29F SLE CKD Severe Hypertension CCF Telengana PaJR




[11/11/2022, 8:43 AM] Dr Rakesh Biswas Sir Hod Gm Kam: What's the population of NKP? 

In one of our previous patients from Mothkur we realized we couldn't use that identifier.

One of the deidentification guidelines suggests that areas identified with the patient, needs to have a population of 20,000

Mothkur has a population of 12,000 as of 2011 and hence I went with associating her only with the state name. 

One could have mentioned her district Yadadri which has a population of 770,000

Let us all PaJR volunteers remember to please check the population of the location before we code our patient in association with that location.
[11/11/2022, 9:16 AM] saicharankulkarni: Narketpalle Mandal of Nalgonda district has total population of 50,864 as per the Census 2011. Out of which 25,916 are males while 24,948 are females. In 2011 there were total 12,770 families residing in Narketpalle Mandal.


[11/11/2022, 9:17 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Is she also from Mumbai?

[11/11/2022, 9:18 AM] Dr Rakesh Biswas Sir Hod Gm Kam: If so then which serial number SLE would she be amongst our dashboard collected SLEs over last few years?

[11/11/2022, 2:27 PM] saicharankulkarni: Yes sir

[11/11/2022, 4:18 PM] Dr Rakesh Biswas Sir Hod Gm Kam: 👆

[11/19/2022, 9:04 AM] saicharankulkarni: Biopsy report mostly Monday kalla ostadi
[11/19/2022, 9:04 AM] Pt advocate  SLE: Ok sir

[11/19/2022, 9:04 AM] saicharankulkarni: @⁨Dr Keerthi Jnr Gm Kam⁩ mam try chesthunnaru

[11/19/2022, 9:04 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Please share her case report link

[11/19/2022, 9:05 AM] saicharankulkarni: Okay sir

[11/19/2022, 9:05 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Which biopsy report?

[11/19/2022, 9:05 AM] saicharankulkarni: Renal Biopsy sir. Which I have shared video with you

[11/19/2022, 9:05 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Share the case report link

[11/19/2022, 9:06 AM] Dr Keerthi Jnr Gm Kam: case report link

[11/19/2022, 9:08 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Please update her charts and soap notes asap in the case report
[11/19/2022, 9:08 AM] Dr Keerthi Jnr Gm Kam: okay sir

[11/19/2022, 9:08 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Make all admins

[11/19/2022, 9:13 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Share her sugar trends in her fever charts since admission. 

Is she still on insulin? Is this steroid induced hyperglycemia?

[11/26/2022, 5:49 PM] saicharankulkarni: Latest creatinine on today is 4.0mg/dl.

[11/26/2022, 5:52 PM] saicharankulkarni: Currently Not using Steroids or Azathioprine.

[11/26/2022, 7:19 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Off course pathologists are not supposed to know medicine so they can be excused for their confusion. 

They should know that there is nothing diagnostic in renal biopsy for lupus nephritis. Our last presentation review drove that point further for us. 

This is just showing features of advanced renal disease and in the clinical context the major reason for this is lupus while there are other tell tale evidences of drug induced interstitial damage 

There is
[11/26/2022, 7:59 PM] saicharankulkarni: Okay sir. Thank you.

[11/26/2022, 8:00 PM] saicharankulkarni: I think she is gloomy sir. May be our psychologists could be help ful here.

[11/26/2022, 8:04 PM] Rajkumar Sir DAC Kam Rajkumar Sir DAC Kam: Sure Dr. Saicharan

[11/26/2022, 8:13 PM] saicharankulkarni: Thank you sir.

[11/26/2022, 9:53 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Her case report doesn't mention her marital status or any personal history. 

I guess she's not married and has spent her majority of childhood in Mumbai and works as a software engineer from home here in Chityal?

[11/26/2022, 9:54 PM] saicharankulkarni: She is married with daughter sir. Sorry sir. Will update her marital and personal history sir.

[2/9, 10:23 PM] saicharankulkarni: previous case report link

@⁨Rajkumar Sir DAC Kam Rajkumar Sir DAC Kam⁩ sir
she is the 29/F sle patient who was admitted in our hospital 3 months back and met you at that time .. again she was admitted 3 days back and will be sending her for the review 
Sir Can you please let us when can we send her for pni .?

[2/9, 10:23 PM] saicharankulkarni: Now can you send please

[2/9, 10:23 PM] saicharankulkarni: What are her vitals...? Is she stable enough to shift..??

[2/9, 10:23 PM] saicharankulkarni: 29/F sle pt :- 
Bp:- 180/100 mmhg 
Spo2:- 97 percent on RA
Rr:- 24 cpm
Pr:-118bpm
Temp:- 98F 

Already spoke to dr.raj kumar sir regarding the appointment 
Will be shifting only after the blood pressure is under controll sir

[2/9, 10:23 PM] saicharankulkarni: Please update

[2/9, 10:32 PM] saicharankulkarni: @⁨Dr Rakesh Biswas Sir Hod Gm Kam⁩ sir as she is in Heart failure adding afterload reducing agent is needed now, 
Now my question is what afterload reducing agent is to be added..??

Telma - cant be added beacuse of renal failure ( crcl 22 )
Hydralazine - could cause/aggrevate drug induced Lupus / pneumonitis 

What other afterload reducing agents can be added sir..?? Oral nitrates..??

[2/9, 10:33 PM] saicharankulkarni: She was on met xl 25mg sir
Nicardia 20 mg tid,
 Now added long acting cilnidipine 10mg BD, nicardia 20 mg SOS.

[2/9, 10:39 PM] Dr Rakesh Biswas Sir Hod Gm Kam: What is the difference in aortic vasodilation by nicardia vs arb vs hydralazine?

[2/9, 11:22 PM] saicharankulkarni: https://pubmed.ncbi.nlm.nih.gov/3671250/

The three drugs didnot differ significantly as regards changes in supine bloodpressure at six months (TableIV). The fall in supine mean arterial pressure (diastolic+1/3pulsepressure) with nifedipine was slightly largerthan that for hydralazine(by 4.1mmHg,95%confidence interval[CI]-2.6to +10.7mmHg),and prazosin(by1.3mmHg95%CI-4.6to7.1mmHg).Of all those randomized,target bloodpressure (supinesystolic<140mmHgand diastolic<95mmHg) was attained at 6months in 52% with nifedipine, 45% with prazosin and 33% with hydralazine. Comparing measurements 13hours after dosing to those 3hours after dosing, blood pressure tended to rise on all three drugs. Supine mean arterial pressure rose by 7.0mmHg on nifedipine (n=11), 3.5mmHg on prazosin(n=10) and 4.7mmHg on hydralazine(n=7).

*Pharma sponsered*

Grants in support of L.P and P.C.W from I.C.I and Janssen PharmaceuticalLtd. respectively, are gratefully acknowledged.

[2/10, 7:57 AM] Dr Rakesh Biswas Sir Hod Gm Kam: But our main question was around the efficacy of aortic vasodilation and afterload reduction in these groups, not BP reduction?

[2/27, 6:57 PM] saicharankulkarni: Thank you.. coordinate with nephrology team and plan for urology referal for AV fistula.

[2/28, 9:07 AM] Dr Raveen Gm Kam: Good morning Seema gaaru 
AV fistula ki Arogyasree osthadi 

Okasari nanna ni card teskoni 
Arogyasree Office ki vellamanandi 
Swathi garu untaru check chestharu

[2/28, 9:07 AM] Pt advocate SLE: Good morning ☺️ok sir

[2/28, 9:07 AM] Pt advocate SLE: But at what time

[2/28, 9:08 AM] Dr Raveen Gm Kam: Eppudu untaaru  

[2/28, 9:08 AM] saicharankulkarni: 9 to 4 pm

[2/28, 1:35 PM] saicharankulkarni: @⁨Pt advocate SLE⁩ what about urology team consultation regarding AV fistula..?? When is your operation scheduled..??

[2/28, 1:41 PM] Pt advocate SLE: He said more 1 week u have to press the ball

[2/28, 1:41 PM] Pt advocate SLE: Veins r not seen properly

[2/28, 1:44 PM] saicharankulkarni: Okay thank you.. do regular ball excercise as a part of pre operation pre-requisite

[2/28, 1:50 PM] Pt  advocate SLE: Haa
[2/28, 1:51 PM] Pt advocate SLE: I m having dialysis in the evening I m in ward

[2/28, 1:57 PM] saicharankulkarni: Okay I will come and meet you

[2/28, 2:50 PM] Pt advocate SLE: Ok sir
[2/28, 10:57 PM] saicharankulkarni: Always share pre and post dialysis weight and fluide taken from your body..

[3/1, 7:27 AM] Pt advocate SLE: Pre-45,post-41, yesterday dialysis

[3/1, 7:40 AM] saicharankulkarni: Thanks

[3/1, 9:07 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Can we also have her daily intake output and pre and post dialysis creatinine?

[3/1, 9:41 AM] saicharankulkarni: post dialysis creatinine we are sending 2-3 times for 10 dialysis sir.

[3/1, 9:42 AM] saicharankulkarni: Please share you daily water intake and urine output

[3/1, 9:46 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Share her last

[3/1, 9:47 AM] saicharankulkarni: @⁨Pt  advocate⁩ please share your latest creatinine.. last i remember was 5.4 mg/dl sir.

[3/1, 9:49 AM] Dr Pradeep Gm Kam: @⁨Pt advocate SLE⁩ do u have bp machine at home,it would be very helpful if u share ur bp recordings with bp medications u are taking.

Did u check ur bp today??

[3/1, 9:51 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Rephrase this as @⁨Pt advocate SLE⁩ Does your patient have a BP machine at home, please share HER hourly BP readings

[3/1, 9:55 AM] Dr Pradeep Gm Kam: Sir,I thought she might get confused if i use 3rd person pronoun

[3/1, 10:02 AM] Dr Rakesh Biswas Sir Hod Gm Kam: Pm her and clear the confusion first emphasizing why she needs to protect her patient's privacy and confidentiality

[3/1, 10:03 AM] Dr Pradeep Gm Kam: Ok sir

[3/1, 4:53 PM] Pt advocate : I don't have bp machine
[3/1, 4:54 PM] Pt advocate: And I also want to know my last blood report

[3/5, 7:13 PM] saicharankulkarni: TIN has been described in association with systemic inflammatory conditions such as inflammatory bowel disease, TINU syndrome, sarcoidosis, systemic lupus erythematosus (SLE), and Sjögren's disease. IgG4-associated immune complex multiorgan autoimmune disease (MAD) has also been linked with development of TIN with IgG4 positive plasma cell interstitial infiltrates and C3 deposition [32]. Autoimmune pancreatitis is in the spectrum of IgG4-associated MAD where TIN is part of the disease manifestation [33-35].


[3/5, 7:17 PM] saicharankulkarni: @⁨Dr. Haripriya Gm Pgy1⁩ This explains her biopsy report.. though her histology of kidney is not in favour of Lupus nephritis but chronic TIN can be seen as a part of SLE associated TIN.
[3/5, 7:23 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Please share her biopsy report
[3/5, 7:29 PM] Dr Rakesh Biswas Sir Hod Gm Kam: There are no updates in this case report 👇

https://rishithareddy30.blogspot.com/2022/11/30-yrs-old-female.html?m=1

@⁨saicharankulkarni⁩
[3/5, 7:35 PM] saicharankulkarni: Updating in my blog sir will share here

[3/5, 8:33 PM] Dr. Haripriya Gm Pgy1: Ok sir
Thankyou

[3/5, 9:09 PM] Dr Rakesh Biswas Sir Hod Gm Kam: @⁨saicharankulkarni⁩ @⁨Dr. Haripriya Gm Pgy1⁩ This is not the interpretation of her biopsy report. 

Read it carefully as a whole 

Would the others like to try? When was this available? Could it have been shared earlier?

[3/5, 9:12 PM] Dr. Dinesh Datta Jr Kam: Sir,do we have histopath pic?
I mean,are we sure that pathologists give the same description if we didn't subtly suggest them about lupus nephritis or etc?
Remember that time when patho report came suggesting for Gilbert's and we don't understand what to do with it,lol.
Do we get same inference and report if we don't mention our clinical inputs?

[3/5, 9:18 PM] Dr. Haripriya Gm Pgy1: The report was available in the month of nov/dec sir

[3/5, 9:27 PM] Dr Rakesh Biswas Sir Hod Gm Kam: And the last futile question was... Could it have been shared earlier

[3/5, 9:30 PM] saicharankulkarni: Already shared earlier.. will read it again sir Thank you

[3/5, 9:30 PM] Dr Rakesh Biswas Sir Hod Gm Kam: Unlike radiology, the histopathology image that is shared is too less a cross sectional view that would be useless unless one is trained and gets to run through the entire slide. 

The narrative report is predominantly that of CGN and not CIN

[3/5, 9:30 PM] Dr Rakesh Biswas Sir Hod Gm Kam: I guess we didn't have her PaJR group then

[3/5, 9:31 PM] Dr. Dinesh Datta Jr Kam: No indication needle poke the kidney for biopsy?

[3/5, 9:32 PM] saicharankulkarni: Yes sir

[3/5, 9:36 PM] saicharankulkarni: Already shared here sir.. from November 11 she is in paJR group sir

[3/5, 10:25 PM] Dr Rakesh Biswas Sir Hod Gm Kam: 👆You didn't get my comment at that time and hence interpreted it now as CIN?

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