Evidence based date wise workflow logs collated by the intern with clickable and verifiable links

Evidence based date wise workflow logs collated by the intern with clickable and verifiable links 

Case :1 

https://chat.whatsapp.com/KL4ow3jjldQ0ovKKklCYNi

 [06/11/23, 8:11:39 AM] Rakesh Biswas Sir GM HOD: The case report link in the description box is incorrect. Share the correct link. See how correct links to your batchmate's online learning portfolios look like at our dashboard here 👇

http://medicinedepartment.blogspot.com/2022/02/?m=0

[06/11/23, 8:13:44 AM] Vinil Reddy: Ok sir

[06/11/23, 8:14:09 AM] 75F FEVER , BURNING MICTURATION SINCE 4 DAYS Telangana Pajr: ‎You changed the group description

[06/11/23, 8:51:32 AM] Vinil Reddy: S: Fever and burning micturition since 4 days 

O: pt is conscious, coherent,cooperative.

BP: 120/80mmhg

PR: 96

RR: 20

Temp: 98.5F

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS:NAD

A: AKI on CKD with sepsis secondary to UTI

P: 

1.IV fluids (NS AND RL) 50ml/hr

2.Inj.ceftriaxone 2gm/IV/BD

3.Inj.lasix 20mg/IV /BD 

4.Inj. Buscopan 1amp IM/sos

5.Inj. Tramadol 1amp in 100ml NS IV/sos

6.Tab.clinidipine 10mg PO/BD

7.Tab. Tolvaptan 50mg PO/BD

8. Syp. Citralka 10ml with 1glass of water PO/TID

9.Tab.Livogen 100mg PO/OD

10. Tab. Pregabalin 75/10 

11.Tab. Azithromycin 500mg PO/OD

‎[06/11/23, 8:53:55 AM] Vinil Reddy: ‎image omitted

[06/11/23, 8:54:25 AM] Rakesh Biswas Sir GM HOD: Role of azithromycin in urosepsis? 

Any cardiovascular harms of azithromycin that you can search for?

[06/11/23, 8:56:50 AM] Vinil Reddy: Azithromycin causes disturbances in the rhythm of Heart causing arrhythmias .

[06/11/23, 8:57:27 AM] Rakesh Biswas Sir GM HOD: Share some scientific articles reporting the same

[06/11/23, 8:57:52 AM] Rakesh Biswas Sir GM HOD: Links with quotes only and no PDFs

[06/11/23, 8:58:36 AM] Vinil Reddy: Sepsis is due to the infection sir . Hence we have given Azithromycin which is broad spectrum antibiotic

[06/11/23, 8:59:18 AM] Vinil Reddy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3374857/

[06/11/23, 9:00:25 AM] Rakesh Biswas Sir GM HOD: See the question again. 

Doesn't everyone know that sepsis is due to infection? 

The question is specific to :

Role of azithromycin in urosepsis?

[06/11/23, 9:00:50 AM] Rakesh Biswas Sir GM HOD: ‎Rakesh Biswas Sir GM HOD changed the group name to “75F FEVER , BURNING MICTURATION SINCE 4 DAYS Telangana Pajr”

[06/11/23, 10:44:53 AM] 75F FEVER , BURNING MICTURATION SINCE 4 DAYS Telangana Pajr: ‎You changed this group's icon

[06/11/23, 12:55:45 PM] Vinil Reddy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840933/#:~:text=Most%20patients%20require%20treatment%20for,in%2048%20to%2072%20hours.

[06/11/23, 2:45:43 PM] Rakesh Biswas Sir GM HOD: Please quote the relevant portion

[06/11/23, 2:48:56 PM] Vinil Reddy: Most patients require treatment for about 14-21 days. Successful antimicrobial therapy will usually ameliorate symptoms promptly, with substantial clinical improvement in 48 to 72 hours.

[06/11/23, 2:49:56 PM] Vinil Reddy: Sir , there is no specific article about  role of Azithromycin in urosepsis . 

Everywhere they mentioned about use of antibiotic based on the culture report

‎[06/11/23, 2:50:42 PM] Vinil Reddy: ‎image omitted

[06/11/23, 2:54:25 PM] Vinil Reddy: But culture report came negative

[06/11/23, 3:03:05 PM] Rakesh Biswas Sir GM HOD: What can explain this negative culture report in our patient? 

No urosepsis to begin with? 

What can explain her symptomatology?

[06/11/23, 3:06:58 PM] ~ Dr.Dinesh Datta: ‎~ Dr.Dinesh Datta joined using this group's invite link

[06/11/23, 3:07:06 PM] Navyatha Kims : ‎Navyatha Kims  joined using this group's invite link

[06/11/23, 3:29:54 PM] Vinil Reddy: One of the Differntials may be pyelonephritis. Which may explain her burning micturition, fever associated with chills , pain the lower abdomen .

[06/11/23, 3:31:19 PM] ~ Dr.Dinesh Datta: Any other likely possibilities?

Say viral?

Or any other?

Do a literature review and update us.

After sharing patient complaints and SOAP notes today

[06/11/23, 3:32:30 PM] ~ Dr.Dinesh Datta: Ever heard 'sterile pyuria/hematuria'?

[06/11/23, 3:33:51 PM] ~ Dr.Dinesh Datta: Share the CUE report

[06/11/23, 3:34:50 PM] Vinil Reddy: Yes sir . Sterile pyuria / hematuria is the presence of wbc or blood in the urine . With out any infection .

‎[06/11/23, 3:35:39 PM] Vinil Reddy: ‎image omitted

[06/11/23, 3:35:39 PM] ~ Dr.Dinesh Datta: We aren't clear if it's sterile pyruria/hematuria too.

Any documented evidence/patient reports?

[06/11/23, 3:37:03 PM] Vinil Reddy: CUE is also normal . And patient didn’t complain of red colour urine

[06/11/23, 3:38:25 PM] Swagath Kims : ‎Swagath Kims  joined using this group's invite link

[06/11/23, 3:38:07 PM] ~ Dr.Dinesh Datta: How is our provisional diagnosis AKI due to UTI?

Can it be a viral UTI?When did the complain start?

Looks like you assumed 160 systolic bp to AKI.

What's the normal bp range of patients previously?

How does bp affect due to age?

[06/11/23, 3:40:03 PM] Vinil Reddy: Complaint started  9 days back . It can be viral .

[06/11/23, 3:40:36 PM] Vinil Reddy: But now patient has bp in the normal range . Today at 2:00pm 120/80

[06/11/23, 3:40:40 PM] ~ Dr.Dinesh Datta: How can it be viral?is it your assumption due to duration of 9 days?

Or any actual reasoning?

[06/11/23, 3:40:46 PM] ~ Dr.Dinesh Datta: Any meds taken?

[06/11/23, 3:41:50 PM] Vinil Reddy: Inj. Lasix 20mg

[06/11/23, 3:42:03 PM] ~ Dr.Dinesh Datta: Any examination findings suggestive of Pyelonephritis?

Any tenderness etc?

[06/11/23, 3:43:52 PM] Vinil Reddy: Cell counts are increased . So it may not be viral

[06/11/23, 3:44:28 PM] ~ Dr.Dinesh Datta: Which cells?

When?

[06/11/23, 3:44:35 PM] Vinil Reddy: Total count

[06/11/23, 3:44:52 PM] ~ Dr.Dinesh Datta: Please share the cbp

‎[06/11/23, 3:45:27 PM] Vinil Reddy: ‎image omitted

[06/11/23, 3:45:43 PM] ~ Dr.Dinesh Datta: Found it. 

And also pedal edema may suggest AKI?

‎[06/11/23, 3:45:45 PM] Vinil Reddy: ‎image omitted

‎[06/11/23, 3:46:13 PM] Vinil Reddy: ‎image omitted

[06/11/23, 3:46:15 PM] ~ Dr.Dinesh Datta: Just checked the blog

[06/11/23, 3:46:55 PM] ~ Dr.Dinesh Datta: Add the cell counts and vital trends in graph and update,since admission

‎[06/11/23, 3:57:22 PM] Vinil Reddy: ‎image omitted

[06/11/23, 4:19:18 PM] Rakesh Biswas Sir GM HOD: Share the cue report that was done outside

‎[06/11/23, 4:24:13 PM] Vinil Reddy: ‎image omitted

[06/11/23, 4:24:25 PM] Vinil Reddy: On 31/10/23

[06/11/23, 4:25:30 PM] Vinil Reddy: Based on this it  may be sterile pyuria

[06/11/23, 4:25:51 PM] Vinil Reddy: As culture report is negative

[06/11/23, 4:35:46 PM] GM PG harika Ma'am PgY1: ‎GM PG harika Ma'am PgY1 joined using this group's invite link

[06/11/23, 4:40:16 PM] Rakesh Biswas Sir GM HOD: But the culture was done long after this pyuria report and not on the same day? 

The culture is negative because the patient was already well fed with antibiotics before we could send the cultures?

[06/11/23, 4:40:50 PM] Vinil Reddy: Culture was sent on 2/11/23

[06/11/23, 4:41:49 PM] Vinil Reddy: Does antibiotic will work within 2 days ?

[06/11/23, 4:42:00 PM] Rakesh Biswas Sir GM HOD: Why not?

[06/11/23, 4:42:05 PM] Rakesh Biswas Sir GM HOD: Long after

[06/11/23, 4:42:55 PM] Rakesh Biswas Sir GM HOD: How long was the patient already on antibiotic before this cue on 31/10?

[06/11/23, 4:47:56 PM] Vinil Reddy: Not sure sir . Will update here shortly .

[06/11/23, 5:23:12 PM] Vinil Reddy: Inj piptaz and Inj metrogyl given on 1/11/23

[06/11/23, 5:24:17 PM] Vinil Reddy: Also they have done CT abdomen outside and it shows pyelonephritis

‎[06/11/23, 5:24:26 PM] Vinil Reddy: ‎image omitted

[06/11/23, 7:03:14 PM] Rakesh Biswas Sir GM HOD: Antibiotics started for the first time on 1/11/23? No antibiotics received outside before that?

[06/11/23, 7:03:52 PM] Rakesh Biswas Sir GM HOD: Share the image. Never share written radiology reports before that

[06/11/23, 7:15:01 PM] Vinil Reddy: No sir

[06/11/23, 7:15:07 PM] Vinil Reddy: Ok sir

[07/11/23, 9:37:12 AM] Vinil Reddy: ‎You deleted this message.

‎[07/11/23, 9:37:47 AM] Vinil Reddy: ‎image omitted

[07/11/23, 10:31:54 AM] Vinil Reddy: ‎You deleted this message.

[07/11/23, 10:35:58 AM] Vinil Reddy: S: Fever and burning micturition subsided

O: pt is conscious, coherent,cooperative.

BP: 110/70mmhg

PR: 121

RR: 20

Temp: 98.6F

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS:NAD

A: AKI on CKD with sepsis secondary to UTI

P: 

1.IV fluids (NS AND RL) 50ml/hr

2.Inj.ceftriaxone 2gm/IV/BD

3.Inj.lasix 20mg/IV /BD 

4.Inj. Buscopan 1amp IM/sos

5.Inj. Tramadol 1amp in 100ml NS IV/sos

6.Tab.clinidipine 10mg PO/BD

7.Tab. Azithromycin 500mg PO/OD

8.Tab. Tolvaptan 50mg PO/BD

9.Syp. Citralka 10ml with 1glass of water PO/TID

10.Tab.Livogen 100mg PO/OD

11. Tab. Pregabalin.NT /OD

‎[07/11/23, 10:41:07 AM] Vinil Reddy: ‎image omitted

[07/11/23, 1:20:31 PM] ~ Madeeha Abrar: ‎~ Madeeha Abrar joined using this group's invite link

[08/11/23, 2:24:36 PM] Vinil Reddy: ‎You deleted this message.

[08/11/23, 2:29:23 PM] Vinil Reddy: S: Fever and burning micturition subsided

O: pt is conscious, coherent,cooperative.

BP: 110/70mmhg

PR: 86

RR: 18

Temp: 98.2F

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS:NAD

A: AKI on CKD with sepsis secondary to UTI

P: 

1.IV fluids (NS AND RL) 50ml/hr

2.Inj.ceftriaxone 2gm/IV/BD

3.Tab .lasix 20mg/PO /BD 

4.Inj. Buscopan 1amp IM/sos

5.Inj. Tramadol 1amp in 100ml NS IV/sos

6.Tab.clinidipine 10mg PO/BD

7.Tab.Livogen 100mg PO/OD

8. Tab. Pregabalin.NT /OD

9. Tab.Ofloxacin PO/BD

‎[08/11/23, 3:04:01 PM] Vinil Reddy: ‎image omitted

[08/11/23, 3:13:27 PM] Rakesh Biswas Sir GM HOD: Put a pointer to the evidence of pyelonephritis in this CT abdomen

‎[08/11/23, 3:38:14 PM] Vinil Reddy: ‎image omitted

[08/11/23, 3:46:04 PM] Rakesh Biswas Sir GM HOD: What are the normal measurements of the kidneys considering her height and when can one say that the kidneys are enlarged (bulky), at what measurement cut off?

[08/11/23, 3:53:14 PM] Vinil Reddy: Normal measurement of kidneys

 Is about 10-13 cm . 

We can say it is enlarged if size is >15cm

[08/11/23, 4:05:37 PM] Rakesh Biswas Sir GM HOD: Length? What was it in your patient?

[08/11/23, 4:08:06 PM] Vinil Reddy: Length

[08/11/23, 4:09:13 PM] Rakesh Biswas Sir GM HOD: Bulk is length? 

What was the length and breadth of the kidneys in your patient and what would be the expected length for her height and body mass?

[08/11/23, 4:12:45 PM] Vinil Reddy: In this patient length is normal 

Right kidney -11cm

Left kidney-10.5cm

[08/11/23, 4:13:16 PM] Vinil Reddy: Iam saying in general if length is more than 15cm it is enlarged kidney

[08/11/23, 4:16:50 PM] Anurag Kims : ‎You added Anurag Kims 

[08/11/23, 4:24:13 PM] Rakesh Biswas Sir GM HOD: So why are we calling his kidneys enlarged? 

Is the breadth increased?

[08/11/23, 4:24:39 PM] Rakesh Biswas Sir GM HOD: In general? 

Can you search and share a scientific reference?

[08/11/23, 4:26:26 PM] Vinil Reddy: They have given perinephric fat stranding in the report sir .

[08/11/23, 4:27:11 PM] Vinil Reddy: From his figures we may conclude that a kidney measuring longer than 14 em on a supine abdominal film is a large kidney and 

https://radiology.rsna.org/doi/10.1148/84.4.688#:~:text=From%20his%20figures%20we%20may,be%20regarded%20with%20some%20suspicion.

[08/11/23, 4:28:07 PM] Rakesh Biswas Sir GM HOD: Point that out in the image 

Get the radiologist's help in trying to understand how it appears asap

[08/11/23, 4:28:57 PM] Rakesh Biswas Sir GM HOD: What is the significance of fat stranding?

[08/11/23, 4:58:51 PM] Vineela Kims : ‎Vineela Kims  joined using this group's invite link

[08/11/23, 5:24:07 PM] Manvi Sharma Kims : ‎Manvi Sharma Kims  joined using this group's invite link

[08/11/23, 5:30:16 PM] Vinil Reddy: While a degree of symmetric bilateral perinephric stranding is common, particularly in the elderly, asymmetric or unilateral perinephric stranding is an important sign of renal inflammation or of acute obstruction. As such, it is seen in conditions such as acute pyelonephritis and with ureteric calculi.27-Aug-2021

https://radiopaedia.org/articles/perinephric-stranding#:~:text=While%20a%20degree%20of%20symmetric,pyelonephritis%20and%20with%20ureteric%20calculi.

[10/11/23, 7:23:20 PM] Rakesh Biswas Sir GM HOD: Update?

[10/11/23, 7:26:37 PM] Vinil Reddy: Patient discharged yesterday sir

[10/11/23, 7:29:10 PM] Rakesh Biswas Sir GM HOD: Can you share yesterday's update before discharge?

[10/11/23, 7:36:07 PM] Vinil Reddy: S: No fever spikes (98.4F)

O: pt is conscious, coherent,cooperative.

BP: 110/80

PR: 79

RR: 18

Temp: 98.4F

RS: BAE+ clear

CVS: s1,s2 no added sounds

P/A: not tender

CNS:NAD

A: AKI on CKD with sepsis secondary to UTI

P: 

1.IV fluids (NS AND RL) 50ml/hr

2.T.Lasix  20mg po/BD

3. T.Clinidipine 10mg PO / BD

4.T.Livogen 100mg PO/OD

5.T.pregabalin NT PO/OD/HS

6.T.Oflaxacin 200mg PO/BD

‎[10/11/23, 7:38:18 PM] Vinil Reddy: ‎image omitted

‎[10/11/23, 7:38:30 PM] Vinil Reddy: ‎image omitted

[10/11/23, 7:43:53 PM] Rakesh Biswas Sir GM HOD: 👆yesterday's fever chart?

[10/11/23, 7:46:50 PM] Vinil Reddy: Didn’t updated sir 

Yesterday morning Iam in the opd 

By the time I went to ward patient discharged

[10/11/23, 7:52:55 PM] Vinil Reddy: Sir , why did her hb count decreased  day by day ?

[10/11/23, 7:56:06 PM] Rakesh Biswas Sir GM HOD: Ask @Lasyapriya and @Muvva this question. They are experts by now in answering this question

[10/11/23, 8:14:43 PM] Vinil Reddy: Can it be due to low EPO levels due to kidney injury ?

[10/11/23, 8:18:51 PM] ~ Dr.Dinesh Datta: How do you know EPO levels are lowered?

Did you measure it?

Or assumed?

[10/11/23, 8:19:39 PM] Vinil Reddy: Assumed

[10/11/23, 8:23:24 PM] Vinil Reddy: Is there any other reason which will explain drop in hb count ?

[10/11/23, 8:23:25 PM] ~ Dr.Dinesh Datta: Plausible assumption

[10/11/23, 8:24:44 PM] ~ Dr.Dinesh Datta: What's the normal variation in Hb levels?

If I take a sample from your left hand and right hand,will they both be same?

Does fluids effect Hb levels too?

Clotting/blood thickening?

[10/11/23, 8:40:38 PM] Vinil Reddy: Normal variation in Hb is 10%

[10/11/23, 8:41:50 PM] ~ Dr.Dinesh Datta: ‎This message was deleted.

[10/11/23, 8:41:58 PM] Vinil Reddy: In attempting to assess the significance of changes in haemoglobin levels following burns (Brown, 1944), it was found necessary to reinvestigate the variations which occur in normal individuals. Dreyer, Bazett & Pierce (1920) recorded the haemoglobin levels of normal adults at intervals during the day, and found a maximum variation of 30 %. They regarded changes of 10% as

common.

https://physoc.onlinelibrary.wiley.com/doi/pdf/10.1113/jphysiol.1946.sp004133#:~:text=Diurnal%20variations%20in%20haemoglobin%203,g.%2F100%20ml.)&text=same%20period%20was-,4%2D12%20%25%20of%20the%20mean.,%2D67%20%25%20of%20the%20mean.

[10/11/23, 8:42:42 PM] ~ Dr.Dinesh Datta: How much did hb drop here over last 2 days?

[10/11/23, 8:43:50 PM] Vinil Reddy: On7/11/23 it is 9.0mg/dl

On 9/11/23 it is 7.4mg/dl

[10/11/23, 8:44:39 PM] ~ Dr.Dinesh Datta: What's subjective findings?(patients complaints etc)Did you talk to patient?

[10/11/23, 8:48:11 PM] Vinil Reddy: Generalised weakness

[10/11/23, 8:48:58 PM] Vinil Reddy: Other complaints are as mentioned in the blog .

[10/11/23, 8:49:40 PM] ~ Dr.Dinesh Datta: Share the grbs trends over last 2 days

[10/11/23, 8:49:54 PM] Vinil Reddy: By the time patient discharged , she told all other complaints are subsided except for weakness and generalised body pains

[10/11/23, 8:56:03 PM] Vinil Reddy: As patient is not diabetic they didn’t check Grbs .

Rbs - on 2/11/23 is 154mg/dl

[10/11/23, 8:56:22 PM] Vinil Reddy: G/dl*

[10/11/23, 10:31:37 PM] ~ Dr.Dinesh Datta: Was she febrile?Share the trends over last 2 days

How do we quantify the weakness?

Can it be due to age or fever or diet? ‎<This message was edited>

[10/11/23, 10:47:41 PM] Vinil Reddy: Not febrile

[10/11/23, 10:47:56 PM] Vinil Reddy: Or can it be due to low Hb?

[10/11/23, 10:48:37 PM] ~ Dr.Dinesh Datta: How's her weakness or activeness levels over last 15days?

Even before she admitted

[10/11/23, 10:51:27 PM] Vinil Reddy: Before she admitted she was active 

Weakness was started  after she got the complaints mentioned in the blog

[10/11/23, 10:52:12 PM] ~ Dr.Dinesh Datta: What's 'postdrome'?

[11/11/23, 8:46:34 AM] Vinil Reddy: A postdrome is a symptom or set of symptoms that occurs after a particular condition has passed.

[11/11/23, 4:09:46 PM] Rakesh Biswas Sir GM HOD: @917386552514 's thesis

Case :2 

https://chat.whatsapp.com/IU4A0RKUcrO1RnQXdDyHeq

[17/11/23, 2:31:04 PM] Vinil Reddy: S - pain in the abdomen -decreased 

O- pt is conscious, coherent, cooperative. 

       Bp - 130/70mmhg 

        PR - 60bpm 

        Temp - afebrile 

RS - BAR + , clear 

CVS - s1,s2 no added sounds and no murmurs 

P/A - soft and tenderness positive 

CNS - NAD

A- ?alcoholic hepatitis 

P- 

1.Nil per oral 

2.NS and RL 125ml/hr , DNS -25ml/hr

3.Inj . Thiamine 500mg in 100ml NS Over 20min OD 

4.Inj.optineuron 1amp IV /OD 

5.Inj.Tramadol 1amp in 100ml NS IV/sos

6.Tab. Lorazepam Po/TID

[20/11/23, 3:04:03 PM] Vinil Reddy: S - pain in the abdomen -decreased 

O- pt is conscious, coherent, cooperative. 

       Bp - 120/70mmhg 

        PR - 87bpm 

        Temp - afebrile 

RS - BAR + , clear 

CVS - s1,s2 no added sounds and no murmurs 

P/A - soft and non tender 

CNS - NAD

A- ?acute pancreatitis (resolved)

    

        Alcohol dependence syndrome 

       Tobacco dependence syndrome

        Delirium 

P- 

1.allow soft diet 

2.NS and RL 100ml/hr 

3.Inj . Thiamine 500mg in 100ml NS Over 20min OD 

4.Inj.optineuron 1amp in 100ml NS IV /OD 

5.Inj.pan 40mg IV/OD

6. Inj. Lorazepam 4mg in 100ml NS 

7. Tab. Librium 2.5mg OD

8.Tab. Olanzepine 2.5mg Po/BD

9. Nicotine gums 2mg TID

10.syp.potchlor 15ml in 1glass water TID

11.Syp.lactulose 15ml PO/BD

[20/11/23, 3:04:59 PM] 58  M c/o pain abdomen since 2 days  Telangana pajr: ‎You changed this group's icon

‎[20/11/23, 3:05:39 PM] Vinil Reddy: ‎<attached: 00000026-PHOTO-2023-11-20-15-05-39.jpg>

[20/11/23, 4:49:34 PM] Rakesh Biswas Sir GM HOD: What are your questions around this patient's problems?

[20/11/23, 5:13:49 PM] Vinil Reddy: Sir , can alcoholic hepatitis present without ascites ?

[20/11/23, 8:30:02 PM] Rakesh Biswas Sir GM HOD: Why not?

[20/11/23, 8:42:39 PM] Vinil Reddy: Can alcoholic hepatitis cause portal HTN? ‎<This message was edited>

[20/11/23, 8:44:10 PM] Rakesh Biswas Sir GM HOD: What is the cause of portal hypertension in alcoholic cirrhosis?

[20/11/23, 8:48:35 PM] Vinil Reddy: In alcoholic cirrhosis because of fibrosis there is increased vascular resistance causing the Portal HTN

[20/11/23, 8:49:18 PM] Vinil Reddy: The primary cause of portal hypertension in cirrhosis is an increase in intrahepatic vascular resistance due to massive structural changes associated with fibrosis and increased vascular tone in the hepatic microcirculation.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3971388/#:~:text=The%20primary%20cause%20of%20portal,tone%20in%20the%20hepatic%20microcirculation.

[20/11/23, 8:58:53 PM] Rakesh Biswas Sir GM HOD: "multiple possible mechanisms, including increased portal inflow, increased intrahepatic vasoconstriction, inflammation, and changes in the liver vasculature such as perisinusoidal fibrosis and phlebosclerosis."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10075503/