TheLiverDoc Profile picture
Jul 13, 2020 15 tweets 13 min read
#crazy Useless #patient

1/n
Middle-aged man, loves his #family, #farming, drives a cab, #happy. Son & wife at #home. Father-son relationship strong as rock. One #morning, son finds father mumbling to self. Mother says he hardly slept
Mumbling becomes angry ramblings. #Clinical LAENNEC WAS TAUGHT THE IMPO...
2/n
Has very little #breakfast. Walks excessively. Goes and lies down, only to get up and walk again. Family interactions little. Sleeps well for 2 hours from 12 to 2PM. Lunchtime. Groggy #father gets on the lunch table and defecates near plates and food. Son and mother aghast.
3/n
Father has gone mad. Calls the friendly neighbor, brings his car, rushes to #Medical specialty #clinic nearby. Father disoriented. Son gets the Fword from his own father multiple times, he is shocked! Then comes hurling of abuses after which they restrain him in the car.
4/n
In the clinic, #young duty-doc LOOKS at the patient, diagnoses #psychosis, advises observation and sedatives. After 2mg lorazepam, patient knocked out, later wakes up confused. Starts gibberish talk again. In between he identifies the wife, not son. This is devastating.
5/n
The young #Doctor is called again. He says this needs advanced #treatment. Psychosis is ‘refractory’ - he tells the #nurse – like a bloody crazy useless mad person (son overhears). Saddened by the fact that his father is driven to crazy for what reason?
6/n
So, they rush him in an ambulance to a bigger General #hospital nearby where an elderly #emergencymedicine doc sees the confused, groggy, occasionally abusive patient in restraints. He LOOKS attentively, but also #touch and #EXAMINE the patient.
7/n
Lesson 1: don’t #practice visual medicine. CLINICALLY EXAMINE the patient. The patient and family are gladdened by this. They get a sense that there is #care and #comfort is on the way if a doctor places her/his hands on the patient. Don’t be shy. #MedicalStudents The Doctor, 1891 painting b...
8/n
He finds a firm liver, enlarged spleen and spider angioma signs of cirrhosis. Son says father used alcohol heavily, stopped a year ago after #Blood vomiting after binge&retching. Doc says looks like he has cirrhosis and issues – needs gastro/liver doc. #Medical #examination
9/n
Our evaluation confirms #cirrhosis and portal hypertension (PHT; increase in liver pressure when liver shrinks). PHT is like a block in the highway. Cars get to take service roads and bypasses. These service roads/bypasses for #Portal venous blood are called #collaterals
10/n
Some collaterals are huge – called shunts, drawing blood away from liver, increasing #ammonia waste, resulting in brain failure – hepatic encephalopathy. In patient, blood ammonia levels were >300 and patient diagnosed with hepatic encephalopathy. #CT #Scans show large shunt
11/n
What was done? Lower ammonia. Look if patient candidate for liver #Transplant (using #MELD score and if not a transplant candidate, then block the shunts. How? Simple non-surgical #interventional #radiology procedure – shunt embolization by @SRajesh_IR
#irad #GITwitter
12/n
See what happens in the image below. Large shunts are taken care of. Ammonia reduction brings patient back to senses. Discharged a week later; CT scan done 3 months later showed shunts are gone. #Sedatives and #hypnotics worsen #encephalopathy in cirrhosis. Image
13/End
Do not forget to examine. Examine. Examine.
‘A good physician treats the disease but a great physician treats the patient who has the disease’
Not every cirrhosis patient is a goner at diagnosis.
“Diagnosis is not the end, but the beginning of practice”

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More from @theliverdr

Jun 26
‘Hepatology case’?
I ask the ER doc

‘Not sure doc’, he replies

‘Severe pancreatitis, but something is off.’
I think your Unit needs to look at it

‘Liver looks coarse & thers fluid in abdomen’

& we prepare ourselves for a confrontation so sinister, we did not know we'd lose... Image
39y old, healthy mother of 2 children

10y pretty girl, 5y little boy

Husband works as an office staff for a large MNC

Loss of appetite was first symptom, followed by abdominal discomfort

These went on for 1mo

An ultrasound done at the time revealed coarse fatty liver...
‘Just gas’

an elderly physician told them as he prescribed omeprazole

It did reduce the discomfort for a while

but did not abolish symptoms

But then, discomfort turned to severe pain

The physician prescribes her diclofenac
– it again helps

But 2d later, pain recurs...
Read 54 tweets
Jun 21
I think India should be proud about the most glorious stretching it has gifted to the world

But glorifying it using sick kids inhospital is kind of begging for credibility for a pseudoscientific practice that has pseudo-modernized through the ages

#InternationalYogaDay2022
Many will be surprised to see the term pseudoscience associated with Yoga. Thats bcoz u dont really know principles behind Yoga which is at best, contorted stretches to improve flexibility, nothing more

Yoga delusion
nirmukta.com/2011/10/31/the…
Yoga woo
sciencebasedmedicine.org/yoga-woo/
This. Exactly this is my point.
Yoga has been falsely modernized to embrace credibility via scientific studies, when in fact, it's principles are still based on ancient pseudoscientific writings. Read about Kundalini and Bindu in Hatha Yoga!
Read 5 tweets
Jun 18
Im lukin at the middle-aged man
His eyes deeply jaundiced
I was sure he saw everythin yellow

Diagnosed with severe alcohol-hepatitis (AH), docs elsewer went up to third line therapy
without any success

So here he was with me
Both of us battling an enemy hiding in plain sight...
6 wks back he started complaining of loss of appetite and fatigue

No fever, joint pains, skin rash

Tests for Covid were negative
As were other viral diseases

In a wks time, he saw his eyes turn yellow
and his urine a dark orange

He admitted to binge drinking...
once every 2 wks

and his last binge was 5 days prior to current symptoms

Pretty straight forward, the first doctor who saw him thought

– the guy has alcohol-hepatitis (AH)

The history fits
Clinical examination fits
and the investigation was also quite fitting...
Read 34 tweets
Jun 16
EVERYONE PLZ see this theory question
asked for Final Year Bachelor's in Ayurveda degree

Question is write short essay on
"Woman as an Aphrodisiac item"

In the next tweets, I will show the textbook which students of Ayurveda are made to study and the answer to this question...
...this is the answer that students are studying in their Bachelor's degree, instead of progressive, scientific facts that are to be useful for community and humanity

Chapter teaches how to objectify women into aphrodisiac 'items' and 'baby making factories'
This is the textbook from which students learn Kayacikitsa (or Internal Medicine of Ayurveda) - it is Government approved, prepared according to syllabus by Central Council for Indian Medicine

Are we teaching our young students the way of 'rape culture' by objectifying women?
Read 13 tweets
Jun 16
Assistant Commisioner of Police Traffic West, Kochi, has blocked entire public road for his morning walk

Morning school buses are unable to pick children from respective apartments

Children are forced to cross road between cars coming from both sides on the opposite road

1/3
Parents spoke to Officer, but doesnt budge, wants to continue his 'kingly' routine

Queens Walkway Kochi has separate jogging track & service road

But this man blocked entire public road for his morning routine, endangering kids
2/3

@TheKeralaPolice @HibiEden @kochicitypolice
Public roads cannot be blocked for personal use, especially when it's school time & children's buses are plying!

@TOIKochiNews @ZeeMalayalam @manoramaonline @manoramanews @AsianetNewsML @tvjanam @mathrubhuminews @manoramanews @24onlive @marunadannews @CPIMKerala @ShashiTharoor
Read 5 tweets
Jun 15
As Indian medical education system is headed towards "Integrated Medical Care" which means, scientific medicine will work along side Ayurveda and such alternative practices,

I would like to point out why this is a marvelous idea and one that will strengthen public health.... Image
Middle aged man is diagnosed with reactivation of chronic hepatitis B virus infection

He was seen in 2010 with flare of hepatitis B and that settled spontaneously. An integrated medicine practitioner treated at that time.
No antivirals given, patient did well... Image
So he goes to the same guy with the same problem and this time too,

He is advised a lot of dietary changes, started on multiple "safer" herbal drugs and advised complete rest

Whatever happened in 2010, will happen in 2022 - he was assured by the integrative medicine doc... Image
Read 7 tweets

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