been a long time since he had a sound sleep. We would want him to get back on his legs, to boost his self confidence and support his family and take care of them.
[3/30/23, 8:41:36 AM] +91 87908 89907: Partially sir just for the missing points from my history taking
[3/30/23, 8:45:01 AM] Dr. Dinesh Datta: @919966699473 AC is currently missing and unavailable for some unknown reason.
Do let me know if he contacts anyone of us
[3/30/23, 8:47:35 AM] +91 87908 89907: Yeah he didn’t respond to my messages too
@919885321401 is he doing okay?
[3/30/23, 8:51:26 AM] Dr. Dinesh Datta: Your history taking in this scenario is satisfactory.
Great capture of data points.
Again,there's always scope for improvement as there is no 'best',there's only 'excellence' where one tries to push themselves a little but further every passing day
[3/30/23, 8:55:48 AM] +91 98853 21401: Yes, he is...in fact he called me yesterday asking as to when his visit to the hospital could be scheduled. Plz let us know, so that we can arrange accordingly.
[3/30/23, 8:57:44 AM] Dr. Rakesh Biswas sir: Any time from today
[3/30/23, 9:01:04 AM] +91 98853 21401: Sure, sir...I shall talk and post the details here.
[3/30/23, 9:02:49 AM] Dr. Rakesh Biswas sir: Excellent summary of the patient requirements.
Now for the solutions plan after we break up his requirements one by one priority wise
Priority 1:
Bowel bladder accidents frequency and mitigation
Priority 2:
Barely able to walk
Priority 3:
Numbness
Currently medical science has to depend on engineering solutions to all the above and there is no effective pharmacological solution for the above except if he has pain along with the numbness
[3/30/23, 9:05:10 AM] +91 98853 21401: He isn't educated and hence cannot respond to messages....i.e if they are text messages
[3/30/23, 9:05:48 AM] Dr. Dinesh Datta: He's one of my inspiration to be in academia.
How's he not educated?
[3/30/23, 9:06:08 AM] Dr. Dinesh Datta: Perhaps you are talking about patient srinu,and I'm talking about AC
[3/30/23, 9:06:11 AM] +91 98853 21401: I mean the patient sir
[3/30/23, 9:06:23 AM] Dr. Dinesh Datta: Sorry
[3/30/23, 9:06:23 AM] +91 98853 21401: My bad....I am sorry
[3/30/23, 9:07:02 AM] Dr. Rakesh Biswas sir: @8801316197024 Please collate all the conversational transcripts in this PaJR above along with the the previous case report data for the AJND report asap
[3/30/23, 9:07:36 AM] Dr. Rakesh Biswas sir: Except the patient identifiers here and elsewhere @8801316197024
[3/30/23, 9:11:42 AM] +91 98853 21401: Abhishek is having a problem with his phone and is available only on calls for now...says he shud be available on WhatsApp by tomorrow once he fixed it.
[3/30/23, 9:12:12 AM] Dr. Dinesh Datta: That's great to hear
[3/30/23, 9:18:12 AM] +91 98853 21401: Jus spoke to the patient, he is ready to come to the hospital tomorrow by 10 am ...plz let me know where to come and whom to meet. Like I said earlier these guys are not educated and hv some comprehending issues too and hence found it difficult last time to visit the hospital. So I would like to ensure they don't miss it this time. Plz advice
[3/30/23, 9:20:53 AM] Dr. Rakesh Biswas sir: @918790889907
[3/30/23, 9:33:02 AM] +91 87908 89907: Please ask them to enter the hospital and take op slip for general medicine and visit room no 78
[3/30/23, 9:33:14 AM] +91 87908 89907: I will wait for them at room 78
[3/30/23, 9:55:07 AM] +91 98853 21401: Sure, thankyou
[3/30/23, 10:53:58 AM] +91 83328 74734: +91 83328 74734 joined using this group's invite link
[3/31/23, 8:41:52 AM] +91 98853 21401: Good morning all, the patient and the attendant are @da hospital.
[3/31/23, 8:45:44 AM] +91 87908 89907: Okay I am in the class. Please ask he patient to take op card and wait at room 78 I will be there shortly
[3/31/23, 8:46:19 AM] Dr. Rakesh Biswas sir: Oh when did they start? Are you sure they are in Narketpally KIMS and not KIMS Secunderabad?
[3/31/23, 9:19:23 AM] +91 98853 21401: They r there doctor...hv taken OP and now enroute room number 78
[3/31/23, 9:19:31 AM] +91 98853 21401: Jus spoke
[3/31/23, 9:41:48 AM] +91 98853 21401: They are waiting @ the room sir, thankyou
[3/31/23, 9:58:27 AM] Dr. Rakesh Biswas sir: @918790889907 is currently seeing them
[3/31/23, 11:52:48 AM] +91 83176 69334: Sir, the patient is waiting in our ward, as they did not bring any of their belongings, they want to come back and get admitted tomorrow
[3/31/23, 12:01:26 PM] +91 98853 21401: Ok, Dr Himaja adviced them to meet Dr.Biswas I guess...plz advice if they hv to wait or if they can leave.
[3/31/23, 12:04:43 PM] Dr. Rakesh Biswas sir: Please bring them to the ICU where we are starting our rounds
[3/31/23, 12:04:50 PM] +91 83176 69334: Okay sir
[3/31/23, 1:28:50 PM] +91 83176 69334: <attached: 00000125-VIDEO-2023-03-31-13-28-50.mp4>
[3/31/23, 1:28:50 PM] +91 83176 69334: <attached: 00000126-VIDEO-2023-03-31-13-28-50.mp4>
[3/31/23, 1:28:51 PM] +91 83176 69334: <attached: 00000127-VIDEO-2023-03-31-13-28-51.mp4>
[3/31/23, 1:28:52 PM] +91 83176 69334: <attached: 00000128-VIDEO-2023-03-31-13-28-52.mp4>
[3/31/23, 1:28:52 PM] +91 83176 69334: <attached: 00000129-VIDEO-2023-03-31-13-28-52.mp4>
[3/31/23, 1:28:52 PM] +91 83176 69334: <attached: 00000130-VIDEO-2023-03-31-13-28-52.mp4>
[3/31/23, 1:28:53 PM] +91 83176 69334: <attached: 00000131-VIDEO-2023-03-31-13-28-53.mp4>
[3/31/23, 1:44:40 PM] Dr. Rakesh Biswas sir: @918790889907 Hypertonia of lower limbs
[3/31/23, 1:46:52 PM] Dr. Rakesh Biswas sir: Increased jaw jerk taking the level of the lesion to cortico bulbar tracts above mid pons.
[3/31/23, 1:48:36 PM] Dr. Rakesh Biswas sir: There was another video @918317669334 showing the reduced pharyngeal movement well?
[3/31/23, 2:03:09 PM] +91 83176 69334: @919121046928 sir MRI technician is saying they have 4-5 OP cases, they will do the MRI after 4pm
[3/31/23, 2:16:33 PM] Dr. Rakesh Biswas sir: But he is also an OP case all the way from Gachibowli! Shouldn't he get preference over those who have come from nearby?
[3/31/23, 2:17:55 PM] Dr.Deepika Ch: Yes sir will speak and try to arrange it accordingly sir
[3/31/23, 2:22:21 PM] Dr. Rakesh Biswas sir: Found some very interesting changes after evaluating him face to face as opposed to our previous telephonic collaborative sharings here.
His father and brothers all have slurring of speech, even his children suggesting an autosomal dominant genetic disorder possibly involving the speech cranial nerves and on examination we found that he had palatal weakness (9,10,11 cranial nerves) along with brisk jaw jerk again suggesting a UMN corticobulbar pathway lesion above mid pons that can also explain all his other problems and findings!
So we have come a long way from an acquired snake bite induced myelopathy to a genetic brainstem neurodegenerative disorder!
[3/31/23, 9:17:15 PM] Dr. Rakesh Biswas sir: Can someone share the representive MRI images of this patient that was supposed to have been done today?
[4/1/23, 11:25:39 AM] +91 94933 40818: https://jnnp.bmj.com/content/91/4/373
Primary lateral sclerosis (PLS) is a characteristically slowly progressive and selective neurodegenerative disorder primarily affecting the adult central motor system. Progressive muscle stiffness leads to an insidious loss of mobility typically with the development of corticobulbar dysfunction, which may be the initial symptom for a minority. Diagnostic criteria for PLS proposed 75 years ago recognised the potential for clinical overlap in the early symptomatic phase with the more common disorder amyotrophic lateral sclerosis (ALS).1 Like PLS, upper motor neuron (UMN)-predominant ALS has a significantly slower rate of progression compared with classical forms of ALS, with survival frequently extending into a second decade from onset of symptoms.2 The development of clinically obvious and functionally significant, progressive lower motor neuron (LMN) involvement is inevitable in ALS, in contrast to PLS, but may not emerge for several years from the initial clinical UMN syndrome.3 As a result, criteria for the definite diagnosis of PLS have enshrined a minimum duration of symptoms, varying from 3 to 5 years.
[4/1/23, 11:25:47 AM] +91 94933 40818: The core clinical syndrome
There have been consistent clinical observations reported across multiple case series in PLS.8 Mean age at symptom onset is around 50 years which is at least a decade earlier than non-familial ALS, and a decade later than HSP. While there have been cases reported with symptoms beginning in childhood, many of those might now be linked to developmental or monogenetically mediated disorders. A male predominance has been consistently noted in PLS (range 2–4:1).
An insidious onset is the rule in PLS, so that individuals are unlikely to reach specialised neurological services soon after the very earliest symptoms. For the majority of patients, symptoms emerge in the lower limbs first, but for a significant minority in the corticobulbar pathways with dysarthria and often prominent emotionality (pseudobulbar affect). Although dysphagia may become marked, the value of gastrostomy is far less clear than in ALS, and the need for non-invasive ventilation in PLS more exceptional. Lower limb involvement in the early symptomatic phase may be articulated as a sense of dysequilibrium or loss of fluidity in gait. Prominent sensory involvement should not be evident. Spasticity with pathological hyperreflexia are invariable examination findings. Although PLS typically generalises to include the upper limbs, a focal upper limb onset to symptoms is very unusual in PLS.
In our patient, can we explain bowel bladder and sensory involvement with PLS? As per your review apparently not?
Let's further review to accomodate these two features as well as the possibility of a genetic autosomal dominant disorder
[4/1/23, 12:34:32 PM] +91 91 6035 954 5: Adrenomyeloneuropathy (AMN) presents in adulthood and affects the spinal cord and peripheral nerves, with a slower progression leading to gait and balance disturbances, sensory impairment, and bowel and bladder dysfunction
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789359/
[4/1/23, 2:49:18 PM] Dr. Rakesh Biswas sir: Share the images asap
[4/1/23, 2:51:55 PM] Dr. Rakesh Biswas sir: Looks like our approximation regarding the neuroanatomical localization was better correlated with these MRI findings before we actually got to examine him in detail yesterday!
@919885321401 Unexpectedly this MRI was very very very useful in the patient's evaluation 👍
The next step would be neurosurgical evaluation asap
Replaced the dp with another snake that is residing inside our patient's vertebral column and appears to have a very very very unexpected significant pathology
[4/1/23, 2:02 PM] Dr. Rakesh Biswas sir
In our patient, can we explain bowel bladder and sensory involvement with PLS? As per your review apparently not?
Let's further review to accomodate these two features as well as the possibility of a genetic autosomal dominant disorder
[4/1, 2:12 PM] Deepika 2021 Kims PG: Brain??
[4/1, 2:17 PM] Ajay Reddy 2022 Med PG Kims: No abnormality detected
[4/1, 2:19 PM] Rakesh Biswas: Share the images asap
[4/1, 2:21 PM] Rakesh Biswas: Looks like our approximation regarding the neuroanatomical localization was better correlated with these MRI findings before we actually got to examine him in detail yesterday!
[4/1, 3:34 PM] Rakesh Biswas: Share these in separate frames
@919885321401 Unexpectedly this MRI was very very very useful in the patient's evaluation 👍
The next step would be neurosurgical evaluation asap
[4/1/23, 4:15:51 PM] Dr. Rakesh Biswas sir: @918790889907 The pathology is visible well in these and the one I put in the dp and not much in any of the other images you shared
[4/1/23, 4:22:41 PM] Dr. Rakesh Biswas sir: Show us some coronal and transverse sections
[4/1/23, 4:59:45 PM] Dr. Rakesh Biswas sir: FAQs on further course of action for spinal cord pathology
[4/1, 4:16 PM] Query:
Doctor, what is the next course of action for our spinal cord pathology patient? How serious is the issue and what is the hope for recuperating...plz advice
[4/1, 4:19 PM] Rakesh Biswas: Let's hope it's an infective or a benign lesion of the spinal cord.
The next step is operating his spinal cord and seeing the pathology under the microscope to understand if it's infective, benign (easily treatable) or malignant (not easily treatable)
[4/1, 4:20 PM] Query: Ok, how much wud this entire treatment mount to?
[4/1, 4:22 PM] Rakesh Biswas: It would depend on where it is done
At our place it may be much less compared to say Yashoda and we currently have a young neurosurgeon who may be keen to operate him asap
[4/1, 4:23 PM] Query: Can a benign lesion cause a slow and progressive problem like he is currently facing?
[4/1, 4:24 PM] Query: If it cannot, can we say it cud be a malignant lesion?
[4/1, 4:25 PM] Rakesh Biswas: Yes it's a slow progressing lesion and hence we are hoping it's benign (could even be an infection like TB).
If it had been malignant it would have progressed faster
[4/1/23, 6:05:58 PM] +91 99666 99473: Like a fugitive?🙂
[4/1/23, 6:06:47 PM] +91 99666 99473: Sorry my phone has died... using a temporary setup in my father's phone... secure folder
[4/1/23, 6:07:51 PM] Dr. Rakesh Biswas sir: Mine still survives with it's neurodegenerative disorder
[4/1/23, 6:11:02 PM] +91 99666 99473: Ah... that's how ...
These are great videos for training remote patient advocates
[4/1/23, 6:12:13 PM] +91 99666 99473: Wonderful
[4/1/23, 6:15:58 PM] +91 99666 99473: Neoplastic...!
Is there any NAAG / related mri protocol... non invasive?
[4/1/23, 6:18:23 PM] Dr. Rakesh Biswas sir: Look at the climax today
We shall always remember this case as one where our clinical neuroanatomical localization through this PaJR discussion without seeing the patient was more accurate and correlating radiologically than after actually having seen the patient here with our accurate supposedly better clinical examination and history taking skills.
Lesson learnt: More clinical data may not necessarily translate to better diagnostic outcomes unless there actually two pathologies, the other explaining his familial autosomal dominant speech disorder and subtle brain stem features
[4/1/23, 6:18:44 PM] +91 99666 99473: T2 weighted? CSF dark...
[4/1/23, 6:21:02 PM] Dr. Rakesh Biswas sir: T1 is CSF dark
This one is T2 weighted and doesn't show much findings as it's a lateral saggital section
[4/1/23, 6:21:45 PM] Dr. Rakesh Biswas sir: 👆This shows the pathology best
[4/1/23, 6:21:56 PM] +91 99666 99473: Our synthetiforms are more resilient (and disposable) by design
[4/1/23, 6:52:20 PM] +91 99666 99473: We need PaJR protocols across the ICD spectrum...
ICLE proponents may suggest SCT 🙂
Sorry, Dr Rho proto was open and non functional during this case initiation... later I did think of repurposing AusculAid 1.0 for remote examination in the absence of TARA/Dr Tho
[4/1/23, 6:57:36 PM] +91 99666 99473: The genetic history should be part of our regular protocol
[4/1/23, 8:06:24 PM] +91 98853 21401: Hi All,
Request you to provide an estimate for the treatment. I feel it cud be an expensive one.
I would like to be practical with regards to financial assistance to the patient and establishing their hopes in terms of support both from you and our side.
We have raised around 35k from our society to support their medical expenses from which we have already spent 8k on his MRI. I am left with only 27k now with no hope of raising any funds further . As per my discussion with the patient sometime back they have already exhausted their resources for his treatment for the last 4 years and are in no state to afford further expenses.
So, having an estimate(approximate at least) wud be of much help for us to give them a heads-up and for them to decide on how to proceed.
Thank you in advance.
[4/1/23, 8:53:18 PM] Dr. Rakesh Biswas sir: We'll try to finish his surgical treatment and subsequent medicines , if a benign infection on biopsy(for example TB) in 27,000.
If it turns out to be a malignancy or even localized lymphoma it may require more but that's later
[4/1/23, 9:10:49 PM] +91 99666 99473: Let's hope it's a benign infection...
Informed guess / wish... he does manual collection of waste and follows up with manual sorting...
No tetanus inoculation! I have learnt from my more conscientious worker friends they take a TT shot twice or thrice a year...
[4/1/23, 9:11:33 PM] +91 99666 99473: How likely is a vitamin B / D deficiency being a causative factor for similar presentation?
[4/1/23, 9:16:46 PM] +91 99666 99473: Sorry for the share based on enthusiasm...!
Just wishing for something mundane... given the known possibilities
https://medlineplus.gov/ency/article/000723.htm#:~:text=SCD%20is%20caused%20by%20vitamin,mainly%20affects%20the%20spinal%20cord.
[4/1/23, 10:34:31 PM] Dr. Rakesh Biswas sir: Vitamin B or D deficiency is unlikely with the kind of pathology that is visible in MRI
[4/1/23, 11:48:23 PM] Dr. Abhishek: Is this the prominence we can palpate on the spine around the level of the lower margin of his scapula?
[4/2/23, 12:10:42 AM] Dr. Rakesh Biswas sir: No there doesn't appear to be any such suggestion in the MRI
[4/4/23, 9:13:03 AM] +91 88973 61788: audio omitted
[4/4/23, 9:13:03 AM] +91 88973 61788: audio omitted
[4/4/23, 9:15:19 AM] +91 88973 61788: image omitted
[4/4/23, 9:23:11 AM] ✍🏼Dr. Himaja: Patient attender concerns
Will 37M gets cured completely after surgery ? And will the patient have to undergo any more further surgeries after this?
[4/4/23, 11:28:01 AM] Dr. Abhishek: They both met @919885321401 Asha garu and me today morning.
Other concerns they shared
1. Children have exams in the next 1 month. Can the surgery be delayed?
2. Will there be adverse outcome from the treatment?
Is is feasible to get a plan from a neuro surgeon and help them understand
A. Possible negative outcome of *not* getting treated (like mets in case of malignancy, or further degradation of sensory motor functions etc)
B. Risk profile and prognosis for such cases
C. Possible adverse outcome of the proposed treatment, if any
Just some humble thoughts 🙏
[4/4/23, 12:22:12 PM] +91 97033 88855: +91 97033 88855 joined using this group's invite link
[4/4/23, 12:12:31 PM] Dr. Rakesh Biswas sir: 1) Perhaps. Who knows how old the pathology is and going by his symptoms it could be years old
2) They will need to meet the neurosurgeon face to face unless @919059022329 can add him or the appropriate surgery PG here
A) Only after excising the pathology can one see it under the microscope and then figure out from a prior database the pattern of what outcomes such pathologies produce. If only we had an MRI that could show us the pathology at the cellular level things may have been different
B)Ditto
C) He could become worse after treatment losing full control and power and becoming bed ridden. Medicine is always a gamble and all our current thesis projects are to elucidate the factors that makes one win or lose and be able to predict the game better for each individual. Not sure how successful these projects will be
[4/4/23, 12:16:12 PM] Dr. Abhishek: Thank you @919121046928
[4/4/23, 3:05:17 PM] +91 70136 80111: +91 70136 80111 joined using this group's invite link
[4/4/23, 6:22:18 PM] +91 90590 22329: Spoke with neurosurgeon ,Sir asked them to meet him in opd tomorrow... shall we call them sir ?
[4/4/23, 8:04:34 PM] ✍🏼Dr. Himaja: Patient wants to come after his children exams that is 20th April if the surgery can wait sir
[4/4/23, 8:49:48 PM] Dr. Rakesh Biswas sir: Did he see the MRI images?
[4/4/23, 9:45:48 PM] +91 90590 22329: Yes sir , Sir saw the MRI , as it was intramedullary lesion plan of action was to do biopsy and then based on report further plan of radio or chemotherapy sir. He also said excision of intramedullary lesions will lead to neurological deficit so we can't do total excision for this case sir .
[4/4/23, 11:08:46 PM] Dr. Rakesh Biswas sir: Yes as mentioned above earlier biopsy will provide us a direction regarding the probable outcomes in his illness
[4/5/23, 3:23:04 AM] Dr. Abhishek: Thank you. That is very reassuring.
[4/5/23, 3:32:43 AM] Dr. Abhishek: Is a minimal access biopsy feasible / indicated?
FNAC for spinal cord lesions?
[4/5/23, 3:58:36 AM] Dr. Abhishek: The patient is very concerned about adverse outcomes and how they impact the future of his children. A central theme during his 10-15 mins interaction with me yesterday was this.
Given that the condition may deteriorate even without any intervention, we may want to explain the narrative to him.
How much of that will be understood apart from the risk factors is arguable.
The downside is that without an acceptable supportive management, the patient may return to the quacks he purportedly visited earlier.
If post Biopsy, radiotherapy / chemo are indicated would it be feasible to get him an affordable solution? Basvatarakam does offer discount based on needs, but how much depends. Anyway, that's only after biopsy, if needed
[4/5/23, 8:19:36 AM] +91 90590 22329: Outcomes will be depend on the type of pathology whether it is benign or malignant ( if malignant grade is important ) . In grade 1 and 2 there are better outcomes compared to grade 3 and 4. As our plan is to get a biopsy not subtotal or total resection chances of iatrogenic damage to neuronal structure will be less and post procedure morbidity.. He may only complicate by the disease persae ( growth and extent of the lesion ) .
Do they have arogyasree ?? if he needs radiotherapy or chemotherapy ,it can be covered under Arogyasree in NIMS , Hyderabad.
[4/5/23, 8:34:24 AM] Dr. Abhishek: I don't think they have arogyasree
@919885321401 would you have a perspective on their registration for arogyasree? If they enrol now will they be covered? Can MLA garu be approached for his case? Maybe we can discuss in the society forum
[4/5/23, 8:37:09 AM] Dr. Dinesh Datta: Does he have white ration card?
[4/5/23, 8:39:19 AM] Dr. Abhishek: Does he have a ration card at all?
What I recollect is that they don't have any government registration...
He has a GHMC garbage truck... maybe they have some support scheme
[4/5/23, 8:40:39 AM] +91 98853 21401: He has
[4/5/23, 8:41:05 AM] +91 98853 21401: Absolutely no idea on any of these
[4/5/23, 8:41:29 AM] Dr. Abhishek: He has...
So how does it help @919000166698
[4/5/23, 8:43:16 AM] Dr. Dinesh Datta: https://www.acko.com/health-insurance/aarogyasri-telangana/
[4/5/23, 8:43:50 AM] Dr. Dinesh Datta: Ask him to apply Arogyasri card with his white ration card
[4/5/23, 8:44:12 AM] Dr. Dinesh Datta: There's also a arogyasri counter in NIMS where he can apply offline
[4/5/23, 8:45:17 AM] +91 90590 22329: Old white ration card is not useful .. they need to get new one , which has unique number ( this paper or card will be issued by local ration manager in their village
[4/5/23, 8:46:22 AM] Dr. Dinesh Datta: Old one can be renewed to new one.And arogyasree card maybe applied with new one?
[4/8/23, 2:28:47 PM] +91 81859 44161: +91 81859 44161 joined using this group's invite link
[4/18/23, 8:42:52 AM] +91 97040 90596: +91 97040 90596 joined using this group's invite link
[4/18/23, 8:16:55 AM] Dr. Rakesh Biswas sir: @8801316197024 Have you allotted this patient to someone for the AJND piece?
[4/18/23, 8:18:25 AM] Dr. Rakesh Biswas sir: https://chat.whatsapp.com/C4Fhdc1z8c0IktVOvpDOBg
Someone will need to copy paste the conversational learning transcripts here into another blog
[4/18/23, 8:27:53 AM] Dr. Rakesh Biswas sir: @8801316197024 and team :
Check out the blogged case here 👇
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6163835/
In reference 20 to understand how to blog each one of your cases so that they are useful standalone publications to be referenced in their own right. Even reference 20 there isn't perfect and there is a lot of scope for improvement here too
[4/18/23, 9:11:45 AM] +91 77802 85086: +91 77802 85086 joined using this group's invite link
[4/18/23, 10:07:02 AM] Arefin Sadat: Yes sir, this case had been added
[4/18/23, 10:43:27 AM] +91 88862 02111: +91 88862 02111 joined using this group's invite link
[4/19/23, 8:58:30 PM] +91 6303 465 606: +91 6303 465 606 joined using this group's invite link
[4/20/23, 12:03:09 PM] Dr. Rakesh Biswas sir: Project: Factors influencing outcomes in neuroparalysis
https://chat.whatsapp.com/E7YD7GElMg5IkIBIsTJ7dX
[4/20, 8:08 AM] +91 83672 34566: http://vishnurohithreddy.blogspot.com/2023/04/a-45-year-old-female-came-to-opd-with.html
[4/20, 11:03 AM] Rakesh Biswas: The CNS muscle power is mentioned as 4 but is probably 3- in right and 3+ in left?
Also need to test individual joints and muscles.
PGs who witnessed our clinical examination during rounds yesterday to please guide @Deepika 2021 Kims PG @Pavan 2021 PG Kims Med
Also the trunkal muscle testing to localize further to the thoracic spinal cord although again it may also become difficult to then explain her upper limb weakness!
[4/20, 11:05 AM] Rakesh Biswas: Also we need a more detailed event history of her upper and lower limb paralysis and pain
[4/20, 11:05 AM] Himaja Kims Med Pg 2022: There is bilateral knee joint tenderness in the medial side
Left middle finger dip tenderness
Right third finger dip tenderness sir
[4/24/23, 8:17:27 PM] Sanjana Palakodeti: Sanjana Palakodeti joined using this group's invite link
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