This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.
Patient history by author -__
38 year old woman from ******* currently on hemodialysis in our hospital for renal failure.
She has been having a struggle life since 1995 when her mother passed away due to a medical condition ( reason not known by the patients husband) who was a known diabetic and a known hypertensive. In 1998, her father passed have because of an unknown cardiac condition. She got married in 2000 to her husband who works at a rice mill industry. She has 2 daughters, the elder daughter is 19yrs of age and currently in her btech 2nd year, 2nd daughter is 17yrs old and is in her inter 2nd year.
In 2006 she paid a visit to her dentist for getting a rootcanal done that was when she got diagnosed with type 2 diabetes mellitus and was put on Tab Zoryl 2mg BD. She has been switching from Tab Zoryl 2mg to 1mg depending on her blood sugar levels on her own .
6 yrs back, her husband had to sell their *** store ****** because of road construction work, since then her husband says she has been more stressed and she would randomly throw tantrums It had got to such a point that she would throw objects aggressively at others and over the past 5 years she has also been having visual and auditory hallucinations. She was taken to a psychiatrist in **** ( hospital) and the doctor there started her on tab Sizodon Forte ( risperidone and trihexyphenydryl ) and Tab Dayo 250mg ( Divalproex) and they even consulted a neurophysician who advised for a CT brain which turned out to be normal. She got diagnosed to be a hypertensive 3 yrs back and has been using Tab metxl 25mg once daily on and off since then.
One and a half years back she consulted an obstetrician since she had amenorrhea since 3 months, her husband says that he even found her to be pale then and on routine investigations she got diagnosed with renal failure with a serum creatinine of 5mg/dl and Sr urea of 70mg/dl for which they consulted a nephrologist who started her on sodium bicarbonate and calcium supplements.
1 month back she presented to our hospital dyspneic with bilateral pedal edema extending to her thighs for which she was started on hemodialysis.
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVeS1A5l7gLz-2V5hgy8pr0FpqktiZI94Rbq19PqqHDQhUxM_sKSKsyzx_7uYTNdSMhAWJ5m8F-C4nnX4R7_shCztvNHuP2Vjm63_PsQpyM5HEjSykP-yHBoSUxWlkbymQQBLHYh8jpfJJ/s400/1.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBLPub-ScjZahSCzTS4wgaG0FXKkx7ecGRXWpABXP9Z1aJNk4Bd50YawzzuLuWKhzND12Sb8OFXvmKAe7xmuNsX1qeyCE0TO0q87Z32LRS9NhCc7PKpee3dPQrmRyB8LGEL0GSvBFsTrkM/s640/2.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQJOmW9UYpA4s9HRdiARDfhPrruZRqS0FKnGKjoxp1PuKqEX5v9YtoHEnbtY7VHQfGeGI8FNl3L6ZHro5xNxpDsCfpKDV0-ioUmBBRzreva2o3F7Jw5MVGiNa7uRbHdddmZ-_6y5e4BNJo/s400/3.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg90pS8-uW5pvevEYRNfMsk5KYM5o39C19BHN0PQQoVjIx-DQaFUfxX1S1ddIIJkFKdmnn4gPijSnk-3A4ytHSOYDjSw9XxoAkiPEw1WSXtfnROUEFhJINOn6Choo3bOX-ikh7p0piVUOA6/s400/4.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr52vS_LTFJJ6iCtG5v4TjXYHT2hZtPXjegPR4lGw3Yc8Wgusoc3R8El91yyfnoYz1rCPaf-TsT-KVHUUW9U9nl-KZenq4UM3ZVP3JaIsiNr_fDG9gkiRWAPcne7dNi-WQuvfMqe3mUtCC/s400/5.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhui3gCrMlSFGmlgy9AHyQwZqnrV2FhV1ZBp7SGQeVYO9Lr_Jxbax-y7psaob9MD38KGrK6QTYgMP2zv5MfF__wOLpO957G1AHW9_nA0bSLSmTiTnYvu-4sv9dVN8LWDsCkYzTgjJjmOOsc/s400/6.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxaBVILW4fSJic2XnDv4YCGI9ICTfeUFKJxn4nBsPAZcev93olNmn9tT8aw2FRfetmADtQFvTNKZmpNKeAsoGnqFxUNShtSQT-0xvqNbCP1u5GaNePsMJiRqSsA6Df7S1pahcrnKCvDK5d/s400/7.jpeg)
Day1 post admission
-![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7kyyLTjF8Dc2LVOK1yIAoVJVvL85nBQtPU20NKEeq0rVN2jzpBHnlUdSR1msZGkb7yz1bqQjsFoo2x4OErjjtdMjVvJ_6xf5SD0pHgOHAdjJtC7zroqqDVAxp3l5A3K76OYK1gsBdaHDO/s400/11.jpeg)
Day 3 post admission
-![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9IKuYMbb07PLqMbw2DMZbExz_VBZEZ3O5fo3owBxlBGlboR30n2_UlOZCGFu5hLsCyaQnmn7oCLVwgM8sq8KGwGanAdHKx_mdUnVDEI40v5rBvS3NS9wdl1Gc1HW1xDsuF2kPB4zQDCVp/s400/12.jpeg)
Day 4 post admission
-![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixi3HS46zYf6cSBkKUkDRtqijb-N6qJyde_JDTJ0Ld6HtEnkVtRMWUbblFitrujGX2qbcNk0VnjG-wDmBcpLx2scjM98E8m9bTwj_F-6PUmd9F-W-28c7YG0NTBUrlVTWS2J1OD1_X3ROo/s400/13.jpeg)
Patient history by author -VV
38yr old woman
Renal failure on MHD
S - Complaining of non productive cough and aggravated dyspnea since last night.
She also complains of feeling febrile since last night.
O - Patient is pale and bilateral pedal edema present
Patient appears to be in respiratory distress
- PR-99bpm
BP- 120/80mmhg
Spo2-98% at 2 litres of oxygen
RR-24cpm
Cvs -S1 S2 present
Lungs- bilateral inspiratory crackles present
Abdomen-distended with everted umbilicus
A- ckd on mhd
Type 2 diabetes since 15 years on medication
Htn since 3 years
Schizophrenic since 5 years
? Pulmonary koch’s / ? Septic emboli
P- 2D ECHO in view of any infective endocarditis changes
Sputum for cbnaat to be sent
Coagulation profile to be sent
Debate on whether to start on antitubercular therapy
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMtjtWhiqocv68dJdleWzGD1JDDkpYt5cRit2sG0IZ1JZxI3ZfjC48ZRbM_a9z4k377zt1cEPJ8PmZgo4qWwFtRh4VOkR9D4dn846yBDb1lkFnp332zWYjkrSobZM26kCrXtY7TONID-z4/s640/1.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6lZhARjbo7CVB4CxqtCJZrMv3eimGAf_0d7xDeeKtxr4yW47geJeUa70QPrpLCmXMtzXxzmR4r6BpQBXsQPLw31a_I3xpYQeqGAWX5j2ZGdkbxz9f8PVFguCWyZWaTMZQYgtWp7X5IaNQ/s640/2.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYpQtKxmZW03UTtTmO9RcZYnz8NlrCdqgjBrz6gSr1xMw-q-NFmHWmnuI6MAMCKypkM8jyzCOTF50NANAgtGtTxR9pgm1bYEzCi1hrQid__2YlkpM4oGepjsPos7bUcZrbTTVHelSnz9li/s640/3.jpeg)
Conversational Learning/CDSS -
AT- Palpable skin lesions with Cavitary lung lesions and rapidly progressive renal failure. All roads lead to Rome (GPA in this case ?)
RB- Someone still has to carve out a generous amount of lung tissue from her to prove that Rome exists? 😅
AT- In an ideal non covid world, yes sir. However, a skin biopsy with cANCA titres would be helpful here.
RB- Or can we take a short cut to Rome through her skin tissue which would be more easier? 🤔
AT- What would you expect in the skin biopsy that would take us to Rome conclusively?
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFfumeQmKFfzEL72Ojr4A4ZAwMkEJ4_cPoR9dbXMgsKqd2pg2m4lAi3jkuovUIOtiwex3_eZrISULfzCvt0hWMiZ-2d94WAmn9VzuKlhFwkwMeVpXTDAaNyt_z4IvkqpKUii7z587W8BTS/s400/14.jpeg)
AT- Necrotizing granulomatous vasuclitis. I think I saw rim enhancement of the cavity walls in the CT and also the renal lesion appears aggressively active. Some system 1 learning says cANCA in active inflammatory lesions is strongly positive and suggests a small vessel vasculitis, particularly GPA.
RB- What would be the sensitivity and specificity of this finding?
Enough to consider immunosuppresives over Sepsis treatment as both are antithetical to each other
AT - Even a renal biopsy showing pauci immune glomerulonephritis can help. Will share some system 2 data.
AT - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059091/#!po=0.943396
Between February 1, 2005 and February 1, 2015 a total of 8403 IIF for ANCA was performed of which 1238 tested positive (27% p-ANCA, 71% c-ANCA pattern, 1% aspecific pattern) in 279 patients. A total of 5370 immunoassays for PR3 and/or MPO ANCA was performed of which 1218 samples tested positive in 239 patients (Fig.1)
RB - Can we fit our patients to any of the patients in the study you quoted here?
What are the attributes she shares with them?
AT-
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiolWlKg613rb41MOTIeSjEPIkh-n_qagr7lXFTbAnh13za5G4zp8Kx1iflaMMKEuuMBboScEX8wmBPbXe9iIl71McEbiE8LALfs-ykALxYkwT2k9eMClEbLrU2jRB4FzUy_2jUs1ws1PUn/s640/WhatsApp+Image+2020-07-24+at+10.31.31+AM.jpeg)
- The table explains quite a lot. Patients were initially diagnosed on clinical features and then ANCA samples were sent for.
RB - Looks reassuring.
DV -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014960/
Patient history by author -__
38 year old woman from ******* currently on hemodialysis in our hospital for renal failure.
She has been having a struggle life since 1995 when her mother passed away due to a medical condition ( reason not known by the patients husband) who was a known diabetic and a known hypertensive. In 1998, her father passed have because of an unknown cardiac condition. She got married in 2000 to her husband who works at a rice mill industry. She has 2 daughters, the elder daughter is 19yrs of age and currently in her btech 2nd year, 2nd daughter is 17yrs old and is in her inter 2nd year.
In 2006 she paid a visit to her dentist for getting a rootcanal done that was when she got diagnosed with type 2 diabetes mellitus and was put on Tab Zoryl 2mg BD. She has been switching from Tab Zoryl 2mg to 1mg depending on her blood sugar levels on her own .
6 yrs back, her husband had to sell their *** store ****** because of road construction work, since then her husband says she has been more stressed and she would randomly throw tantrums It had got to such a point that she would throw objects aggressively at others and over the past 5 years she has also been having visual and auditory hallucinations. She was taken to a psychiatrist in **** ( hospital) and the doctor there started her on tab Sizodon Forte ( risperidone and trihexyphenydryl ) and Tab Dayo 250mg ( Divalproex) and they even consulted a neurophysician who advised for a CT brain which turned out to be normal. She got diagnosed to be a hypertensive 3 yrs back and has been using Tab metxl 25mg once daily on and off since then.
One and a half years back she consulted an obstetrician since she had amenorrhea since 3 months, her husband says that he even found her to be pale then and on routine investigations she got diagnosed with renal failure with a serum creatinine of 5mg/dl and Sr urea of 70mg/dl for which they consulted a nephrologist who started her on sodium bicarbonate and calcium supplements.
1 month back she presented to our hospital dyspneic with bilateral pedal edema extending to her thighs for which she was started on hemodialysis.
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVeS1A5l7gLz-2V5hgy8pr0FpqktiZI94Rbq19PqqHDQhUxM_sKSKsyzx_7uYTNdSMhAWJ5m8F-C4nnX4R7_shCztvNHuP2Vjm63_PsQpyM5HEjSykP-yHBoSUxWlkbymQQBLHYh8jpfJJ/s400/1.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBLPub-ScjZahSCzTS4wgaG0FXKkx7ecGRXWpABXP9Z1aJNk4Bd50YawzzuLuWKhzND12Sb8OFXvmKAe7xmuNsX1qeyCE0TO0q87Z32LRS9NhCc7PKpee3dPQrmRyB8LGEL0GSvBFsTrkM/s640/2.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQJOmW9UYpA4s9HRdiARDfhPrruZRqS0FKnGKjoxp1PuKqEX5v9YtoHEnbtY7VHQfGeGI8FNl3L6ZHro5xNxpDsCfpKDV0-ioUmBBRzreva2o3F7Jw5MVGiNa7uRbHdddmZ-_6y5e4BNJo/s400/3.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg90pS8-uW5pvevEYRNfMsk5KYM5o39C19BHN0PQQoVjIx-DQaFUfxX1S1ddIIJkFKdmnn4gPijSnk-3A4ytHSOYDjSw9XxoAkiPEw1WSXtfnROUEFhJINOn6Choo3bOX-ikh7p0piVUOA6/s400/4.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjr52vS_LTFJJ6iCtG5v4TjXYHT2hZtPXjegPR4lGw3Yc8Wgusoc3R8El91yyfnoYz1rCPaf-TsT-KVHUUW9U9nl-KZenq4UM3ZVP3JaIsiNr_fDG9gkiRWAPcne7dNi-WQuvfMqe3mUtCC/s400/5.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhui3gCrMlSFGmlgy9AHyQwZqnrV2FhV1ZBp7SGQeVYO9Lr_Jxbax-y7psaob9MD38KGrK6QTYgMP2zv5MfF__wOLpO957G1AHW9_nA0bSLSmTiTnYvu-4sv9dVN8LWDsCkYzTgjJjmOOsc/s400/6.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxaBVILW4fSJic2XnDv4YCGI9ICTfeUFKJxn4nBsPAZcev93olNmn9tT8aw2FRfetmADtQFvTNKZmpNKeAsoGnqFxUNShtSQT-0xvqNbCP1u5GaNePsMJiRqSsA6Df7S1pahcrnKCvDK5d/s400/7.jpeg)
Day1 post admission
-
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7kyyLTjF8Dc2LVOK1yIAoVJVvL85nBQtPU20NKEeq0rVN2jzpBHnlUdSR1msZGkb7yz1bqQjsFoo2x4OErjjtdMjVvJ_6xf5SD0pHgOHAdjJtC7zroqqDVAxp3l5A3K76OYK1gsBdaHDO/s400/11.jpeg)
Day 3 post admission
-
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9IKuYMbb07PLqMbw2DMZbExz_VBZEZ3O5fo3owBxlBGlboR30n2_UlOZCGFu5hLsCyaQnmn7oCLVwgM8sq8KGwGanAdHKx_mdUnVDEI40v5rBvS3NS9wdl1Gc1HW1xDsuF2kPB4zQDCVp/s400/12.jpeg)
Day 4 post admission
-
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixi3HS46zYf6cSBkKUkDRtqijb-N6qJyde_JDTJ0Ld6HtEnkVtRMWUbblFitrujGX2qbcNk0VnjG-wDmBcpLx2scjM98E8m9bTwj_F-6PUmd9F-W-28c7YG0NTBUrlVTWS2J1OD1_X3ROo/s400/13.jpeg)
Patient history by author -VV
38yr old woman
Renal failure on MHD
S - Complaining of non productive cough and aggravated dyspnea since last night.
She also complains of feeling febrile since last night.
O - Patient is pale and bilateral pedal edema present
Patient appears to be in respiratory distress
- PR-99bpm
BP- 120/80mmhg
Spo2-98% at 2 litres of oxygen
RR-24cpm
Cvs -S1 S2 present
Lungs- bilateral inspiratory crackles present
Abdomen-distended with everted umbilicus
A- ckd on mhd
Type 2 diabetes since 15 years on medication
Htn since 3 years
Schizophrenic since 5 years
? Pulmonary koch’s / ? Septic emboli
P- 2D ECHO in view of any infective endocarditis changes
Sputum for cbnaat to be sent
Coagulation profile to be sent
Debate on whether to start on antitubercular therapy
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMtjtWhiqocv68dJdleWzGD1JDDkpYt5cRit2sG0IZ1JZxI3ZfjC48ZRbM_a9z4k377zt1cEPJ8PmZgo4qWwFtRh4VOkR9D4dn846yBDb1lkFnp332zWYjkrSobZM26kCrXtY7TONID-z4/s640/1.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6lZhARjbo7CVB4CxqtCJZrMv3eimGAf_0d7xDeeKtxr4yW47geJeUa70QPrpLCmXMtzXxzmR4r6BpQBXsQPLw31a_I3xpYQeqGAWX5j2ZGdkbxz9f8PVFguCWyZWaTMZQYgtWp7X5IaNQ/s640/2.jpeg)
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjYpQtKxmZW03UTtTmO9RcZYnz8NlrCdqgjBrz6gSr1xMw-q-NFmHWmnuI6MAMCKypkM8jyzCOTF50NANAgtGtTxR9pgm1bYEzCi1hrQid__2YlkpM4oGepjsPos7bUcZrbTTVHelSnz9li/s640/3.jpeg)
Conversational Learning/CDSS -
AT- Palpable skin lesions with Cavitary lung lesions and rapidly progressive renal failure. All roads lead to Rome (GPA in this case ?)
RB- Someone still has to carve out a generous amount of lung tissue from her to prove that Rome exists? 😅
AT- In an ideal non covid world, yes sir. However, a skin biopsy with cANCA titres would be helpful here.
RB- Or can we take a short cut to Rome through her skin tissue which would be more easier? 🤔
AT- What would you expect in the skin biopsy that would take us to Rome conclusively?
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFfumeQmKFfzEL72Ojr4A4ZAwMkEJ4_cPoR9dbXMgsKqd2pg2m4lAi3jkuovUIOtiwex3_eZrISULfzCvt0hWMiZ-2d94WAmn9VzuKlhFwkwMeVpXTDAaNyt_z4IvkqpKUii7z587W8BTS/s400/14.jpeg)
AT- Necrotizing granulomatous vasuclitis. I think I saw rim enhancement of the cavity walls in the CT and also the renal lesion appears aggressively active. Some system 1 learning says cANCA in active inflammatory lesions is strongly positive and suggests a small vessel vasculitis, particularly GPA.
RB- What would be the sensitivity and specificity of this finding?
Enough to consider immunosuppresives over Sepsis treatment as both are antithetical to each other
AT - Even a renal biopsy showing pauci immune glomerulonephritis can help. Will share some system 2 data.
AT - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059091/#!po=0.943396
Between February 1, 2005 and February 1, 2015 a total of 8403 IIF for ANCA was performed of which 1238 tested positive (27% p-ANCA, 71% c-ANCA pattern, 1% aspecific pattern) in 279 patients. A total of 5370 immunoassays for PR3 and/or MPO ANCA was performed of which 1218 samples tested positive in 239 patients (Fig.1)
RB - Can we fit our patients to any of the patients in the study you quoted here?
What are the attributes she shares with them?
AT-
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiolWlKg613rb41MOTIeSjEPIkh-n_qagr7lXFTbAnh13za5G4zp8Kx1iflaMMKEuuMBboScEX8wmBPbXe9iIl71McEbiE8LALfs-ykALxYkwT2k9eMClEbLrU2jRB4FzUy_2jUs1ws1PUn/s640/WhatsApp+Image+2020-07-24+at+10.31.31+AM.jpeg)
- The table explains quite a lot. Patients were initially diagnosed on clinical features and then ANCA samples were sent for.
RB - Looks reassuring.
DV -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014960/