WhatsApp Chat with Project txt book
14/05/2017, 1:20 pm - Messages to this group are now secured with end-to-end encryption. Tap for more info. 14/05/2017, 1:20 pm - Rakesh Dir created group "Project txt book " 14/05/2017, 1:20 pm - Rakesh Dir added you 14/05/2017, 1:25 pm - Rakesh Dir: We may soon have all the material ready to create a text book of Theory questions, conversations and MCQs in Medicine, that could be one of a kind globally. We have a local publisher who is requesting us and once we prepare a word file we can share it with them. We can draw from the patient blogs already created and discussed in Tabula rasa and some of our 8th semester students have already begun to add theory questions and MCQs in their blogs as in the samples shared below 14/05/2017, 1:26 pm - Rakesh Dir: A few theory questions and MCQs shared by some of our 8th semester students in their web based log books linked here below : http://medicinecase-aparnatewari.blogspot.in/2017/05/mr.html?m=1 http://medicineriziaakhtar.blogspot.in/2017/05/24-yr-old-female-with-fever-and-chest.html?m=1 http://medicinecase-anjalikumari.blogspot.in/2017/05/mrs.html?m=1 https://pratibha-medicine.blogspot.in/2017/05/hepatic-encephalopathy.html?m=1 14/05/2017, 1:26 pm - Rakesh Dir: Thanks Keya I have gone through the theory questions and MCQs that you have framed drawing on university questions from 2008 to 2013 based on your patient here: http://taniachowdhry.blogspot.in/2017/05/53-years-male-patient-admitted-on-8.html?m=1 Very well done beginning I must say. The MCQs leave more to be desired. For example in MCQ 1 we could have had just 4 options without option E? Also MCQ 3 is quite simplistic as well as the subsequent true and false question? 14/05/2017, 1:57 pm - Rakesh Dir: There will be authors and editors from students as well as faculty side 14/05/2017, 1:59 pm - Rakesh Dir: I need both your help as student editors to collate the potential chapters currently already discussed in Tabula rasa and add university theory questions as well as MCQs to them 14/05/2017, 2:01 pm - dvp (Vivek): Sir, I will start doing this. Will it be a narrative medicine followed by MCQ and theory question related to a particular case sir? 14/05/2017, 2:04 pm - Rakesh Dir: Yes the case will begin with the patient history narrative and quickly move over to clinical findings, investigations and management followed by conversations and theory questions and MCQs (as in the 8th semester blogs) 14/05/2017, 2:07 pm - Rakesh Dir: Even if we can get a student team to collate this from the Tabula rasa cases and discussions with addition of Theory questions and MCQs already asked in previous exams (by citing the exams as references) we should be able to ready it quickly? 14/05/2017, 2:11 pm - dvp (Vivek): Absolutely sir. It will be faster and each student will assinged a different role on a complete case e.g. two student will look over the MCQs and make MCQs and one editor will oversee the written MCQs and make necessary changes before it can go to the faculty. Samething will be applied for other parts and we can make 3-4 small pods with editor for each pod. 14/05/2017, 2:14 pm - Rakesh Dir: So can we recruit those students and add them to Tabula rasa to begin the process? I guess we can also ask them to first go through the 8th semester blogs above as a simpler starting point? 14/05/2017, 2:15 pm - dvp (Vivek): Yes sir that is important to collect those cases from Tabula Rasa. 14/05/2017, 2:16 pm - dvp (Vivek): I can begin collecting the cases from Tabula rasa. 14/05/2017, 2:21 pm - dvp (Vivek): Avinash, lets start this and sir, it would make students more enthusiast, if you assign them to start this process along with us. 14/05/2017, 2:23 pm - dvp (Vivek): E.g. going through tabula rasa and blogs 14/05/2017, 2:31 pm - Rakesh Dir: Yes we could motivate a few more students here and add them to this group as well as Tabula rasa? 14/05/2017, 2:44 pm - dvp (Vivek): Sure sir 14/05/2017, 4:07 pm - Avinash Home: pods means? 14/05/2017, 4:08 pm - Avinash Home: thanks dada, started. 14/05/2017, 4:08 pm - dvp (Vivek): Small groups. Just a small and sweet word. 14/05/2017, 4:08 pm - Avinash Home: okk 14/05/2017, 4:44 pm - dvp (Vivek): Avinash, any plan that how could we collect all the cases and store in one common place? 14/05/2017, 4:47 pm - Avinash Home: yes dada, i have completed building thescifimed.com similar to biohack.in where all cases will be *collected* and *tagged* chapter/topic wise, and then any MCQ book (better if digital) having list of previous questions can be used to easily find all cases in a chapter and link with questions. 14/05/2017, 4:48 pm - Avinash Home: sir had liked biohack.in but i had to close that, so built everything from basic. 14/05/2017, 4:50 pm - dvp (Vivek): Ya. Lets do onething collect it and organize a bit first on MS word and then to google doc 14/05/2017, 4:50 pm - dvp (Vivek): I will do the same. 14/05/2017, 4:51 pm - Avinash Home: how will organise? chapter wise? 14/05/2017, 4:51 pm - Avinash Home: i will collect all at one place 14/05/2017, 4:52 pm - dvp (Vivek): First we need to collect all the cases and organize by numbers or we can divide system wise first. And then we can make chapters. 14/05/2017, 4:52 pm - Avinash Home: okk 14/05/2017, 4:54 pm - dvp (Vivek): Okay. I will collect 2016 and 2017 cases and you can collect 2015 and 2014 cases OR the oppositw 14/05/2017, 5:05 pm - Avinash Home: give me 30. min. dada, will show you something 14/05/2017, 5:05 pm - dvp (Vivek): Okay 🙂🙂 14/05/2017, 5:52 pm - Rakesh Dir: Thanks Vivek and Avinash. Let's do it asap 14/05/2017, 6:00 pm - Avinash Home: http://thescifimed.com/test a password protected case for sharing non de-identified cases in case of serious/emergency to discuss with another expert. password = qwerty 14/05/2017, 6:01 pm - Avinash Home: yes sir 14/05/2017, 6:01 pm - Avinash Home: https://docs.google.com/document/d/1g26kxgNFoVkloELrJhOSKIHCVIIZt2Y8XziRWBq5n3s/edit?usp=sharing 1st case demo for book 14/05/2017, 6:03 pm - dvp (Vivek): Can you tell me a bit more about where should I put the data? And will it automatically generate a google doc format? 14/05/2017, 6:03 pm - Avinash Home: yes dada 14/05/2017, 6:04 pm - Avinash Home: are you on laptop? 14/05/2017, 6:04 pm - dvp (Vivek): Yes 14/05/2017, 6:04 pm - Avinash Home: plz open http://thescifimed.com 14/05/2017, 6:06 pm - Avinash Home: and then click on top to login and then login with your Facebook. 14/05/2017, 6:06 pm - dvp (Vivek): Yes 14/05/2017, 6:07 pm - dvp (Vivek): done 14/05/2017, 6:07 pm - Avinash Home: after login you will see this page 14/05/2017, 6:08 pm - Avinash Home: IMG-20170514-WA0018.jpg (file attached) 14/05/2017, 6:08 pm - dvp (Vivek): Ya 14/05/2017, 6:08 pm - Avinash Home: this is a small social network i have built. like fb but to *learn* collaborative way 14/05/2017, 6:08 pm - Avinash Home: on top you can find cases. 14/05/2017, 6:09 pm - Avinash Home: plz click on cases and then 1st post you will find recent case that i shared here in docs. 14/05/2017, 6:09 pm - Avinash Home: IMG-20170514-WA0019.jpg (file attached) 14/05/2017, 6:10 pm - Avinash Home: i can see you here online now 😊 14/05/2017, 6:11 pm - Avinash Home: i recollected content from blog where the case was initially posted and also discussion from Facebook in google docs. this is just blogging using WordPress platform. 14/05/2017, 6:12 pm - Avinash Home: after case is posted here, all we need is to copy and paste in google docs and un a second book like format is ready. 14/05/2017, 6:13 pm - dvp (Vivek): Actually, this will be a re-blogging and would be of great help in creating cases there. But utilizing it for collecting the cases would add one extra step in making this book, I think, I f I didn't understand wrong 14/05/2017, 6:14 pm - dvp (Vivek): Can it be possible that we put facebook link there and it will will generate a file containing the case plus its discussion? 14/05/2017, 6:14 pm - Avinash Home: also at end of each case in book, this web link can be added to have further discussion 14/05/2017, 6:14 pm - Avinash Home: IMG-20170514-WA0020.jpg (file attached) 14/05/2017, 6:14 pm - dvp (Vivek): We shouldn't add the links in the book, I guess. 14/05/2017, 6:15 pm - dvp (Vivek): Or may be 14/05/2017, 6:15 pm - Avinash Home: not sure. 14/05/2017, 6:15 pm - Avinash Home: but adding as reference will helf exploring further 14/05/2017, 6:15 pm - dvp (Vivek): first of all we need to bring all the cases from tabula rasa and from the blogs of students. And then we will triage the cases. 14/05/2017, 6:16 pm - dvp (Vivek): We are already putting all the details of cases in the blog. So, adding blog link wouldn't add to it. 14/05/2017, 6:17 pm - dvp (Vivek): in the book* 14/05/2017, 6:17 pm - Avinash Home: it is possible by copying. 14/05/2017, 6:17 pm - Avinash Home: okk 14/05/2017, 6:17 pm - Avinash Home: then directly from blog to google docs. can be better. 14/05/2017, 6:17 pm - Avinash Home: 1) blogs to google docs 2) Facebook comments to google docs 14/05/2017, 6:17 pm - Avinash Home: ok? 14/05/2017, 6:18 pm - dvp (Vivek): Ya, how to put blog data into google doc directly? 14/05/2017, 6:19 pm - Avinash Home: open blog, copy it directly top to bottom, paste in docs. 14/05/2017, 6:19 pm - Avinash Home: its fast 14/05/2017, 6:20 pm - Avinash Home: @8801752868045 plz join group http://thescifimed.com/groups/case-discussion 14/05/2017, 6:26 pm - dvp (Vivek): Let's start copy pasting. 14/05/2017, 6:27 pm - Avinash Home: okk 14/05/2017, 6:27 pm - Avinash Home: 👍🏼 14/05/2017, 6:44 pm - Avinash Home: IMG-20170514-WA0021.jpg (file attached) 14/05/2017, 6:44 pm - Avinash Home: @8801752868045 dada plz find this shared folder https://drive.google.com/open?id=0Bziq07duU9QGdWtDS2FaNkVRM28 and add cases. 14/05/2017, 6:45 pm - Avinash Home: i will do 2015 and 2014 14/05/2017, 6:48 pm - dvp (Vivek): Yes, I got it. You did a great job in making this. This will help a lot in putting everything in one place and you have also made a structure of how we would be organizing the cases. 14/05/2017, 6:51 pm - Avinash Home: thanks!! 14/05/2017, 7:04 pm - Avinash Home: http://thescifimed.com/a-26-years-old-man-with-left-hand-matacarpal-bone-fracture/ @919617604831 sir every feature that that was in biohack.in is ready and working now on http://thescifimed.com with inbuilt social network. 14/05/2017, 11:19 pm - Rakesh Dir: Thanks Avinash and Vivek. Good to see this. 🙂 14/05/2017, 11:22 pm - Avinash Home: thanks sir! 15/05/2017, 9:13 am - Rakesh Dir: I think our next step would be to find a table of contents ( may resemble any popular text book format ) and fit our current case list to the table of contents 15/05/2017, 9:57 am - dvp (Vivek): Okay sir. 15/05/2017, 12:45 pm - dvp (Vivek): Two questions sir: 1. What's the minimum or the maximum number of cases I should aim to collect and draft? 2. Does "Conversation" part mean the active discussion occurred around the case or discussions on the general knowledge of that case? 15/05/2017, 4:59 pm - Rakesh Dir: As many cases that can provide a reasonable representation of the final year syllabus in Medicine? 15/05/2017, 5:00 pm - Rakesh Dir: Conversation that reflects general knowledge necessary to help that particular patient at hand? 15/05/2017, 9:36 pm - Rakesh Dir: Here's another recent 8th semester post https://medium.com/@riddhasaha.rs/medicine-case-15a3bf565541 15/05/2017, 10:32 pm - dvp (Vivek): Yes sir. It is well-written with MCQs and theory questions as well. 15/05/2017, 11:03 pm - Rakesh Dir: Here's another one : https://medium.com/@nabyendubiswas/medicine-case-bcf974889af1 16/05/2017, 7:13 pm - dvp (Vivek): Till now, I have collected 55 cases both from the links provided and from Tabula Rasa. And still many more are left to collect. Sir, during this process would you advice to do something else with this? 16/05/2017, 7:26 pm - You changed this group's icon 16/05/2017, 9:24 pm - dvp (Vivek): Avinash, Can you get a chapter list of any popular medical book? 16/05/2017, 11:15 pm - Rakesh Dir added +91 81061 62937 17/05/2017, 12:02 am - +91 81061 62937: Thank you for adding me to the group 17/05/2017, 8:56 am - Rakesh Dir: Avinash can you share what has transpired till now for the benefit of Madhava? 17/05/2017, 12:15 pm - dvp (Vivek): Madhava, We are writing a medicine book where each we will take the real case details from our patients discussed on "Tabula rasa", "UDHC" and the students who shared their cases through blogging. Each case will be divided into Patient History (narrative) Clinical Findings Investigations Management Conversation Theory Questions MCQs 17/05/2017, 12:16 pm - dvp (Vivek): We will try to collect as many many as we can that would cover the final year MBBS. 17/05/2017, 12:20 pm - dvp (Vivek): "Clinical Findings Investigations Management Conversation" These can be found in each case shared on tabula rasa through blogs and we need to re-organize it to a book format and need to write general knowledge around a particular case e.g. if we are narrating a COPD case, then we will make a conversation of general knowledge on COPD, so that students can logically break down the whole case and followed by theory questions and MCQs (we can add these questions from university question papers as well). 17/05/2017, 12:22 pm - dvp (Vivek): Here, we will work together and need your active participation. We are in the phase now where, I am collecting those cases of interest and at the same time>> 17/05/2017, 12:24 pm - dvp (Vivek): 1. we need to draft the collected cases and make a chapter list (we can take any popular medicine book as a help in making our chapter list). Here is a link, https://docs.google.com/document/d/1G7I2NZtnwTMeBEyOwqe8z6pObUitCnBQDEpacaVm7hs/edit you can go though this link where I have collected about 55 cases. 17/05/2017, 12:26 pm - dvp (Vivek): If you feel overwhelmed from my discussion above, ask as many questions as you want to clear your confusions and share your opinion. 17/05/2017, 12:46 pm - +91 81061 62937: I will definitely love to get involved in this project and thanks for sharing it me 17/05/2017, 12:46 pm - +91 81061 62937: I will talk to you in the evening 17/05/2017, 12:52 pm - dvp (Vivek): Sure 17/05/2017, 9:46 pm - Avinash Home: @8801752868045 dada, thanks 17/05/2017, 9:54 pm - Rakesh Dir: The list links have come up very well Vivek and Avinash. Now all we need to do is fit these cases to the table of contents from the most popular book of Medicine that you can find. Should we use the table of contents from Harrison or Davidson? 17/05/2017, 9:55 pm - dvp (Vivek): Sir, they have arranged it like system wise e.g. CVS, respiratory system, GIT. So, should we put like pneumonia, COPD, Lung cancer, ILD under Respiratory system? 17/05/2017, 9:58 pm - +91 81061 62937: If we keep something like that it would be the same book like any other book in the market instead how about something outside the box?? 17/05/2017, 9:59 pm - Rakesh Dir: Yes I like out of the box 🙂 17/05/2017, 10:00 pm - +91 81061 62937: Like start with emergency of a case then by how we managed him at EMERGENCY then at shifted to ward then how did he come to normal 17/05/2017, 10:00 pm - +91 81061 62937: And as I am saying how means what we have there so that the patient has come to normal 17/05/2017, 10:01 pm - Rakesh Dir: Very interesting 17/05/2017, 10:01 pm - +91 81061 62937: So reader can read it like a novel understanding the pathophysilogy and then the investigations and then follow up 17/05/2017, 10:02 pm - dvp (Vivek): Yes, that's the real thing happened with the patient and that we want to let students know. As like they are experiencing a real case while reading book 17/05/2017, 10:02 pm - +91 81061 62937: Beacause I see most my frnds remembering a novel better than a text book 17/05/2017, 10:03 pm - Avinash Home: if pneumonia is 4th topic, lung cancer is 15th. COPD is 19th, hypertension is 33. then after case name in index, we can also add other topic No. like when we are having a case of MI (29th topic) in CVS system in book who also have Lung cancer and hypertension. system : CVS 29 - Myocardial Infarction a) - 55 year male (15, 33) b) - 70 year female ( 4, 19) 17/05/2017, 10:03 pm - Rakesh Dir: So input of patient information from 2 points : casualty and OPD followed by work up and course at ICU, SICU, HDU and general wards 17/05/2017, 10:04 pm - +91 81061 62937: Sir like if we could narrate some incidents like we saw tody in SICU interchange of leads lead to confusion and change in ECG 17/05/2017, 10:04 pm - Rakesh Dir: Yes great ideas here 🙂 17/05/2017, 10:04 pm - +91 81061 62937: Exactly sir 17/05/2017, 10:04 pm - Avinash Home: system : CVS 29 - Myocardial Infarction a) - 55 year male (15, 33) -page 55 b) - 70 year female ( 4, 19) - page 56 .... .... 17/05/2017, 10:04 pm - dvp (Vivek): Madhava, this is a fantastic idea. Can you take one of the case and make a draft? But here, may be many of the real of cases we have, were not presented in the same setting. In that case, we may need to modify our real cases to have such stimulation. 17/05/2017, 10:06 pm - +91 81061 62937: I was thinking if we could share some incidents with your experiences I would love to make a case like that as a draft and show it to you but I needed some time for that 17/05/2017, 10:06 pm - Avinash Home: yes, there are case video serious /movies similar way and they are very easy to recall 17/05/2017, 10:06 pm - dvp (Vivek): We can divide our work 17/05/2017, 10:06 pm - +91 81061 62937: I agree with you avinash 17/05/2017, 10:09 pm - dvp (Vivek): It's a good idea. Now first draft should be made. Madhava, we need to start with our existing cases and as we go through, we will add up more cases/ 17/05/2017, 10:12 pm - Rakesh Dir: Yes this is very similar to our first book that we published where we had conceived of it as a novel. Vivek may have the link to its table of contents 17/05/2017, 10:15 pm - +91 81061 62937: U already published a book sir?? 17/05/2017, 10:16 pm - dvp (Vivek): Sir has many medical books 17/05/2017, 10:17 pm - +91 81061 62937: Ohhh i didnt know that sir 17/05/2017, 10:17 pm - +91 81061 62937: Sorry 17/05/2017, 10:19 pm - dvp (Vivek): Let me re-search that book link 17/05/2017, 10:24 pm - dvp (Vivek): Read this article written by Rakesh sir 17/05/2017, 10:24 pm - dvp (Vivek): I started as a medical student 15 years ago. Now I am part of a teaching faculty, but I still feel like a student. The professor also feels the same way after 40 years. Science is always changing, and whatever we learn today is soon washed away by a deluge of newer evidence. I remember how much I was in awe of my seniors, who always seemed to know so much. I thought that I too would know as much when I got to be a senior. Many years later and that moment of increased knowledge never came; I only find myself being thought of as more knowledgeable by my juniors. Whatever we learnt was instilled in us, such as the capability to apply a rule of thumb in the management of patients. But rules of thumb never work when confronted with diagnostic uncertainty complicated by the dense jungle of 17/05/2017, 10:43 pm - Avinash Home: dada, plz send link 17/05/2017, 10:43 pm - +91 81061 62937: That's awesome sir 17/05/2017, 10:43 pm - Avinash Home: very curious to read more 17/05/2017, 10:43 pm - dvp (Vivek): http://student.bmj.com/student/view-article.html?id=sbmj030241 17/05/2017, 10:43 pm - Avinash Home: thanks! 17/05/2017, 10:45 pm - +91 81061 62937: Thank you bro 17/05/2017, 10:51 pm - Rakesh Dir: Here's the link http://www.igi-global.com/book/user-driven-healthcare-narrative-medicine/41908 To our previous book Scroll down to see the table of contents 17/05/2017, 11:04 pm - dvp (Vivek): Ow thanks sir. I already had it. I was looking for a pdf copy😀😀 17/05/2017, 11:13 pm - dvp (Vivek): http://www.igi-global.com/pdf.aspx?tid=109373&ptid=41908&ctid=15&t=Table%20of%20Contents 21/05/2017, 6:34 pm - dvp (Vivek): Madhava, need your help in accelerating this writing as soon as possible. Let's divide few cases between us. I am feeling a bit overwhelmed thinking about so many cases need to be drafted lol. But I am also excited about it as well. Your writing on clubbing was very nice. We can make at least few first and once we do this, then process down the line will be faster. 21/05/2017, 6:43 pm - +91 81061 62937: Yes I think I took a lot of time to adjusting into the environment and now I am all adjusted and I am sure I will contribute my work towards it more sincerely 21/05/2017, 6:44 pm - +91 81061 62937: So how shall we divide the cases 21/05/2017, 6:44 pm - +91 81061 62937: Is it like shall we do it by systemwise or case wise 21/05/2017, 6:53 pm - dvp (Vivek): No worries Madhava. I took much more than you to adjust myself as I am a slow learner. We can divide cases case wise or system wise, anything u like easier. 21/05/2017, 6:55 pm - Rakesh Dir: Divide them topic wise based on the table of contents of the current popular text book of Medicine 21/05/2017, 7:01 pm - dvp (Vivek): Thanks, Sir. Let's follow this, madhava. I will send you copy of a table of contents from Harrison or Davidson tonight. 21/05/2017, 7:19 pm - +91 81061 62937: Yeah 21/05/2017, 7:19 pm - +91 81061 62937: That will be good 22/05/2017, 8:38 pm - dvp (Vivek): Here is the link to table of contents from Harrison http://www.harrisonsim.com/mm_toc.php 26/05/2017, 9:16 am - dvp (Vivek): http://taniachowdhry.blogspot.in/2017/05/53-years-male-patient-admitted-on-8.html?m=1 26/05/2017, 9:18 am - Rakesh Dir: Yes we hoped to fast track cases such as these into the book 26/05/2017, 9:19 am - dvp (Vivek): I have started drafting sir and already made some cases which i will give you soon for a review. I wish I could have few more students to help here, sir. But, madhava will be able to help me. 26/05/2017, 9:22 am - dvp (Vivek): Sir, if you link to these kind of cases and links, do share. 26/05/2017, 9:22 am - dvp (Vivek): If you get* 26/05/2017, 9:22 am - Rakesh Dir: Sure 26/05/2017, 9:23 am - Rakesh Dir: Have you checked out all the Tabula rasa links? 26/05/2017, 9:23 am - Rakesh Dir: Also the other cases in the same blogs? 26/05/2017, 9:24 am - dvp (Vivek): I have collected around 100-110 cases. Some other cases were very incomplete, so excluded those. Yes sir, Other cases on the same blogs will increase the number. 26/05/2017, 9:29 am - Rakesh Dir: http://globaludhc09.blogspot.in/, http://globaludhc07.blogspot.in/ http://globaludhc26.blogspot.in/ 26/05/2017, 9:31 am - Rakesh Dir: Some blogs done by our "patient information communication managers " above. They may need a lot of working on 26/05/2017, 9:34 am - dvp (Vivek): Sir, there are multiple cases of same disease, so while writing on any topic, should I need to take one best case of that disease? 26/05/2017, 9:35 am - Rakesh Dir: Yes choose the best 26/05/2017, 9:35 am - Rakesh Dir: adhavi: https://www.blogger.com/profile/14713506954507734603 Dr Arti: https://www.blogger.com/profile/08543457215724518158 26/05/2017, 9:36 am - dvp (Vivek): Many cases are in one place. It will help. 01/06/2017, 3:11 am - Avinash Home: @8801752868045 dada, sorry i was off for few days, please suggest any cases that you need me to start drafting. 01/06/2017, 4:29 pm - dvp (Vivek): Right now I am on respiratory system. You can find out cases which has significant information for drafting. 01/06/2017, 4:29 pm - Avinash Home: ok. will find and update tonight 01/06/2017, 4:30 pm - dvp (Vivek): Sir already has given two links with lots of cases above. You may wanna check out those 01/06/2017, 4:35 pm - Avinash Home: yes 01/06/2017, 4:35 pm - Avinash Home: will do them 01/06/2017, 4:54 pm - Rakesh Dir: Thanks Vivek, Good to see this update. Also Madhava has a lot of neuro cases. Some of them can also be published in the Annals of Neurosciences 01/06/2017, 4:55 pm - dvp (Vivek): That is awesome, sir. Madhava is really doing great. 10/06/2017, 9:46 pm - Avinash Home: added in docs 10/06/2017, 9:46 pm - Avinash Home: added in docs 10/06/2017, 9:47 pm - Avinash Home: medicinedepartment.blogspot.in also added 10/06/2017, 9:47 pm - Avinash Home: classworkdecjan.blogspot.com also added 10/06/2017, 9:48 pm - Avinash Home: @918106162937 @8801752868045 plz give your case blog links to add 10/06/2017, 9:49 pm - Avinash Home: some still need to be added from TR and some from udhc.co.in/SOLUTION/solutionList.jsp 10/06/2017, 9:50 pm - Avinash Home: next we need to enrich cases and make drafts for publishing. 10/06/2017, 9:50 pm - Avinash Home: @8801752868045 plz teach how you making drafts. 10/06/2017, 9:51 pm - Avinash Home: 😊 10/06/2017, 10:01 pm - Rakesh Dir: Thanks Avinash 10/06/2017, 10:02 pm - Avinash Home: thanks sir! 10/06/2017, 10:04 pm - Avinash Home: @918106162937 we can read all cases and tag them with chapter/disease so can be indexed and preapred for book. also will be easy to limit cases on same disease 10/06/2017, 10:08 pm - Rakesh Dir: Almost like a case based Wikipedia 🙂 10/06/2017, 10:11 pm - +91 81061 62937: Sure avinash could u please send me link of all cases 10/06/2017, 10:15 pm - Avinash Home: yes here it is https://docs.google.com/document/d/1G7I2NZtnwTMeBEyOwqe8z6pObUitCnBQDEpacaVm7hs/edit?usp=drivesdk 11/06/2017, 12:14 am - dvp (Vivek): Thank you so much Avinash. 11/06/2017, 12:18 am - Avinash Home: welcome dada 11/06/2017, 12:20 am - dvp (Vivek): I am moving like a Turtle in making this book. 11/06/2017, 9:00 am - Rakesh Dir: Very impressive work done till now. 🙂 11/06/2017, 9:01 am - Rakesh Dir: The paper based publishers are also waiting to grab this book. 🙂 11/06/2017, 9:15 am - Avinash Home: Thanks sir! we aiming for paper based publisher. There are enough pictures to go for picture based MCQ based questions. also nearly all cases are good enough to be added in book. 11/06/2017, 9:15 am - Avinash Home: . 11/06/2017, 9:17 am - Avinash Home: to proceed for book, next step i feel are 1) tagging each case with chapter/disease 2) cleaning each case history / data good enough for a book 3) enrich with good theory questions & MCQs. 11/06/2017, 9:19 am - Avinash Home: @8801752868045 is it good? anything to midify? 11/06/2017, 9:19 am - Avinash Home: *modify 11/06/2017, 9:32 am - dvp (Vivek): Yes its very good. If you and madhava could work for no1 & no2 that would boost the process. 11/06/2017, 9:32 am - Avinash Home: ok. sure. will try asap. 11/06/2017, 9:33 am - Avinash Home: @918106162937 can you write one case the way you had said once? 11/06/2017, 9:33 am - Avinash Home: i will try to tag enough cases tonight. to proceed step 2 & 3 11/06/2017, 9:33 am - Avinash Home: in parallel 11/06/2017, 9:34 am - dvp (Vivek): Avinash if you could tag the cases and complete the step 1 that would help a lot. 11/06/2017, 9:34 am - Avinash Home: yes i will complete that 11/06/2017, 9:34 am - dvp (Vivek): Yes. 🙂 11/06/2017, 10:18 am - +91 81061 62937: Yes I will try to do that and send it to you 11/06/2017, 10:27 am - Rakesh Dir: A tentative title for the book is " Cases, conversations and questions (theory MCQs) in Medicine" and if you look at this one http://medicinecase-aparnatewari.blogspot.in/2017/05/mr.html?m=1 It appears to have elements of all three? 11/06/2017, 10:30 am - Rakesh Dir: In those collected online records where we don't have learning conversations similar to the above we may insert the learning conversations in Tabula rasa? 11/06/2017, 10:43 am - Avinash Home: thanks sir. great to see this conversation. yes we can insert from TR & create where not available. 11/06/2017, 10:47 am - dvp (Vivek): 😳 This case discussion is too good, Sir. Where were these discussed? 11/06/2017, 11:30 am - Rakesh Dir: In the Whatsapp group with the 8th semester students (you were not in that group) 🙂 11/06/2017, 4:24 pm - Rakesh Dir: Vivek hope you are in touch with the publisher and do keep calling him from time to time. Let's wrap this up asap 11/06/2017, 4:33 pm - dvp (Vivek): Sure sir. 11/06/2017, 9:06 pm - Rakesh Dir: Sorry we mistakenly started conversing on the other group. Let's get that previous discussion here 11/06/2017, 9:06 pm - dvp (Vivek): Oh yes 11/06/2017, 9:10 pm - Avinash Home: sry, didn't noticed 11/06/2017, 9:11 pm - Avinash Home: IMG-20170611-WA0014.jpg (file attached) 11/06/2017, 9:11 pm - Avinash Home: this way good to tag? 11/06/2017, 9:12 pm - dvp (Vivek): Awesome. Take the best one and tag it. Thanks 11/06/2017, 9:12 pm - Avinash Home: okkk 11/06/2017, 9:14 pm - Rakesh Dir: Interesting so each one of our cases may contain various related or even remotely related chapters. So we may have to develop a new system beyond the current system of anatomical systemic classification of chapters 11/06/2017, 9:15 pm - Avinash Home: yes sir 11/06/2017, 9:15 pm - Avinash Home: 100% needed 11/06/2017, 9:16 pm - Avinash Home: because anatomical way not taking pt. completely 11/06/2017, 9:17 pm - dvp (Vivek): We are making the common one but shall try for that once we build the basic structure. Otherwise I afraid of confusion ☹ 11/06/2017, 9:19 pm - dvp (Vivek): We may write in index like pancytopenia 10, 18, 119 11/06/2017, 9:20 pm - dvp (Vivek): But definately we will discuss all the tagged concepts in a particular case. 11/06/2017, 9:20 pm - dvp (Vivek): Definitely** 11/06/2017, 9:23 pm - Avinash Home: going anatomical indexing way we need to proceed conversation towards that chapter way, going patient centered way indexing we can keep conversation not bound to that organ system but to that patient. i don't know which way is best or attractive to learn, just one view. 11/06/2017, 9:23 pm - Avinash Home: will tag more caeses first, then may be more clear way to go. 11/06/2017, 9:24 pm - Avinash Home: also this way it doesn't tell how focused case and discussion (quantity of information) is on that topic to gain knowledge. 11/06/2017, 9:30 pm - dvp (Vivek): Avinash, can you give an example the way you think? 11/06/2017, 9:30 pm - Avinash Home: trying to understand 11/06/2017, 9:31 pm - Avinash Home: will send here once i can think 11/06/2017, 9:32 pm - Avinash Home: seems like a multidimentional matrix where multiple things (disease) meeting at some point and need to be arranged in single row and column. 11/06/2017, 9:32 pm - dvp (Vivek): Primary thing is to make each case discussion conversations and theory MCQs. Once we do that rest will settled down. And as we move forward everything will be cleared. 11/06/2017, 9:32 pm - Avinash Home: yes 11/06/2017, 10:00 pm - Avinash Home: @918106162937 sry madhava, in this group 11/06/2017, 10:10 pm - +91 81061 62937: Sir and guys I think we should follow ptoent centered way where we have to focus on main complaint and remaining may be the complications of main complaint 11/06/2017, 10:10 pm - +91 81061 62937: So that we could find a link 11/06/2017, 10:11 pm - +91 81061 62937: If we go anatomical way we may get confused which will lead to improper indexing of cases 11/06/2017, 10:11 pm - Avinash Home: then how should we plan index so that it remains correlated with standard textbook to add up to what leant but also giving a pt. centered knowledge. 11/06/2017, 10:11 pm - +91 81061 62937: We should plan system wise it is better 11/06/2017, 10:11 pm - +91 81061 62937: As for example if a patient has COPD and presented with hemiparesis too 11/06/2017, 10:12 pm - +91 81061 62937: We will take it in Respiratory system but not CNS as hemiparesis has developed as a complication of COPD 11/06/2017, 10:13 pm - Avinash Home: so system - common disease - additional condition ? right? 11/06/2017, 10:13 pm - +91 81061 62937: So that we could be explaining what actually happened to patient and we could teach them patient centered learning 11/06/2017, 10:13 pm - +91 81061 62937: Not additional condition may be a complication of the common disease 11/06/2017, 10:14 pm - +91 81061 62937: Yeah but the essence is the same 11/06/2017, 10:17 pm - Avinash Home: okk 11/06/2017, 10:17 pm - Avinash Home: i am tagging cases 11/06/2017, 10:17 pm - Avinash Home: will try to complete tonight 11/06/2017, 10:17 pm - Avinash Home: you can help index them. 11/06/2017, 10:17 pm - Avinash Home: then vivek dada will write chapters, we will see and try to help same 11/06/2017, 10:17 pm - Avinash Home: okk? 11/06/2017, 10:20 pm - dvp (Vivek): We don't need to make index as it can be made only after completing book. Madhava, if you can help in making chapters please 11/06/2017, 10:21 pm - dvp (Vivek): Madhava, you mean to say rather than making "Approach to dyspnea" we should make it like COPD? 11/06/2017, 10:26 pm - Avinash Home: ok dada.. after tagging i will also start in making chapters 11/06/2017, 10:41 pm - Rakesh Dir: Yes the first few chapters in Harrison that introduce approach to problems such as dyspnoea or weakness are more of patient problem focused approaches whereas when the same chapters branch out to various differentials of dyspnoea or weakness we enter the system based approach where all the possible pathologies (morbid anatomies ) of that system is played out. So let's maintain this traditional approach and once we have the first edition published we shall invite our readers to Avinash's website for this book where we can harness the power of the crowd (other interested student contributors) to add more and more cases and chapters for the subsequent volumes as well as our case based database (in Avinash's website ) where soon anyone can key in a few symptoms and find the exact similar case that may have happened to other people of the same age and gender and find out what their past outcomes were and what to expect from their own current problem. 11/06/2017, 10:42 pm - Rakesh Dir: The above may go into our introductory preface? 11/06/2017, 10:53 pm - dvp (Vivek): What's your opinion on the preface madhava and avinash? 11/06/2017, 10:58 pm - Avinash Home: case based studying, MCQ from past year questions, discussion b/w beginner to expert, exploring a case like a medical detective, finding uniqueness in common cases and value of a good history. 12/06/2017, 8:57 am - Avinash Home: https://hme-male-25-yr.blogspot.in/2017/03/25-year-male-case-history-from-2010.html?m=1 12/06/2017, 8:57 am - Avinash Home: IMG-20170612-WA0000.jpg (file attached) 12/06/2017, 9:17 am - Rakesh Dir: Thanks Avinash this is very well done. Was it your blog or done by Rajib or his network? I guess we have the patient's consent? 12/06/2017, 9:18 am - Avinash Home: i didn't made this case sir, this is blogger id https://www.blogger.com/profile/06934399878981457394 12/06/2017, 9:20 am - Rakesh Dir: Alright looks like Rajib and the mission Arogya network 12/06/2017, 9:22 am - Avinash Home: yes sir 12/06/2017, 9:22 am - Avinash Home: and this is a recent post - 18 March 2017 12/06/2017, 9:22 am - Avinash Home: so may be helpful for pt. 12/06/2017, 9:22 am - Avinash Home: and rare diseaseindia is looking for helping rare disease pt. 12/06/2017, 9:23 am - Avinash Home: also with financial and diagnostic aid 12/06/2017, 9:23 am - Avinash Home: afaik 12/06/2017, 9:23 am - Avinash Home: will find and share link here 12/06/2017, 8:12 pm - Rakesh Dir: Good Avinash. Why not tag Rajib with this information about the funding source around the patient record in Tabula rasa 12/06/2017, 8:17 pm - Avinash Home: yes sir i will update him. 12/06/2017, 8:19 pm - Avinash Home: but unable to find helpful link. 12/06/2017, 8:19 pm - Avinash Home: will update as soon i find. 13/06/2017, 6:59 pm - dvp (Vivek): Today MMSE concept saved me a lot 😜 13/06/2017, 7:00 pm - dvp (Vivek): I was feeling dumb in the class but as soon as they asked about altered sensorium and MMSE, I felt like Let's do it 13/06/2017, 7:17 pm - Rakesh Dir: Great to hear this Vivek. 🙂 17/06/2017, 6:34 am - Avinash Home changed from +91 95655 00640 to +91 91406 54820 17/06/2017, 6:39 am - Avinash Newest left 18/06/2017, 1:22 pm - dvp (Vivek): <Media omitted> 18/06/2017, 1:23 pm - dvp (Vivek): Please just have a look at this pdf which I started for our book. Approach to pleural effusion will be discussed too. 18/06/2017, 1:24 pm - Rakesh Dir added Avinash Newest 18/06/2017, 1:24 pm - dvp (Vivek): I just wanted to know if I am moving in a right way 18/06/2017, 1:26 pm - Rakesh Dir: Looks good. Is it one of our patients. Do we have his prior link? 18/06/2017, 1:26 pm - dvp (Vivek): Yes sir 18/06/2017, 1:26 pm - dvp (Vivek): https://medium.com/@riddhasaha.rs/medicine-case-15a3bf565541 18/06/2017, 1:26 pm - Rakesh Dir: The opening with CASE is quite good 18/06/2017, 1:26 pm - Rakesh Dir: The conversation perhaps didn't happen here? 18/06/2017, 1:27 pm - dvp (Vivek): No sir 18/06/2017, 1:28 pm - Rakesh Dir: That is better labelled DISCUSSION then 18/06/2017, 1:28 pm - Rakesh Dir: Part of the case 18/06/2017, 1:28 pm - Rakesh Dir: Will be looking forward to the conversation 18/06/2017, 1:30 pm - dvp (Vivek): Sir, if a case doesn't have any conversations then what should we do? 18/06/2017, 1:32 pm - Rakesh Dir: We may need to begin one? 18/06/2017, 1:33 pm - Rakesh Dir: What are the basic questions that anyone would have for a particular case? 18/06/2017, 1:33 pm - Rakesh Dir: Where is the problem? 18/06/2017, 1:34 pm - Rakesh Dir: Anatomically it is in the pleura. 18/06/2017, 1:34 pm - Rakesh Dir: Obvious 18/06/2017, 1:34 pm - Rakesh Dir: But realistically? 18/06/2017, 1:35 pm - Rakesh Dir: Sorry etiologically 18/06/2017, 1:35 pm - Rakesh Dir: At a cellular level, at a molecular level where is the problem? 18/06/2017, 1:37 pm - Rakesh Dir: What did we do for this patient? 18/06/2017, 1:41 pm - dvp (Vivek): http://medicinecase-aparnatewari.blogspot.in/2017/05/mr.html?m=1 As in this case where teacher is asking questions around that case and diaglogues are made between teacher and student? 18/06/2017, 1:43 pm - dvp (Vivek): Teacher: How we differentiate trasudaive and exudative pleural effusion? Student: Answered? 18/06/2017, 2:56 pm - Rakesh Dir: Yes but eventually all the questions will lead us to answer two basic questions i e where is the anatomical, pathological $cellular) and biochemical (molecular )location of the problem and are the pharmacological and non pharmacological solutions for it. 18/06/2017, 3:08 pm - Rakesh Dir: Yes but eventually all the questions will lead us to answer two basic questions around every case i e where is the anatomical, pathological (cellular) and biochemical (molecular)location of the problem and what are the pharmacological and non-pharmacological solutions for it. 18/06/2017, 4:33 pm - Rakesh Dir: Trying to manage time to work on the preface. 🙂 Quite difficult to find time here particularly without any elective students to help out with our patients 18/06/2017, 10:40 pm - dvp (Vivek): Sure sir. In that case we may need to make conversations because many conversations are satisfactorily leading us to that two answer. 18/06/2017, 10:41 pm - Avinash Newest: thanks for adding me sir.😊 18/06/2017, 10:45 pm - dvp (Vivek): We miss those times badly when we used to be a part of the clinical team and we were experiencing like that we are really part of a bigger thing than ourselves. This is a really rare thing that we, medical students, are given main clinical responsibility and take over the care of our patients. 18/06/2017, 10:47 pm - Rakesh Dir: I have nearly finished the first draft of my preface mainly inspired by the fact that you are all working on the chapters. Will post it shortly below 18/06/2017, 10:52 pm - Avinash Newest: yes sir 18/06/2017, 10:53 pm - dvp (Vivek): okay sir 18/06/2017, 11:10 pm - Rakesh Dir: Preface to first edition "Cases, conversations and questions (theory and MCQs) in Medicine 18/06/2017, 11:10 pm - Rakesh Dir: Preface : The cases in this book begin with the patient history narrative and quickly move over to clinical findings, investigations and management followed by conversations and theory questions and MCQs that tries to address an important requirement for all students who definitely need to leverage case based learning to further their academic careers in the pursuit of further post graduate degrees. In the Indian subcontinent the undergraduate medical degree is known as MBBS and the post graduate residency completion is certified with an MD degree and completion of a fellowship in a subspecialty is further certified with a DM degree and this book is a primer to enable most medical students to achieve their career goals that not only hover around these degrees but also move beyond them to create a life long self directed and collaborative learning ecosystem. " The prevalent system of Undergraduate Medical Education in the Indian subcontinent by and large thrives on a system of didactic lectures or antiquated textbooks based teaching-learning rather than dynamic patient based interaction. Couple that with minimal motivation and future incentives for students pursuing undergraduate research as well as the lack of formal training, a graduate medical doctor is not equipped with the basic mandatory skill set of appraising available evidence for treating patients in his practise."1 "While lack of time and incentives are not an insurmountable roadblock, what further complicates the situation is the failure to find like minded academic peer groups and the absence of mentors which really dent the interest of even students ready to break through the barriers."2 The current text book has been developed "harnessing the power of Web 2.0, where social media, dynamic interaction and academic learning all join forces to not only better patient care but improve medical student learning. Case based patient centered narratives can improve learning experiences, instill stronger confidence in decision making, and inculcate learning based on real world scenarios with a tangible consequence."2 This not only forces the student to think on his feet but also allows him to develop confidence in his decision making process especially with the gratification of knowing that his management strategy can be used effectively in an actual setting."2 The first edition and first volume of this book shall be a primer to many more volumes to come along with a website that may act as a case based reasoning database where more and more students and physicians will be encouraged to submit their cases in the format presented in this book such that anyone keying in the symptoms of their case at hand can easily find a few/many similar cases with their outcomes to draw inferences on their current cases and subsequent work will enable automated case based reasoning engines to draw these inferences. This will be a significant contributor to a fast growing field called 'patient centered outcomes research.'3 We wish the best for this team comprising of students and teachers who worked hard toward achieving an important milestone with completion of the first edition and first volume and look forward to many more volumes and audience feedback. The proceeds from this book shall be utilized by the authors and editors to create a patient centered learning fund to help patients and further learning and research in this evolving area. References 1. Amy P, Shivika C, Kaustav B . In. Understanding Clinical Complexity through conversational learning in medical social networks: Implementing User Driven Health care. In: J.P SturmbergCarmel. M Martin Ed., editor. Handbook on Complexity in Health. New York, NY: Springer; 2013. pp. 767–793. 2. Bera, K., Seth, B., & Biswas, R. (2013). Conversational learning among medical students: harnessing the power of web 2.0 through user driven healthcare. Annals Of Neurosciences, 20(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117104/ 3. Gabriel SE, Normand S-LT: Getting the methods right - the foundation of patient-centered outcomes research. N Engl J Med 2012;367:787-790. http://www.nejm.org/doi/full/10.1056/NEJMp1207437 18/06/2017, 11:24 pm - Rakesh Dir: So Vivek we can now begin the conversations for each one of your chapters and ensure that we are able to finally answer those two afore mentioned basic questions around your patients and following that you may also add the university theory questions as well as USMLE MCQs 18/06/2017, 11:24 pm - Rakesh Dir: Let's complete one chapter for each system to begin with 18/06/2017, 11:33 pm - dvp (Vivek): Sure sir. One thing I still want to clear myself that how the conversation will be formatted in the book like a dialogue between a teacher and a student? "begin the conversations" means we will discuss a particular case here until we are able to get the answers (if not discussed anywhere)? 18/06/2017, 11:34 pm - dvp (Vivek): Although I am asking the same question but if I could get clear idea that would be so helpful for me. 18/06/2017, 11:35 pm - Rakesh Dir: Yes right. We shall again discuss the case if it hasn't been discussed already or fully in Tabula rasa 18/06/2017, 11:37 pm - dvp (Vivek): Thank you. 🙂 Let's start a discussion on the pleural effusion case. (Madhava and Avinash?) 18/06/2017, 11:39 pm - Avinash Newest: yes 18/06/2017, 11:39 pm - Avinash Newest: which case no. ? 18/06/2017, 11:41 pm - dvp (Vivek): I am sharing it below 18/06/2017, 11:41 pm - Avinash Newest: okk 18/06/2017, 11:40 pm - dvp (Vivek): CASE HISTORY: A 60-year-old-male, carpenter by occupation admitted to the hospital with the complaints of fever since last 2 months which characterized by evening rise in temperature and left-sided chest pain associated with a dry cough for past 25 days. He also added that he has difficulty in breathing for last 15 days. Previously, he was taking NSAIDS to reduce fever. After taking medications fever subsided, but few days’ later patient started feeling those symptoms with a continued rising temperature. Patient has a significant history of smoking and chewing tobacco for last 35 years. The patient also had a history of difficulty in breathing during heavy work for a certain period of time since past 40 years. On November 2016, he went through a cardiac surgery in Bangalore and following which his breathing difficulty improved. 18/06/2017, 11:40 pm - dvp (Vivek): Physical Examination: General examination: The respiratory rate was 24/min, pulse rate was 80/min with a normal rhythm, and blood pressure was 110/70 mmHg, and a temperature was 99° F. Respiratory system examination: On Inspection, respiration was abdominothoracic in type, diminished movement of the chest on left side and patient was using accessory muscles. On palpation, his trachea was in normal position and apex beat could not be localized, vocal fremitus was diminished on the left side but normal palpatory findings on right sided chest. On Percussion, revealed Stony dullness on middle and lower zones of left sided chest which does not alter with a change in posture. Shifting dullness was absent. On Auscultation revealed diminished vesicular breath sound on left side and normal in the right side. Vocal resonance diminished on left side, normal vocal resonance on right side. 18/06/2017, 11:46 pm - Avinash Newest: cough for 25 days (more than 3 weeks) is it TB? 18/06/2017, 11:47 pm - Avinash Newest: also smoking tobacco and carpeter indicate may be some occupational effect and respiratory disease. right? 18/06/2017, 11:48 pm - Avinash Newest: 1 key point i get is left sided chest pain, need to ascultate there 18/06/2017, 11:49 pm - Avinash Newest: also i will look for if chest is barrel shape 18/06/2017, 11:50 pm - Avinash Newest: what was caridac surgery? 18/06/2017, 11:50 pm - dvp (Vivek): diminished vesicular breath sound and vocal resonance on left side 18/06/2017, 11:50 pm - Avinash Newest: it all indicate to damage in lower left lung. 18/06/2017, 11:51 pm - Avinash Newest: no shifting dullness so may not be pleural effusion 18/06/2017, 11:51 pm - Avinash Newest: did we had a xray or something to look at his lungs? 18/06/2017, 11:52 pm - dvp (Vivek): IMG-20170618-WA0000.jpg (file attached) 18/06/2017, 11:54 pm - Rakesh Dir: Clinically even minus the CxR pa it does fit in to a pleural effusion 18/06/2017, 11:55 pm - Rakesh Dir: Shifting dullness is not an often utilized criteria for pleural fluid 18/06/2017, 11:56 pm - Avinash Newest: got it sir, i was expecting it effusion but confused on shifting dullness point. 18/06/2017, 11:57 pm - Avinash Newest: he is having fever since 2 months 18/06/2017, 11:58 pm - Avinash Newest: so this may be time when infection started in his body 18/06/2017, 11:58 pm - Avinash Newest: or in left side of lung 18/06/2017, 11:59 pm - Avinash Newest: and it progressing so cough (dry) and then difficulty in breathing 18/06/2017, 11:59 pm - Avinash Newest: if this pt. tested his chest might be barrel shaped 18/06/2017, 11:59 pm - Avinash Newest: and lesser movement on left lungs 19/06/2017, 12:01 am - Avinash Newest: to correctly identify what infection it is we need to do sputum culture. right? 19/06/2017, 12:01 am - Avinash Newest: or take fluid out by pleural tap to culture if possible 19/06/2017, 12:02 am - dvp (Vivek): The patient presenting with evening rise of temperature (2 months) with left sided chest pain associated with a dry cough (25 days) and shortness breath (15. 19/06/2017, 12:02 am - Avinash Newest: (pleural tap needle is inserted in lower part of upper rib, right? ) 19/06/2017, 12:03 am - Avinash Newest: once we identify bacteria in culture we can give targetted antibiotics for that 19/06/2017, 12:04 am - dvp (Vivek): where we see evening rise in temparature? 19/06/2017, 12:04 am - Avinash Newest: but how we can access harm done by tobacco + smoking + occupational hazard in carpentry 19/06/2017, 12:04 am - Avinash Newest: in Tuberculosis? 19/06/2017, 12:05 am - Avinash Newest: also in malaria but with shivering and sweating. right? 19/06/2017, 12:06 am - dvp (Vivek): We do see it in tuberculosis but there are some other conditions where also we see it. 19/06/2017, 12:07 am - Avinash Newest: IMG-20170618-WA0001.jpg (file attached) 19/06/2017, 12:07 am - dvp (Vivek): What evening rise in temperature signifies when a patient reveals in the history? 19/06/2017, 12:07 am - Avinash Newest: i am reading about evening rise in Temperature and will get back here asap 19/06/2017, 12:14 am - Avinash Newest: i found that evening rise indicates to Tuberculosis 19/06/2017, 12:15 am - Avinash Newest: if pt. reveals in history. 19/06/2017, 12:16 am - Avinash Newest: we need to start his ATT 19/06/2017, 12:17 am - Avinash Newest: and NSAIDS for fever 19/06/2017, 12:17 am - Avinash Newest: right? 19/06/2017, 12:17 am - Avinash Newest: and confirm by culture 19/06/2017, 12:17 am - Avinash Newest: and tap fluid if its more in quantity 19/06/2017, 12:18 am - dvp (Vivek): No avinash, we need to approach logically and confirm diagnoais before starting treatment. 19/06/2017, 12:18 am - dvp (Vivek): I will explain the evening rise in temperature 19/06/2017, 12:20 am - Avinash Newest: and we confirm by culture only. right? 19/06/2017, 12:20 am - Avinash Newest: okk 19/06/2017, 1:02 am - dvp (Vivek): Evening rise in temperature could be seen in any chronic inflammatory state like in TB or even in Malignancy. 19/06/2017, 1:02 am - dvp (Vivek): There are two possible explanations. 1. Cortisol Diurnal rhythm: Cortisol is secreted in a diurnal variation i.e. higher during the daytime and lesser in the evening. Cortisol is an anti-inflammatory hormone, hence keeps the inflammatory markers in check during the day while due to its low level during the evening, the inflammatory chemicals rise leading to fever in the evening. In TB cytokines specifically IL-1 level markedly increases that leads to fever, but as cortisol level is also HIGHER THAN NORMAL due to it (TB) being a chronic inflammatory state, it counteracts the action of IL-1 & as a resulting fever remains low grade and it is elevated in evening. 19/06/2017, 1:04 am - dvp (Vivek): 2.lower in the mornings. There is a chronic low-level inflammation in TB and fever is one of the manifestations of inflammation which become obvious in the evening. 19/06/2017, 1:05 am - dvp (Vivek): 2. Diurnal variation of body temperature: Body temperature varies according to the activity and highest in the evening and lower in the mornings. There is a chronic low level inflammation in TB and fever is one of the manifestations of inflammation. Which become obvious in the evening 19/06/2017, 1:20 am - Avinash Newest: so now i have info about evening fever and possibility of TB by symptoms. how to confirm? 19/06/2017, 1:21 am - Avinash Newest: and as he is chronic smoker tobacco consumer, how can i conclude there is no malignancy 19/06/2017, 1:24 am - dvp (Vivek): Great question. Once we have history and physical exam findings suggestive of a left sided pleural effusion, now we need to do thoracocentesis for pleural tapping 19/06/2017, 1:25 am - dvp (Vivek): Can we answer how much fluid is clinical detectable and how much is in chest radiograph? 19/06/2017, 1:26 am - dvp (Vivek): What are we aiming for by pleural tapping? 19/06/2017, 1:27 am - dvp (Vivek): I am asking questions pretending to be rakesh sir 😜😜 19/06/2017, 1:27 am - Avinash Newest: 😊😊👍🏻👍🏻 19/06/2017, 1:28 am - Avinash Newest: clinically detectable means how much we get after thoracocentesis? 19/06/2017, 1:29 am - Avinash Newest: how we will answer? 19/06/2017, 1:30 am - Avinash Newest: thoracocentesis is done to remove fluid for relief and culture? 19/06/2017, 1:31 am - dvp (Vivek): As we are telling that patients physical exam findings are suggesting PE. So how much fluid should be accumulated for clinical detection 19/06/2017, 1:32 am - dvp (Vivek): Yes we do diagnostic pleural taping and therapeutic taping. 19/06/2017, 1:34 am - dvp (Vivek): What's the first thing we want to evaluate apart from culture in diagnostic taping? 19/06/2017, 1:36 am - Avinash Newest: gross appearance, turbidity, pus, blood cells 19/06/2017, 1:39 am - dvp (Vivek): Before diagnosing it tuberculosis (infections》inflammation) or malignancy, would you like to see of it is transudative or exudative? 19/06/2017, 1:39 am - dvp (Vivek): If** 19/06/2017, 1:42 am - Avinash Newest: yes 19/06/2017, 1:44 am - dvp (Vivek): How would you do that once you have fluid in a container of your hand? 19/06/2017, 1:45 am - dvp (Vivek): Any criteria you would like to see? 19/06/2017, 5:14 am - Avinash Newest: transudate will be clear while exudate may not be clear and have blood cells etc.. 19/06/2017, 5:15 am - Avinash Newest: and biochemical differences also 19/06/2017, 5:15 am - Avinash Newest: i had forgotten so cheked here 19/06/2017, 5:16 am - Avinash Newest: IMG-20170619-WA0000.jpg (file attached) transudate v/s exudate 19/06/2017, 5:17 am - Avinash Newest: i expect it to be exudate as its possibility to be caused by infection 19/06/2017, 5:21 am - Avinash Newest: i never thought infection and inflammation differently in a disease. treatment plan will be different in both cases.? how we will diffrentiate here if its a infection or inflammation? 19/06/2017, 8:07 am - +91 81061 62937: If it is a infection we can see some bacteria in culture if it is a inflammation we can see neutrophils and monocytes increase 19/06/2017, 8:08 am - Avinash Newest: and treatment plan? 19/06/2017, 8:08 am - Avinash Newest: same or different? 19/06/2017, 9:09 am - Rakesh Dir: Good questions Avinash, Madhava and Vivek, I think we shall need to begin our exploration and trying to find out the answers right from clinical localization that the anatomical localization is indeed a pleural effusion till we move deeper into the patient's pathology (cells) and biochemistry (molecules). 19/06/2017, 9:13 am - Rakesh Dir: So can one of us list out the salient clinical features in this patient that enabled our diagnosis of left sided pleural effusion as opposed to let's say a pneumothorax. These may be of historical importance considering that it has been more than 100 years since the CxR pa view but perhaps these are skills that could come in handy someday if/when we may need to work in a place without an X-ray and also they may help us to decide as to who may require an X-ray? 19/06/2017, 9:14 am - Rakesh Dir: Our conversations will be broken and asynchronous due to our individual work pressures but I am sure we shall achieve our learning outcomes even in this asynchronous manner 19/06/2017, 9:15 am - Rakesh Dir: Could we have just ordered a chest X-ray in this patient on the basis of history alone? Perhaps yes? 19/06/2017, 9:21 am - Avinash Newest: clinical features in this patient indicating pleural effusion ( @8801752868045 but i don't know which one to use to compare against pneumothorax ) 1) left sided chest pain 2) difficulty in breathing 3) diminished movement of chest on left side 4) using accessory muscles for breathing 5) stony dullness 6) diminished vesicular breathe on left side 7) vocal resonance diminished on left side. 19/06/2017, 9:22 am - Avinash Newest: yes sir, learning here feels like i am in online electives, asking anything, reading revising, exploring to find answers and learn patient centered way. 😊😊 19/06/2017, 9:30 am - Rakesh Dir: Let's do some micro learning from what you mentioned : 1. What does his left sided chest pain signify? 2. Why and when does difficulty in breathing happen in pleural effusion? And fill in the rest... 19/06/2017, 9:59 am - dvp (Vivek): Pericarditis, costochondritis, GERD, intercostal neuralgia, pneumonia, pleurisy, myocarditis 19/06/2017, 10:28 am - dvp (Vivek): But for this patient left sided chest pain associated with cough tells a pleuritic kind of chest pain. 19/06/2017, 10:33 am - dvp (Vivek): Difficulty in breathing occurs due to stimulation of J receptors in the lung which is an attempt to compensate for the reduced lung volume due to pleural effusion!? 19/06/2017, 11:49 am - dvp (Vivek): Improvements in ventilatory capacity and lung volumes following pleural drainage are small, and correlate poorly with the volume of fluid drained and the severity of breathlessness. Rather than lung compression, expansion of the chest wall, including displacement of the diaphragm, appears to be the principle mechanism by which the effusion is accommodated. Deflation of the thoracic cage and restoration of diaphragmatic function after thoracentesis may improve diaphragm effectiveness and efficiency, and this may be an important mechanism by which breathlessness improves. https://www.ncbi.nlm.nih.gov/pubmed/25978627 19/06/2017, 11:52 am - Rakesh Dir: Excellent Vivek 19/06/2017, 8:12 pm - Rakesh Dir: So clinically Avinash your patient satisfied all the above criteria and the CxR pa was also nearly confirmatory of a left sided pleural effusion. Now to get into the pathology and biochemistry of the lesion. 19/06/2017, 8:13 pm - Rakesh Dir: Vivek can you share some data from this patient that will lead us to it? 19/06/2017, 8:22 pm - dvp (Vivek): Actually the patient's online record had up to this only and pleural taping reports were not included "The patient’s complete blood count was 3.45 million cells/cubic mm, hemoglobin was 9.2 gm/dl, and hematocrit was 30.3, MCV was 87.8, MCH was 26.7, MCHC was 30.4, increased ESR, total leucocyte count was 9200 cells/cubic mm, differential count was for- neutrophils 64%, lymphocytes 25%, eosinophils 6%, and monocytes 5%, platelet count was 5.5, PT-INR 7.04" 19/06/2017, 8:23 pm - dvp (Vivek): 😟😟 19/06/2017, 8:40 pm - dvp (Vivek): Actually, all cases have some parts incomplete like in this case clinical examination findings were good but no reports suggesting nature of fluid. 19/06/2017, 8:44 pm - Rakesh Dir: No problem Vivek let us search out all the pleural effusion records that we have and see what we can do. Let's all get into our online records and fish out all the pleural effusion pieces and share the data here? The original website udhc.co.in was recently deactivated and actually contained a lot of patient data 19/06/2017, 8:45 pm - Avinash Newest: good eve sir and dada. sorry i was inactive and sleepy today. 19/06/2017, 8:47 pm - Avinash Newest: this is also logic for therapeutic thoracocentesis. right? 19/06/2017, 8:49 pm - dvp (Vivek): Yes that is a therapeutic thoracocentesis 19/06/2017, 8:49 pm - Avinash Newest: i am tagging cases so it may be easier to fish out faster all data on pleural effusion. trying to finish soon. 19/06/2017, 8:49 pm - dvp (Vivek): Yes that would be so helpful 19/06/2017, 8:50 pm - Avinash Newest: udhc.co.in if its online next time, i will try to backup whole website offline. didn't expected so haven't downloaded website offline 19/06/2017, 8:51 pm - Rakesh Dir: Thanks Avinash can you ask Rajib if all that data can be salvaged now? 19/06/2017, 8:51 pm - Avinash Newest: yes sir i will ask in email ans try to do that soon. 19/06/2017, 8:51 pm - Avinash Newest: its important resource and can be kept running offline, or other ways. 19/06/2017, 8:52 pm - Rakesh Dir: Meanwhile I shall try to explore the blog links and try and find out a few more pleural effusion records we made in the past 19/06/2017, 8:52 pm - Avinash Newest: i will do that sir asap in some time when i reach college lab and get wifi. 19/06/2017, 9:03 pm - Rakesh Dir: Meanwhile one easy way to search for pleural effusion records (or for that matter any topic) is to type it out in Tabula rasa and see : Here's the first one http://udhc432.blogspot.in/2016/04/zanonia462indica-jst-45yr-old-man-with.html?m=1 19/06/2017, 9:07 pm - dvp (Vivek): Oh yes sir. Its really an easy way to find the cases. 19/06/2017, 9:08 pm - Rakesh Dir: Another one : Interestingly Avinash although the main udhc.co.in is non functional I could open the patient record housed there from its link shared earlier in Tabula rasa. Here I copy it again : http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1801 19/06/2017, 9:23 pm - Avinash Newest: ok sir, then i will go on saving all these cases from links 19/06/2017, 9:23 pm - dvp (Vivek): Its opening here with even 19/06/2017, 9:23 pm - dvp (Vivek): http://www.udhc.co.in/ 19/06/2017, 9:26 pm - Avinash Newest: yes working, issue was with www as its not setup that way.😊 19/06/2017, 9:30 pm - Rakesh Dir: Great so if we start picking up topics and search out those from Tabula rasa we can break rapid ground in creating our chapters 19/06/2017, 9:31 pm - Avinash Newest: yes sir 19/06/2017, 10:10 pm - Rakesh Dir: Vivek let me know how you would like to blend all the pleural effusion records in one chapter 19/06/2017, 10:25 pm - Avinash Newest: starting discussion from one case to follow steps - anatomy - pathology ....while adding next case to continue discussion from previous one and ending chapter with some case reports references in end ? 19/06/2017, 10:31 pm - dvp (Vivek): One way I am thinking is we can add Case 1 and Case 2 (As our discussion is ultimately having a common goal). Without this one simple thing would be to filll up the missing part in the case. (As our case had evening rise in temperature so another case with established tuberculosis can be integrated) but the reality will be lost. 19/06/2017, 10:40 pm - Avinash Newest: https://www.facebook.com/groups/tabularasa/search/?query=pleural 18 posts in TR only. 19/06/2017, 11:14 pm - Rakesh Dir: Alright let's try to answer the pathology (cells) and biochemistry (molecule) question around the first patient by moving on to available data from the second (or 3,4,...n th) patient and see how it works out? 19/06/2017, 11:30 pm - Avinash Newest: ok sir 20/06/2017, 2:33 am - Avinash Newest: UDHC website download. not 100% but maximum available as offline access. will be able to share it also anyday whenever needed later.😊 20/06/2017, 7:10 am - Rakesh Dir: Thanks Avinash this is great news. 🙂 20/06/2017, 7:11 am - Avinash Newest: thanks sir! 20/06/2017, 7:11 am - Avinash Newest: today i will download other blogs also. 20/06/2017, 7:12 am - Rakesh Dir: Yes that will be very useful 20/06/2017, 7:13 am - Rakesh Dir: Perhaps we can upload all of them again in a single website? 20/06/2017, 7:14 am - Avinash Newest: yes sir, its very easy to do that once all downloaded. 20/06/2017, 7:14 am - Avinash Newest: i can that too, within this month. will try. 20/06/2017, 7:32 am - Rakesh Dir: Thanks 20/06/2017, 7:33 am - Avinash Newest: my pleasure sir! 20/06/2017, 7:33 am - Rakesh Dir: Shall we now try to answer the pathology (cells) and biochemistry (molecule) question around the first patient by moving on to available data from the second (or 3,4,...n th) patient and see how it works out? 20/06/2017, 7:39 am - Avinash Newest: infection is since 2 month's so can we call it chronic? 20/06/2017, 7:42 am - Avinash Newest: etiology of this effusion seems to be TB that we are yet to confirm. 20/06/2017, 7:47 am - Avinash Newest: but how to understand mechanism behind this infection reading to effusion? 20/06/2017, 8:27 am - Rakesh Dir: Yes to do that first we may have to collect enough evidence that this effusion is because of an infection and not neoplasm 20/06/2017, 8:30 am - Rakesh Dir: Anatomically speaking if this is a neoplasm one may be able to demonstrate a mass on CT behind the pleural effusion that is otherwise the only thing currently visible on your patient's CxR 20/06/2017, 8:35 am - Rakesh Dir: But Vivek I guess in this patient we do not have any further data beyond the CxR pa? 20/06/2017, 8:37 am - dvp (Vivek): Yes sir. We don't have further data beyond CXR and some blood investigations for this case 20/06/2017, 8:42 am - Avinash Newest: IMG-20170620-WA0001.jpg (file attached) 20/06/2017, 8:42 am - Avinash Newest: another pleural effusion case but with neoplasm 20/06/2017, 8:43 am - Avinash Newest: IMG-20170620-WA0002.jpg (file attached) 20/06/2017, 8:43 am - Avinash Newest: http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1352 20/06/2017, 8:44 am - dvp (Vivek): http://bmjcaselogvivek.blogspot.in/2017/02/multidimensional-challenges-in.html 20/06/2017, 8:45 am - dvp (Vivek): This is the case where we were suspecting malignancy and advised ATT on shared decision. 20/06/2017, 8:48 am - dvp (Vivek): UG guided- diagnostic pleural fluid tap was done showing: 20/06/2017, 8:51 am - dvp (Vivek): Fluid for sugar: 50 mg/dl, protein: 4.6 g/dl, fluid for ADA, 16 U/L, LDH 282 U/L. Serum LDH 158. 20/06/2017, 8:56 am - dvp (Vivek): Serum total protein 7 gm/dl 20/06/2017, 9:27 am - dvp (Vivek): Pleural fluid can be exudative or transudative. Any disease process that will distort Starling forces (body fluid mechanics) will build transudative fluid (low protein fluid) e.g. in CCF (due to high capillary hydrostatic pressure) or liver failure and nephrotic syndrome (due to low oncotic pressure from low protein in the blood). Inflammation due to any cause, and malignancy will build exudative fluid (either by increasing vascular permeability and/or by lymphatic obstruction). 20/06/2017, 9:31 am - dvp (Vivek): One of the first things we may want to tap pleural fluid is to establish if it is transudative or exudative in nature. Because if we can differentiate it then e.g. if it is trasudative then all the causes that disturb starling forces will be in the differential diagnosis and it will be unlikely that patient have malignancy or inflammatory conditions like Tb. 20/06/2017, 9:50 pm - dvp (Vivek): Avinash, can you name the criteria we use to differentiate exudates from transudates and can you interpret from the values mentioned above? I will then show then the microscopic findings of pleural fluid also 20/06/2017, 10:36 pm - Rakesh Dir: Avinash your call 21/06/2017, 8:52 am - +91 81061 62937: IMG-20170621-WA0001.jpg (file attached) 21/06/2017, 8:52 am - +91 81061 62937: IMG-20170621-WA0000.jpg (file attached) 21/06/2017, 8:53 am - +91 81061 62937: The above are the list of criteria through which we can differentiates exudates from transudate 21/06/2017, 8:53 am - +91 81061 62937: Sorry I couldn't participate in the above discussion as I was busy with some exams 21/06/2017, 10:01 am - dvp (Vivek): Out of these which one you think is most appropriate? 21/06/2017, 10:03 am - +91 81061 62937: We can go with lights criteria or LDH / Serum LDH 21/06/2017, 10:04 am - +91 81061 62937: As they have high sensitivity 21/06/2017, 10:05 am - dvp (Vivek): Awesome lets use light criteria from the above values 21/06/2017, 10:11 am - +91 81061 62937: O.6 protein value which states it is exudate and 1.7 for LDH which also suggests the exudate nature of the fluid (Reference : pleural protein/ serum protein >0.5 exudate and pleural LDH / Serum LDH >0.6 is exudate) 21/06/2017, 10:12 am - +91 81061 62937: So from the above findings it is exudate in nature 21/06/2017, 10:12 am - +91 81061 62937: The reference value is the lights criteria 21/06/2017, 10:21 am - Rakesh Dir: This http://bmjcaselogvivek.blogspot.in/2017/02/multidimensional-challenges-in.html is the current case under discussion? Good. 21/06/2017, 10:21 am - dvp (Vivek): Yes sir 21/06/2017, 10:22 am - Rakesh Dir: I feel we can discuss all the representative cases etiologically for any topic 21/06/2017, 10:23 am - Rakesh Dir: So after this we may discuss a case of congenital, immune and infection mediated inflammation as well a case of neoplasm for our current topic of pleural effusion 21/06/2017, 12:46 pm - Rakesh Dir: So Madhava and Vivek we now know that your current patient under discussion is an elderly man with an exudative pleural effusion. What is the cause (pathology or Microbiology) of this exudative pleural effusion? 21/06/2017, 10:46 pm - dvp (Vivek): I am extremely sorry for being late today 21/06/2017, 10:50 pm - +91 81061 62937: Can we rule out TB with negative mantaux test 21/06/2017, 10:50 pm - dvp (Vivek): No 21/06/2017, 10:50 pm - +91 81061 62937: How do we rule out TB 21/06/2017, 10:50 pm - dvp (Vivek): ManToux test just shows that patient has immunity against TB 21/06/2017, 10:51 pm - +91 81061 62937: If we want to confirm a case of TB what is the specific test that to be done 21/06/2017, 10:52 pm - +91 81061 62937: Initially as per protocol sputum test and chest X RAY 21/06/2017, 10:52 pm - +91 81061 62937: How can we confirm it as a case of TB 21/06/2017, 10:52 pm - +91 81061 62937: Bro 21/06/2017, 11:24 pm - Rakesh Dir: Madhava if you look at the next step in pleural fluid evaluation other than biochemistry you may have the answer (cell type and counts Vivek?) 21/06/2017, 11:29 pm - dvp (Vivek): IMG-20170621-WA0009.jpg (file attached) 21/06/2017, 11:30 pm - dvp (Vivek): IMG-20170621-WA0010.jpg (file attached) 21/06/2017, 11:50 pm - dvp (Vivek): Lymphocyte counts were high also 22/06/2017, 5:35 am - +91 81061 62937: The microscopic examination tells us that it may be suspected as malignancy because of anisonucleosis and other features of anaplasia 22/06/2017, 5:36 am - +91 81061 62937: How do we say what kind of malignancy?? 22/06/2017, 7:54 am - Rakesh Dir: Yes how do we confirm if it is malignancy? 22/06/2017, 7:58 am - Rakesh Dir: Can these cellular changes also be seen in infection? 22/06/2017, 7:58 am - Rakesh Dir: I guess an online search at this point to answer the above may help? 22/06/2017, 9:05 am - Rakesh Dir: Also at this point in the chapter, we may need to explore the differentials of pleural effusion using other individual case stories of congenital, immune and infection mediated inflammation as well as neoplasm and finally what one can do if one draws a dead end depending on global health contexts (that can make us come back to this original case by Vivek). This is essentially a qualitative manual approach to clinical problem solving until we have Avinash's quantitative information mining engine 22/06/2017, 9:08 am - Rakesh Dir: The above approach may gel with what Andhra Pradesh is currently trying Madhava? See this http://www.thehindu.com/todays-paper/tp-national/tp-andhrapradesh/state-signs-pact-with-cerner/article19112817.ece 22/06/2017, 11:32 am - +91 81061 62937: Yes sir present CM is showing a very good care towards health care and development of it sir and his recent health insurance policy with in the state is also good which is offering free tests to the insurance holders in all govt and some big Pvt hospitals also 23/06/2017, 4:48 pm - dvp (Vivek): How is it possible to diagnose by looking at the Chest Xrays other than pleural effusion, pneumonia, TB? I mean everything looks like same and feels very disappointed 😟 when people are diagnosing it so accurately and I am not just able to tell more than a pleural effusion/pneumonia!😟😟 When will I learn these? 😭😭 23/06/2017, 4:57 pm - Rakesh Dir: There can be other findings in tubercular such as associated cavities and infiltrates. Google it. 23/06/2017, 5:34 pm - Rakesh Dir: Share those xrays here 27/06/2017, 4:12 pm - Avinash Newest: IMG-20170627-WA0013.jpg (file attached) 27/06/2017, 4:12 pm - Avinash Newest: @8801752868045 cavities here 27/06/2017, 4:12 pm - Avinash Newest: http://classworkdecjan.blogspot.in/2016/12/patient-history-by-pritam-gupta-age-41.html?m=1 27/06/2017, 5:06 pm - Rakesh Dir: Yes this is a very classy cystic Bronchiectasis 27/06/2017, 11:05 pm - Rakesh Dir: Can we create the chapter on pleura effusion as an introduction also to the methodology of the book where after sharing the first case narrative, begin exploring the differentials of pleural effusion using other individual case stories of congenital, immune and infection mediated inflammation as well as neoplasm and finally what one can do if one draws a dead end depending on global health contexts (that can make us come back to the original IQ City case shared by Vivek). This is essentially an intro to a usually practiced qualitative manual approach to clinical problem solving until we have Avinash's quantitative information mining engine 27/06/2017, 11:18 pm - dvp (Vivek): Yes, sir we can. I am actually puzzled in putting the pieces of information from other case stories (does it mean that we will take conversations forward of those differentials by ruling out the differentials ultimately to establish the original case?) 27/06/2017, 11:19 pm - dvp (Vivek): Will we write the case stories for other cases also? 27/06/2017, 11:28 pm - dvp (Vivek): Let me ask my question again, how to begin exploring the differentials through sharing other individual case stories of pleural effusion or by making a conversation of the differentials to make sense that how one can rule out other possible causes before reaching out to diagnosis? I have this question because I am thinking writing all the cases of pleural effusion might make the chapter larger? 27/06/2017, 11:32 pm - Rakesh Dir: Yes you are very right that it will make it much longer and may become dangerously unpalatable for our audience if we are not careful. Yes more thought and research will be needed to move forward in this direction. Let's begin by exploring online short case reports of the other causes such as congenital (Milroy's) 28/06/2017, 1:47 am - dvp (Vivek): A 16-year-old female who presented with fever, chills and cough of 8 days. She also developed acute shortness of breath in the last 2 days. On examination, the patient was in mild distress with dullness of the percussion note and decreased breath sounds in both lower lung fields. A chest radiograph demonstrated blunting of costophrenic angles and bilateral pleural effusion. Worsening of dyspnea necessitated surgical drainage of the pleural effusion. Approximately, 700 mL of serosanguinous fluid was tapped and sent to cytopathology laboratory for evaluation. 28/06/2017, 8:30 am - Rakesh Dir: Thanks Vivek. Yes we can explore some of these cases published online for a learning discussion to develop our textbook/database 28/06/2017, 8:32 am - Rakesh Dir: So if this 16 year old woman was from India inflammation due to either infection (bacterial or mycobacterial) and immune mediated (lupus) would have been foremost in my mind 28/06/2017, 10:52 am - dvp (Vivek): How will we differentiate tubercular pleural effusion from non-tubercular effusion. 28/06/2017, 10:55 am - dvp (Vivek): There are biochemical markers of TB in the pleural fluid which differentiate tubercular pleural effusion from non-tubercular effusion. Adenosine deaminase (ADA) is one of the biochemical markers commonly used in the etiological diagnosis of tuberculous pleural effusion. 28/06/2017, 10:57 am - dvp (Vivek): But according to this study , INF is more sensitive and specific than ADA for the diagnosis of TB (INF is also a biomarker for TB in pleural fluid). 28/06/2017, 10:58 am - dvp (Vivek): The diagnosis is established by demonstrating high levels of TB markers in the pleural fluid (adenosine deaminase >40 IU/L or interferon γ >140 pg/mL). Alternatively, the diagnosis can be established by culture of the pleural fluid, needle biopsy of the pleura, or thoracoscopy. 28/06/2017, 11:00 am - dvp (Vivek): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4920659/ 28/06/2017, 11:20 am - Rakesh Dir: What is the sensitivity and specificity of Ada or inf in comparison to the gold standard i e biopsy 28/06/2017, 11:30 am - dvp (Vivek): ADA activity, IFN-gamma levels, and PCR were 88%, 85.7%, and 73.8% sensitive, respectively, and 85.7%, 97.1%, and 90% specific, respectively, for pleural TB that had been confirmed by either culture or pleural biopsy specimens. The combination of PCR, IFN-gamma measurement, and ADA activity determination allowed the selective increase of sensitivity and specificity for probable and confirmed cases compared to individual methods 28/06/2017, 11:30 am - dvp (Vivek): These were evaluated in 140 cases of pleural effusion, 42 with confirmed pleural TB, 19 with probable pleural TB, 70 with a nontuberculous etiology, and 9 having an undetermined etiology. 28/06/2017, 11:36 am - dvp (Vivek): The pleural fluid ADA level may be useful to establish a diagnosis of tuberculous pleural effusion, even when AFB smear and culture are negative [1,2,5]. A presumptive diagnosis of tuberculous pleural effusion can be made if there is a pleural lymphocytic-to-neutrophil ratio >0.75 and pleural ADA >40 units/L. Pleural effusions with an ADA level <40 units/L are rarely caused by TB; the test has high negative predictive value and is an excellent test to rule out TB [25]. Elevated pleural fluid ADA levels can occur in other conditions besides TB infection. Some studies suggest that an ADA level >45 to 60 units/L is 100 percent sensitive and up to 97 percent specific for tuberculous pleural effusion [13,26,32-37]. In one study including 548 tuberculous pleural effusions in HIV-seronegative patients compared with a control group (including malignant pleural effusion, parapneumonic/empyema, miscellaneous pleural effusion, and transudative pleural effusion), pleural fluid analysis was diagnostic of tuberculous pleural effusion if all of the following criteria were met: pleural fluid protein >5.0 g/dL, pleural fluid lymphocyte count >80 percent, and pleural fluid ADA level >45 units/L [24]. Among HIV-infected patients, one study noted an ADA cutoff level of 60 units/L in HIV-infected patients, provided a sensitivity and specificity of 95 and 96 percent, respectively. 28/06/2017, 11:42 am - Rakesh Dir: Thanks this speaks highly of ADA. Vivek we shall need to check how much of material we can borrow from uptodate for the book and my best guess is that it may definitely not be this much in which case we shall need to find other methods of sharing the literature. 28/06/2017, 11:52 am - dvp (Vivek): Yes sir, that's very true and it will be overwhelming too. Is that possible if we shall build an online site where the pieces of literature will be included and we can refer in the textbook to that site for the evidence? In either case, we can not take this much information. Do you have any recommendations on this? 28/06/2017, 11:53 am - dvp (Vivek): Avinash, can you share your thoughts on this also? 28/06/2017, 11:57 am - dvp (Vivek): A small box (s) of EBM in the corner and referring it to an online site for further information! 28/06/2017, 12:12 pm - Avinash Newest: rather than reinventing wheel by creating a new online resource of such technical information it will be better if we can just use pubmed resources and all used links on one web page per case in book. as these are very technical discussion so better to depend / link to already available reliable resources than creating a new web based content. also creating new resource will delay book that's main aim. i am little lost in today's discussion as things are very new for me, but this helps in learning. today i am trying to read course book patho/biochemistry on pleural effusion to be able to ask more in discussion. 28/06/2017, 12:14 pm - Avinash Newest: also its great way to learn as content is in an interactive discussion way, where some questions leads to generate hypothesis/plans and answers coming later in discussion on topic. 28/06/2017, 12:15 pm - Avinash Newest: but regrading uptodate content its heavy perhaps. 28/06/2017, 12:16 pm - dvp (Vivek): Not totally new web resources rather than making a site》create a page with chapter and links there. So that one can refer online for further info by visiting the site and clicking on the links. 28/06/2017, 12:18 pm - dvp (Vivek): I was telling the same. 28/06/2017, 12:18 pm - Avinash Newest: thanks , i didn't understood well, this way is really useful. 28/06/2017, 12:19 pm - Avinash Newest: what you searched in uptodate to find this? 28/06/2017, 12:21 pm - dvp (Vivek): You need to look at the diagnostic evaluation of tuberculous pleural effusion and then at diagnostic tests and their references 28/06/2017, 12:25 pm - Avinash Newest: thanks! 28/06/2017, 3:59 pm - Rakesh Dir: Yes Avinash and Vivek I think it is a good idea to provide an EBM learning points box with links to the resources. For example the ADA discussion could just mention the sensitivity and specificity values and perhaps box EBM learning points as to the significance of these and their ability to predict outcomes. 28/06/2017, 4:07 pm - Rakesh Dir: Vivek coming back to your 16 year old patient who I thought was being discussed by you as you wanted to present a case of congenital pleural effusion can we move ahead with discussing her pleural fluid analysis? 28/06/2017, 4:11 pm - dvp (Vivek): On examination of the MGG-stained cytospin preparation of the pleural fluid, plenty of LE cells were seen, characterized by a homogenous nuclear material engulfed by neutrophils. 28/06/2017, 4:12 pm - dvp (Vivek): This case I am discussing as an immune-mediated cause of PE. 28/06/2017, 4:13 pm - dvp (Vivek): These cells were present in the background of numerous segmented neutrophils, lymphocytes, plasma cells, and macrophages. Occasional tart cells were also seen. 28/06/2017, 4:29 pm - dvp (Vivek): A 28-year-old white, unmarried woman came to us in August 1977 for evaluation of bilateral pleural effusions of 8 months' duration. At the age of six and one-half years, she developed recurrent episodes of erysipelas involving her face. When she was 14 years of age, these episodes subsided, and she noted swelling of her lower extremities, hands, and abdominal wall in addition to facial edema. Her hands and face were more swollen in the morning and improved as the day progressed; the leg swelling was significantly worse later in the day and during the later part of her menstrual cycles. In January 1967, she underwent plastic surgery for correction of persistent upper and lower eyelid edema. Later that year, she had chest pain, dyspnea, cough productive of sputum, and fever. A diagnosis of pleurisy was made, and she was treated with isoniazid, streptomycin, and para-aminosalicylic acid for 3 months. During subsequent years, she felt well except for the persistence of generalized swelling and one episode of erysipelas involving one leg. 28/06/2017, 4:30 pm - dvp (Vivek): In December 1976, she noticed dyspnea on exertion. A chest roentgenogram revealed bilateral pleural effusions, greater on the right side than on the left. At that time she had no other respiratory symptoms, fever, weight loss, gastrointestinal symptoms, rash, or arthralgia. There was no history of cardiac, renal, or hepatic disease. A short course of treatment with corticosteroids was of no benefit. Intermittent diuretic therapy provided modest relief of edema. 28/06/2017, 4:40 pm - dvp (Vivek): When examined in August 1977, the patient appeared normal except for mild facial edema and a small ectropion of the right eye. There was mild pitting edema over her legs, sacrum, sternum, face, and iliac crest. Her breasts were normal and of equal size. Percussion of the chest showed bilateral dullness posteriorly with decreased transmission of voice and breath sounds; these findings extended superiorly to just below the seventh rib on the right side, and to below the eighth rib on the left. Findings during the remainder of the physical examination were normal. 28/06/2017, 4:41 pm - dvp (Vivek): The pleural fluid was clear and yellow. Chemical studies showed a...................................................................... 28/06/2017, 5:00 pm - Rakesh Dir: 28 year old appears to be the congenital one? Very exciting. 28/06/2017, 5:00 pm - dvp (Vivek): Yes sir 28/06/2017, 5:03 pm - Rakesh Dir: What we can do is create a few graphics to describe the entire story and that way retain our original contribution to someone else's case report too and also considerably shorten the text of our text book. Our aim shall be to provide a palatable gist that may perhaps be best done visually 28/06/2017, 5:06 pm - dvp (Vivek): Absolutely, I just copy pasted it but how to generate graphics from a case story? 28/06/2017, 5:07 pm - dvp (Vivek): A 28-year-old woman with bilateral pleural effusions and generalized, primary lymphedema beginning with facial erysipelas at 6 years of age is presented. The pleural effusions were exudates with 250 cells per mm3, 92 per cent of which were lymphocytes. Lymphatic stasis was demonstrated by persistence of the blue dye in the dorsa of her feet 3 months after a lymphangiogram of both lower extremities, pelvis, and abdomen. Her nails were not remarkable. 28/06/2017, 5:07 pm - dvp (Vivek): This is the abstract of this case 28/06/2017, 5:08 pm - Rakesh Dir: Even as we read it some images and visuals flash through our mind don't they? We just need to draw them on paper. Just think of Gowan's pathology illustrated etc books 28/06/2017, 5:09 pm - dvp (Vivek): Yes sir, with each finding we try to visualize the whole scenario. There are books also making cartoons 28/06/2017, 5:18 pm - dvp (Vivek): But I am not good at drawing, Avinash are you able to draw it or any software to make cartoons? 28/06/2017, 6:57 pm - Rakesh Dir: Or even word pictures. Just scoop out the key words from the entire presentation (which is what the abstract does but we need to do it so as not to give the diagnosis / suspense away at the very first line) 28/06/2017, 11:26 pm - dvp (Vivek): This is a good idea. We will find a way to do this also. 28/06/2017, 11:31 pm - Avinash Newest: we can make stepladder / flowchart with text and different boxes of flowchart to show sign/symptom , then a flowing discussion and extra ebm based boxes. 28/06/2017, 11:36 pm - dvp (Vivek): That's also great. 28/06/2017, 11:39 pm - Avinash Newest: IMG-20170628-WA0002.jpg (file attached) history 28/06/2017, 11:41 pm - Avinash Newest: IMG-20170628-WA0003.jpg (file attached) ebm box 28/06/2017, 11:42 pm - Avinash Newest: IMG-20170628-WA0004.jpg (file attached) list of 100 chapters 28/06/2017, 11:44 pm - Avinash Newest: IMG-20170628-WA0005.jpg (file attached) text + arrow based flowchart (this is huge, smaller ones in book) 28/06/2017, 11:44 pm - Avinash Newest: IMG-20170628-WA0006.jpg (file attached) questions in chatheads 28/06/2017, 11:45 pm - Avinash Newest: IMG-20170628-WA0007.jpg (file attached) answer below chat heads in pointwise/details 28/06/2017, 11:46 pm - Avinash Newest: IMG-20170628-WA0008.jpg (file attached) hint to explore more in topic 28/06/2017, 11:47 pm - Avinash Newest: IMG-20170628-WA0009.jpg (file attached) multiple hints to explore more 28/06/2017, 11:48 pm - Avinash Newest: these are extremely colourful, we can use style to keep things simple clear. 28/06/2017, 11:48 pm - Avinash Newest: and cover all components of book in interesting (interactive) presentation. 28/06/2017, 11:49 pm - dvp (Vivek): We could make atleast one chapter that we can use as a template for rest of the chapters. 28/06/2017, 11:50 pm - Avinash Newest: which case to start for first chapter? 28/06/2017, 11:50 pm - Avinash Newest: lets do it today 28/06/2017, 11:50 pm - Avinash Newest: "pleural effusion" ? 28/06/2017, 11:50 pm - dvp (Vivek): Pleural effusion only 28/06/2017, 11:50 pm - Avinash Newest: respi system? 28/06/2017, 11:50 pm - Avinash Newest: ok 28/06/2017, 11:50 pm - dvp (Vivek): One question for all: What are the clinical features of "Pneumonoultramicroscopicsilicovolcanokoniosis"? 28/06/2017, 11:51 pm - Avinash Newest: ok 28/06/2017, 11:52 pm - Avinash Newest: is it a topic to bring interest in exploring book at UG level? won't be a smiple topic name better ? 28/06/2017, 11:52 pm - dvp (Vivek): Haha..no 28/06/2017, 11:54 pm - Avinash Newest: ok 28/06/2017, 11:54 pm - Avinash Newest: topic set 28/06/2017, 11:54 pm - Avinash Newest: next we had to add case description 28/06/2017, 11:54 pm - Avinash Newest: what way will be better 28/06/2017, 11:55 pm - Avinash Newest: like in movies when they take 2-3 stories together to package all emotions in 3 hr or like one case and add more? 28/06/2017, 11:56 pm - Avinash Newest: can we start making case description with not single but more cases at once? 28/06/2017, 11:57 pm - dvp (Vivek): Main case is there already (the neoplastic pleural effusion I shared). We will make graphics for other cases. Like other causes for pleural effusion. 28/06/2017, 11:57 pm - Avinash Newest: ok 28/06/2017, 11:58 pm - Avinash Newest: this is main case? 28/06/2017, 11:58 pm - dvp (Vivek): No 28/06/2017, 11:59 pm - dvp (Vivek): The one I shared second time (after the large one) 28/06/2017, 11:59 pm - Avinash Newest: ? 29/06/2017, 12:00 am - dvp (Vivek): No 29/06/2017, 12:00 am - dvp (Vivek): 65 years old one 29/06/2017, 12:01 am - Avinash Newest: not in my chat history, plz share again 29/06/2017, 12:01 am - dvp (Vivek): I would take the first one but that doesn't have pleural fluid analysis with it 29/06/2017, 12:02 am - dvp (Vivek): http://bmjcaselogvivek.blogspot.in/2017/02/multidimensional-challenges-in.html 29/06/2017, 12:05 am - Avinash Newest: to open the case 29/06/2017, 12:05 am - +91 81061 62937: It is awesome guys 29/06/2017, 12:06 am - Avinash Newest: we will get pt. in hospital with this history 29/06/2017, 12:06 am - Avinash Newest: The journey of a patient which is raisingmultidimensional issues of both diagnostic challenge, therapeutic challenge & patients uncertainty: ⇒ A 66 years-old-female presented to the emergency department with the complaints of left-sided chest pain for last 3 months which radiates to arm & shoulder and increases with cough. She also complaints of cough & pain in the abdomen & hoarseness of voice. ⇒ She was admitted in the hospital with the same complaints 6 months back. Her past medical history is significant for hypertension (diagnosed 1 & 1/2 years back), osteoporosis D6, vocal cord palsy. 29/06/2017, 12:06 am - Avinash Newest: thanks madhava✌🏼 29/06/2017, 12:07 am - +91 81061 62937: The colour pictures and the intresting points will make the book more tasty 29/06/2017, 12:07 am - +91 81061 62937: to read it and rather eat it 29/06/2017, 12:08 am - Avinash Newest: then we have to approach, 1) anatomical 2) pathological 3) biochemical aspects (by discussion) and then plan tests, and diagnosis from them, and come to any solution (may be an open ended sometimes in hope of a patient centered innovation) 29/06/2017, 12:08 am - Avinash Newest: till now all fine @8801752868045 dada? 29/06/2017, 12:08 am - Avinash Newest: yes madhava 😋 29/06/2017, 12:10 am - dvp (Vivek): Yes, since we have discussed some of the cases of pleural effusion we can now start to make the pictures of other cases as well. 29/06/2017, 12:10 am - +91 81061 62937: vivek bro while I was going through the case reports I found most of the cases incomplete and how to fill those things 29/06/2017, 12:10 am - Avinash Newest: here 29/06/2017, 12:11 am - Avinash Newest: so now we have topic + history 29/06/2017, 12:11 am - Avinash Newest: next is to localize problem in 3 points. 29/06/2017, 12:12 am - Avinash Newest: pictures will be used to represent these 3 points right? (anat path biochem? 29/06/2017, 12:12 am - Avinash Newest: right? 29/06/2017, 12:12 am - dvp (Vivek): No 29/06/2017, 12:12 am - Avinash Newest: thenA 29/06/2017, 12:12 am - Avinash Newest: ? 29/06/2017, 12:13 am - dvp (Vivek): Those 3 things need to discussed in the comversation. 29/06/2017, 12:13 am - Avinash Newest: ok.like.this 29/06/2017, 12:13 am - dvp (Vivek): In pictures we will illustrate the other cases from online case reports 29/06/2017, 12:14 am - dvp (Vivek): So that, during discussion it all gives a real test. 29/06/2017, 12:14 am - Avinash Newest: IMG-20170628-WA0010.jpg (file attached) 29/06/2017, 12:14 am - Avinash Newest: like here, main case + relevant pictures from other cases. 29/06/2017, 12:15 am - dvp (Vivek): It is a good analogy. 29/06/2017, 12:16 am - Avinash Newest: ok, so we can use already available pics in other cases or draw ourself whetever needed for having a complete discussion. 29/06/2017, 12:17 am - Avinash Newest: IMG-20170628-WA0011.jpg (file attached) another example. 29/06/2017, 12:17 am - Avinash Newest: IMG-20170628-WA0012.jpg (file attached) 29/06/2017, 12:17 am - Avinash Newest: labelled pictures if needed 29/06/2017, 12:18 am - dvp (Vivek): No we wont just crop pics like Xrays or other images. Yes like last one where other case details can be written in short. 29/06/2017, 12:18 am - Avinash Newest: 👍🏻👍🏻 29/06/2017, 12:19 am - +91 81061 62937: 👍👍 29/06/2017, 12:19 am - Avinash Newest: something like abstract of entire presentation, will be better once we complete one chapter, right? 29/06/2017, 12:19 am - dvp (Vivek): Thanks avinash. You have made it much more easier as I was thinking about some ways. 29/06/2017, 12:20 am - Avinash Newest: thanks dada 29/06/2017, 12:21 am - Avinash Newest: so next is having relevant cases for pics, lets imagine we have all pics that we need (any test report we can get from previous cases, anything if not available, we can draw) 29/06/2017, 12:21 am - dvp (Vivek): Online case reports most often have sufficient details 29/06/2017, 12:22 am - dvp (Vivek): Yes 29/06/2017, 12:22 am - Avinash Newest: so now left is localising in 3 aspects and approaching patient from history to treatment plan, detecting and discussing topic like we did in electives 29/06/2017, 12:23 am - dvp (Vivek): Yes, as we were discussing above and need to write it on book sequentially finally to identify that 3 aspect and whats the treatment plan once we reach out dead end 29/06/2017, 12:24 am - Avinash Newest: 👍🏻 18/07/2017, 10:23 am - Avinash Newest: IMG-20170718-WA0004.jpg (file attached) 18/07/2017, 10:24 am - Avinash Newest: IMG-20170928-WA0003.jpg (file attached) 18/07/2017, 10:24 am - Avinash Newest: https://hme-male-25-yr.blogspot.in/2017/03/25-year-male-case-history-from-2010.html?m=1 18/07/2017, 10:26 am - Avinash Newest: possibility for help to rare disease patient discussed earlier 18/07/2017, 10:43 am - Rakesh Dir: Thanks were you able to get in touch with Rajib Sengupta who had made the patient's post? 18/07/2017, 10:47 am - Avinash Newest: Thanks sir. yes, i will connect with him and try what possible. 28/09/2017, 5:51 am - Avinash Newest: https://www.amazon.com/Pathophysiology-Heart-Disease-Collaborative-Students/dp/1451192754/ref=sr_1_18?ie=UTF8&qid=1506555103&sr=8-18&keywords=medical+students 20/10/2017, 3:27 pm - Avinash Newest: . 20/10/2017, 3:28 pm - Avinash Newest: only you can add sir as you are admin. 20/10/2017, 3:31 pm - Rakesh Dir: You are an admin Now. 🙂 20/10/2017, 3:31 pm - Avinash Newest added +91 97057 58226 20/10/2017, 3:31 pm - Avinash Newest added Ashwini BMJ 20/10/2017, 3:31 pm - Avinash Newest: thanks sir! 20/10/2017, 3:32 pm - Rakesh Dir: How do we make our invitees see what has already transpired in this group Avinash? Time to create another blog? 🙂
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