3:46 am - Avinash Kumar: 55M, very obese, bmi 39, woke up at 4am on day before yesterday which is very rare for him, he saw yoga in tv and did himself, did lying leg hold too as shown in image, he takes morning tea at nearby shop in hut mostly, rest all food in home during the lockdown. later in day time he complained of leg pain, had mutton in evening though he takes vegeterian food mostly and couldn't sleep whole night due to gas and pain in abdomen, he felt as if gas not passing ahead. next day he avoided any food , only took some ripe papaya pieces in evening and slept whole day. In evening he got paneer and heavy oily food in dinner and felt completely full and took ranitine 300mg before sleep, after 2 hours of dinner he felt too much gas in abdomen which is not passing out, and after 3 hours started vomitting at every 20-25 min., vomit was full watery only, very little quantity of food particles and large quantity of water, ranging may be approx 300-400 ml to 100 ml. everytime in total 7-8 times he vomited in next 2 hours.
after 2nd vomiting took pantoprazole+ domperidone and home made ors
after 8th vommiting his vommiting have stopped now since 30 min. but his abdoiminal pain which started with the gas issues is still there and incresed, dsen't seem to be severe though but he looks exhausted and he is unable to sleep. He is not feeling increased bowel sounds or any sounds, didn't had clear stools in morning and since a few days, its common to him but taking milk and less spicy food helps. He just took Lactulose 10ml, ranitidine 300mg and anafortan ( camylofin 25 mg + Paracetamol 300 mg ), got advice that if this dosen't relieve then may need IV saline in morning.
medication guided on phone consult with local informal healthcare practitioner.
vomitted again now, i.e. after 15 min. of taking above medicine, vomit seems to have some undigested rice which he ate 8 hours back.
3:47 am - Avinash Kumar: <Media omitted>
3:50 am - Avinash Kumar: <Media omitted>
4:15 am - Avinash Kumar: i am with patient, and local informal care provider is also coming as patient is feeling severe pain
4:24 am - Avinash Kumar: intestinal obstruction?
6:01 am - Avinash Kumar: dr. is having piles surgery so can't move. he suggested some medication - phenargan inj, RL iv drip, ondasetron inj, pantoprazole inj.
gave none, visited phc and got dicyclomine inj. and pantoprazole inj, 2 tabs liv 52, sarboline syp, and vomikind sublingual, had no fluids/ors/water since 45 min. so when reached phc, he was much relaxed and not rolling on ground with pain. back to his home and much relaxed now .
there are no radiology and labs here so no testing.
enjoyed to learn interesting things from our phc dr. (only mbbs staying in rural area rest most are not mbbs in all nearby areas) and also see covid situation here.
eager to see the interesting discussion ahead of this live case report, and also what you (anyone here) would have done at different point of time in this scenario.
6:02 am - Dr. Leelavati Maam Iqcity: Plz rule out acute pancreatitis
6:09 am - Avinash Kumar: again pain increasing and trying to vomit.
6:15 am - Dr. Rajesh Menon sir: if he has passed very little stool / no stool, would indicate obstruction. could mean a hernia due to his unaccustomed yoga and leg lifting workout. should be checked. usual care would be raise leg end of the bed if hernia is detected so that it resolves by itself or else surgical intervention...
6:21 am - Avinash Kumar: did dark brown vomit (due to 2 liv 52 tabs i think). after vomit he feels good. good to see frequency going down.
6:23 am - Dr. Leelavati Maam Iqcity: Rest of gut and iv fluids is going to give him relief
6:26 am - Dr. Rajesh Menon sir: tried soap water enema?
6:27 am - Avinash Kumar: thanks maam! interesting finding, that he had alcohol on the night it all started. 50-100 ml. mixed with water. social drinker, 2-3 times a week or less.
i just thought that cage questionnaire says nothing about dose and dose related outcomes.
he didn't had alcohol yesterday. his family is strictly against his alcoholism.
to rule out acute pancrititis, history is suggestive of it, physical examination i am unable to do and he is very ovbese so very tough to find what's happening inside. blood test for amylase and lipase is impossible here unless we travel 30km.
6:39 am - Avinash Kumar: thanks sir, very useful leanring points, there was no hearnia like issues and luckily i had learnt examining for hearnia but didn't tried. the pain is in full abdomen and shifting from one side to other, may be so the patient was lying on ground and rolling due to that shifting.
6:43 am - Avinash Kumar: thanks maam! yesterday he rested whole day without any food and so felt completely relieved by evening, he is resting again and nearly in sleep, so may be now same will happen today.
no iv given, ors is there with him but he is not drinking anymore.
6:45 am - Avinash Kumar: i had suggested to keep an enema from pharmacy, though it wasn't used. his stools are still not passing or any sign of that. it must past, to bring relief, will inquire about that and update here when it happen.
6:47 am - Avinash Kumar: i think, we can say then, that time will heal and rest (removing possible causes of issues though not known precisely).
6:47 am - Avinash Kumar: little stool yesterday and none today.
6:48 am - Dr. Rajesh Menon sir: please be careful though as sudden evacuation may result in hypotension..
6:49 am - Avinash Kumar: thanks sir, didn't knew that. no plans for that yet. i am not making clinical decisions but just supporting a lil. and trying to understand myself.
6:50 am - Dr. Rajesh Menon sir: if u remember piku movie, piku's dad who has chronic constipation passes away after he has jilebi which results in relieving his problem.
6:52 am - Avinash Kumar: thanks sir, noted to see it soon someday.😇
6:54 am - Avinash Kumar: one important question related to this case in above scenario, (any more clinical exam, refer to higher center 30km away, antibiotics, iv line, what medicines.
_what you would have done here and *why*?_
6:55 am - Avinash Kumar: As you said in the group..
For the patient the solution is one spoon of fenugreek seeds and in a cup of curd.. It will cure his pain too.. As we give to our patients.. I have seen the same cases.. So I said
6:56 am - Avinash Kumar: input from another care povider who want to stay anonymous.
7:00 am - Dr. Rajesh Menon sir: fenugreek.. well ive seen few newly diagnosed diabetics developing a lot of flatus and abdominal distension when they tried it..
7:05 am - Avinash Kumar: and it may be to cause flatus and help it all pass out quickly. where curd may be mainly a medium with lactobascillus as added benefit.
but if its obstructive then same may cause more trouble?
@Ahmed any comments?
8:15 am - Avinash Kumar: got one phenergen inj. (Promethazine) and ondansetron inj. around 45 min. back while had 3 more vomits with lil. content only 20-30 ml. he is finally relaxed now and sleeping.
_symptomatic treatment_
8:18 am - Dr. Leelavati Maam Iqcity: Plz take him 30 kms away and get him a proper IPD care
8:19 am - Dr. Leelavati Maam Iqcity: you may not be able to handle the complications at home
8:20 am - Dr. Leelavati Maam Iqcity: He will need a lot of fluids and orally he will be unable
8:28 am - Dr Rakesh sir: 👏👏👏👍
Very nice presentation and discussion Avinash and others.
Let's hope he does well today with your homehealth care or else keep the local PHC in the loop about the patient.
Now is the time in India to get the local PHC doctors or nurse practitioners to make a home visit for such patients.
Avinash would you like to start a petition with change.org? Also ask Rajib and Tamoghna and Kaushik of recent project.
8:32 am - Avinash Kumar: thanks maam, i will convey to family.
but there are 3 problems
1) huge inflow of returning migrants workers have started here in district as its state border area and many of them visiting hospital for fever screening, perhaps they thing its test to help decide if they should go in family or not.
2) nearly all private clinics are closed.
3) I believe that small city nearby at 30km will also bring him same symptomatic treatment and with additional struggle for any local support. they will do some tests surely though may report with delay and analyse never or rare. sorry for sounding bad but i don't mean to speak bad of any real heroes ( healthcare workers) its just system fault i think.
next bigger city is 85km and aiims gorakhpur is there, gives better confidence but is he severe enough to go there, as family members are a bit upset about his occassional drinks and trying to delay medication, saying he will get relief in sometime, luckily doctors , informal health workers and formal and they all are really great and helpful to everyone here) are not in that mood and neither my opinion is for any delay.
8:33 am - Dr. Leelavati Maam Iqcity: Plz seee if the iv fluids can be arranged at home, as only good supportive treatment is all that is indicated
8:34 am - Dr. Leelavati Maam Iqcity: Great that the doctors are helpful at this time also
8:36 am - Avinash Kumar: sure sir, I will be happy to do that, and ask patient for consent to allow for that.
but i perosnally believe change.org petitions are an illusion of good happening. reason is when i ask anyone what will happen if i sign the petition you shared? how change.org will communicate it to relevant officials, and they never have any answer and neither i have. probably its just an overrated platform for showing the no. of people signing for a cause and in real no body see it though and the growth hacking tricks of IT are used to keep change.org growing its user base, audiance, signatures and petitions, and benefit to a business model and illusion of good happeing to all.
sorry for being too skeptic about it, but i will be very happy if proven wrong and for that @Rajib da or @Dr. Tamoghna sir may guide.
8:44 am - Avinash Kumar: thanks maam! this can be arranged.
there is ringer lactate kept already, suggested by informal healthcare worker, unused yet as the informal healthcare worker is himself suffering post elective surgery.
will inform mbbs dr. in phc for that.
to decide if its really needed,if its urgent, i checked for dehydration by pinching skin and it seems fine, also he vomitted 3 liters and now relaxed. 101 kg weight so 3 liters may be only 3% of loss so saline may not be urgent requrement, but a good supportive treatment. am i correct?
(this is for curiousity)
8:45 am - Avinash Kumar: i am yet to study rationale for use of iv fluids RL, D5/10, NS. will search and study later today.
8:47 am - Dr Rakesh sir: Agreed. Didn't realize you were able to see and touch the patient.
One important thing to do here which any hospital doctor would do and even you can do is to feel his abdomen and feel for guarding and rigidity to guage the severity of his abdominal inflammation (if any) as that would considerably help the decision making process. The only reason for referral would be operative intervention as everything else in terms of resuscitation can be done at home. Keep us posted on his abdominal findings. Check out the image of Chamberlain sitting by the bedside of the patient and looking at all the quadrants of the patient's abdomen move with a patient similar to yours
8:49 am - Dr. Leelavati Maam Iqcity: Surprisingly u come to detect hypovolemia very late in an obese patient by checking skin turgor, so don’t go by that, he is already 3ltres. behind fluid and will need this badly
8:49 am - Dr Rakesh sir: Try palpating a few normal abdomens among your family members or even yours to get an idea of what a normal abdomen feels like. This is basic system 1 learning at it's pristine best
8:53 am - Avinash Kumar: did that sir, 2 time, once in beginning of problems and once around 2 hours back..no rigidity.
i am unable to understand and find image of chamberlain sitting by the bedside, may be it means sitting on patient's right and observe for movements (normal movements), this i will try when possible.
8:55 am - Avinash Kumar: thanks maam! will discuss this with patient, family & dr. (who is far at phc)
8:55 am - Avinash Kumar: thanks sir! luckily have done that in a few healthy and a few sick already, so useful today.
9:04 am - Dr Rakesh sir: Yes normal movements in all quadrants of the abdomen to detect any localized inflammation of any abdominal organ 👍
9:04 am - Dr Rakesh sir: 👏👏👍
9:04 am - Avinash Kumar: thanks sir, will do
9:04 am - Avinash Kumar: 🙏🏻
9:04 am - Dr Rakesh sir: 👍👏👏
9:58 am - Avinash Kumar: still feeling vomiting,
iv fluids to be started (which one? ns, rl, d5/d10)
informal dr. asked to bring pt. (as he is not in situation to come) so he can observe and decide what to do further and what fluids to give.
abdomen - no rigidity, seems to be normal movements. rolling on sides while lying in bed to avoid pain that is also shifting sides.
9:59 am - Avinash Kumar: if the rigidity is in mid, below his 8 inches layer of fat layer approx, then i may have missed.
10:05 am - Dr Tamoghana sir: Avinash, is the patient passing flatus? Is he able to sit up? How frequently is he passing urine?
10:06 am - Dr Tamoghana sir: If the pain is shifting sides, is it crampy or colicky?
10:07 am - Dr Tamoghana sir: Plz see if there is any tenderness at any specific point. And the epigastrium
10:07 am - Avinash Kumar: flatus - not at all. want it since early night.
able to sit up- yes, short walk even after 30 min. of taking the injections
10:07 am - Avinash Kumar: only once tonight
10:08 am - Avinash Kumar: urine
10:08 am - Avinash Kumar: yes shifting sides. colicky
10:08 am - Dr Tamoghana sir: If the patient is not able to pass flatus, it might be indicative of an obstruction, which might be difficult to manage at home
10:09 am - Avinash Kumar: checked. not noticable to me.
10:09 am - Avinash Kumar: enema could help if its in end part? we have enema but don't know where the obstruction is. we don't have xray, usg here.
10:10 am - Dr Tamoghana sir: Colicky pain may be present in obstruction or ileus or sometimes even in simple acute gastritis
10:11 am - Avinash Kumar: 5 times vomiting in 1 hour. total 15ml may be.
10:11 am - Avinash Kumar: mostly nothing comes out
10:11 am - Dr Tamoghana sir: But shifting sides may suggest an intestinal pathology
10:14 am - Avinash Kumar: food in vomit. ate 8 hours back.
i am also guessing intestinal obstruction but now way to be sure.
10:18 am - Avinash Kumar: ng tube may help? should only put after its possible benefit confirmed (xray/usg?)
here no one is skilled for that, neither its available.
10:21 am - Suyash Gupta Sir: Bowel sounds?
10:21 am - Dr Tamoghana sir: Ng tube with stomach rest may be helpful. We need to put acute pancreatitis in d/d too, and in mild acute pancreatitis supportive care is possibly the only treatment
10:21 am - Dr Rakesh sir: Yes NG tube would help and perhaps a flatus tube.
Any hospital doctor would try to figure out if the obstruction is mechanical due to some organic pathology or due to ileus.
Please check his bowel sounds and let us know how many you can hear in one minute.
Check our past projects with MANIT Bhopal on bowel sound amplification as a technique to understand dysmotility in certain subsets of intestinal dysfunction
10:21 am - Dr Rakesh sir: 👍👏👏
10:26 am - Avinash Kumar: no steth but seems decreased since early night time - patient reported.
10:26 am - Avinash Kumar: will hear someway and update
10:27 am - Avinash Kumar: thanks sir. will check that project
10:28 am - Suyash Gupta Sir: At least blood investigations like serum amylase, lipase, and serum electrolytes, cbc, If manageable.
10:28 am - Avinash Kumar: impossible. (Update Later - There is a path. lab with some basic reports available, we got a few test later when patient was much fine and lab was accessible)
10:31 am - Suyash Gupta Sir: I remember a time in our phc posting we were asked to go out to some village for awareness purpose. And i forgot my stethoscope as I didn't think I would see any pt.
But as it turned out I had to auscultate some one. Some Cardboard tube, used to keep calenders in place helped. Original laennec stethoscope i guess😅
10:32 am - Suyash Gupta Sir: (it was not of much use though. In this case, I don't know)
10:34 am - Avinash Kumar: i will keep ears directly if i won't get steth from dr. whom we may meet in sometime
😊
10:35 am - Avinash Kumar: ear should work, i have tried in diarrhea patient where it was too many, here its too less but should be audible that way
10:36 am - Avinash Kumar: won't get if patient don't go there. depending on his ssituation
10:36 am - Avinash Kumar: 👏👍
10:38 am - Avinash Kumar: @919619613748 you may also like to try this one
http://classworkdecjan.blogspot.com/2020/01/stethoscope-hack.html?m=1
10:39 am - Avinash Kumar: i am not sure if you have already seen it or not, @Shikhar also did great improvements in idea and demo with it in his college.
10:40 am - Dr Tamoghana sir: If you place ears directly near umbilicus you will hear nice bowel sounds
10:42 am - Avinash Kumar: thanks sir. will do
10:45 am - Suyash Gupta Sir: Brilliant!
10:48 am - Avinash Kumar: thanks!😊
i had shared some sounds in whatsapp here when this group was new. its lost now. you may need to experiment and optimize for best output.
10:50 am - Suyash Gupta Sir: Will sure do
10:56 am - Joyoti Maam Ayurveda HIT: Wonderful👍
10:57 am - Avinash Kumar: thanks ma'am!
10:58 am - Avinash Kumar: bp - 137/89
pulse - 86
bowel sounds - 9 per min. (heard with ear on abdomen)
11:00 am - Joyoti Maam Ayurveda HIT: Just started following all your notes here...Fenugreek with curd is not a good idea at all at this point...if bowel sounds are good, then you may want to try plain luke warm water enema, you maybe already keeping him nbm..
11:03 am - Joyoti Maam Ayurveda HIT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5630621/ Here is a paper describing the steps for remote diagnosis of acute abdomen...just look at the figure ..you will get an idea
11:06 am - Avinash Kumar: thanks.
it will be useful only if obstruction in end parts of large intestine and rectum. right?
11:08 am - Joyoti Maam Ayurveda HIT: No, if patient is vomiting, then first rule would be to keep NBM...till the vomiting is controlled....
11:09 am - Joyoti Maam Ayurveda HIT: curds and methi would still not be useful in this patient..
11:22 am - Joyoti Maam Ayurveda HIT: How do you find the accelerometer in your phone?
12:21 pm - Dr Rakesh sir: 👏👏👍
12:25 pm - Dr Rakesh sir: Pleural effusion less than 100 ml may not be picked up on chest X-ray
12:26 pm - Dr. Rajesh Menon sir: thank you Sir.. will get back with the History.
12:28 pm - Dr. Rajesh Menon sir: my first impression was a boot shaped heart Sir. my mind instantly went TOF but then the age as per the X ray suggests an adult female..
12:30 pm - Dr. Rajesh Menon sir: was searching for life span of people with unoperated TOF.. very few and far between. i came across a man who passed away at the age of 73 but survived till then with no correction.
12:31 pm - Avinash Kumar: ryles tube, ns pushed in, and green color liquid collected in uro bag and and kinely soda also pushed in 500 ml, now clear fluid coming out, around 200ml was darker greenish and rest is coming much clear and slow, the patient is relaxed, not complaining of much problems, medication provided - metrogyl drip, ns saline drip, pantoprazole, ranitidine, cefexime and tazobactum, ondasetron, all injections. will give DNS when the current NS is completed. stuff managed from various shops , they are not used frequently so tough to find, I got to assist a lil. bit to the informal care provider and his experiential learning trainee aka compounder.
12:32 pm - Avinash Kumar: so I guess it was obstructed initial part of the intestine.
12:34 pm - Dr Rakesh sir: Yes there are reports of even more older people
12:36 pm - Dr Rakesh sir: Kinley soda through Ryle's tube 😳
Whose idea was that?
12:38 pm - Dr Rakesh sir: The green liquid is bile and just indicates that the obstruction is beyond the second part of the duodenum.
He's being clearly overtreated with all the antibiotics none of which he probably needs.
I guess this is how a large volume of antibiotics enter in vivo in India
12:42 pm - Dr. Rajesh Menon sir: what could be the reason for this acute episode of obstruction?
12:43 pm - Dr Rakesh sir: Either mechanical aka structural aka anatomical or functional aka physiological
12:44 pm - Dr. Rajesh Menon sir: could it be Ca Pancreas?
12:46 pm - Dr Rakesh sir: That would be mechanical, structural or anatomical pathology but in the problem you cited it's unlikely to present acutely
12:47 pm - Dr Rakesh sir: However as others have stated the odds are high for it being an acute inflammation of the pancreas
12:51 pm - Avinash Kumar: thanks sir, i am happy that my thoughts matches to it, but i didn't discussed about it to treating care provider.
12:52 pm - Dr Rakesh sir: Yes mutual respect is very important in team playing 👍👏👏
12:53 pm - Dr Rakesh sir: Actually you have a tremendous opportunity to collect the world view of an informal healthcare provider that may help us to understand how to optimize it
12:54 pm - Avinash Kumar: soda helps with gas, specially if in upper part and also help digest food or stuff faster (i think, not sure of evidence). giving it via ryles tube was just a medical stunt i think, idk he invented or learned from someone)
12:54 pm - Avinash Kumar: thanks sir!
12:56 pm - Avinash Kumar: yes, same i was thinking sir, like alcohol with meat = day before yesterday, paneer = yesterday. then what stayed in so proximal part of intestine
12:57 pm - Avinash Kumar: he asked me what is this, i said bile, he said no and then i asked twice without irritating him and he didn't answerd and so i understood not to ask more.
12:57 pm - Dr Rakesh sir: Soda scientifically is supposed to produce more gas.
What it does is because the gas it generates is effervescent, it makes the patient develop a placebo effect that the gas has come out while all that came out was essentially what had been introduced but for this placebo effect one may have to pay the price of gastric distension that could have led to perforation and increased gastric acid?
12:58 pm - Dr Rakesh sir: Show him a Google Image of bile
12:58 pm - Avinash Kumar: thanks sir, yes specially in lockdown. earlier I had shared about old lady with flank pain problem frequently, she is no more. just an update.
12:59 pm - Avinash Kumar: he learn by googling sir, and he may not like my interference. (He is nice person)
12:59 pm - Dr Rakesh sir: Would have been nicer if you can direct us to the link of all that we discussed about her
12:59 pm - Avinash Kumar: 👏👏 thanks sir, very interesting
1:03 pm - Dr Rakesh sir: Yes because you presented a detailed history I have a hypothesis that may be a physiological issue (if you see in Ganong's physiology) because of excessive fatty meal the gastric and duodenal emptying reduces and this can lead to this physiological obstruction. When it happens due to pure neural causes which is more common in diabetics due to autonomic neuropathy it's called Ogilvie's syndrome after the intern who first logged it
1:28 pm - Avinash Kumar: i missed to add hyoscin (inj.)
1:29 pm - Avinash Kumar: thanks sir, amazing info!
after current dns given slow, there will be RL.
1:36 pm - Avinash Kumar: after how many/much vomits prefer nbm and same way before what threshold prefer ors?
one more question to group.🙃
1:37 pm - Avinash Kumar: yes, on nbm since 3am and that did some improvement in vomits surely, atleast the water loss.
1:39 pm - Avinash Kumar: thanks, quickly checked it but then got busy with patient and doctor. checking again now.
accelerometer may be good to give data, but will see in paper how good insights it gives after doing the analytics.
1:41 pm - Dr Tamoghana sir: Yes. I have the same question. Probably a rural Indian Jugad.
2:16 pm - Avinash Kumar: now i need to remove dns and give RL, and also informal care provider advised me to give
pantop inj.
rantidine inj. 2 amp.
hyoscine 1 inj
ondansetron 2 amp.
and cefexime + tazobactum 1.5 gm
now to give or not?
guidelines or knowledge?
medically informed choice or legal choice?
eager to know opinions and why?
2:17 pm - Dr. Leelavati Maam Iqcity: No antibiotics indicated
2:22 pm - Dr. Leelavati Maam Iqcity: Only supportive- hydration nga and antacids
4:40 pm - Dr Rakesh sir: What we give depends on the patient's symptoms. If the patient is feeling better and is objectively better he may not need anything
4:40 pm - Dr Rakesh sir: 👍
5:11 pm - Avinash Kumar: i made the decision and gave medication accordingly at 3 pm.
i don't know how wrong i am here but what i did is
informed patient about my points briefly to not take uneccessary medications and informed about all the medication prescribed, dosase and symptomatic benefits.
and then asked patient to choose what he would prefer, he made the choice to follow the doctor's way so i did that.
7:55 pm - Avinash Kumar: please comment on it, positive negative both are welcome. i wish to understand what better i could have done.
7:56 pm - Avinash Kumar: i need to make similar decision again at 9pm for next dose of medication (different medication this time) so comments will help to do better.
7:57 pm - Avinash Kumar: 👍
7:59 pm - Avinash Kumar: i feel guilty of not doing the best possible in medicine based on tiny knowledge world have and much tinier of that i have.
but i have to value the doctor who own the patient and the patient who have right to choose his care and i have no evidence (yet) to say that those medication have more harm than benefit for this *individual*
8:00 pm - Dr Rakesh sir: Well said 👏👏👍
8:00 pm - Dr Tamoghana sir: You did the best possible thing. In absence of any imaging or laboratory support, even experienced doctors would hinge towards overtreatment (read antibiotics) to cover possible infections or peritonitis. So I guess its okay. What ultimately matters is whether the patient can be given relief
8:02 pm - Avinash Kumar: thanks, even i feel relief after reading this!😊👍🙏🏻
8:04 pm - Avinash Kumar: lavage helped, i was right. but i am not very clear how i had this in mind very early, i think just the abive history and some reading online while the events were happening.
8:05 pm - Avinash Kumar: may be just good guess narrowed with information (and lack of information too about differential i haven't learnt yet)
8:06 pm - Dr Rakesh sir: <Media omitted>
8:06 pm - Dr Rakesh sir: From our group members
8:07 pm - Dr. Leelavati Maam Iqcity: You have done wonders, believe me👍🏼👏🏻👏🏻
8:08 pm - Avinash Kumar: thanks maam!🙏🏻🙏🏻
