20M Cervical Myelopathy, Viral Myelitis Since 19yrs at the age of 1.

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EMR SUMMARY

Age/Gender : 20 Years/Male

Address :

Discharge Type: Relieved

Admission Date: 19/12/2024 03:07 PM

Diagnosis

Cervical Myelopathy due a possible viral myelitis since 19 years at the age of 1

Case History and Clinical Findings

C/O WEAKNESS OF RIGHT UL AND LL SINCE CHILDHOOD HOPI:

PATEIENT DEVELOPED WEAKNESS OF RIGHT UL AND LL SINCE CHILDHOOD AND HAD DELAYED MILESTONES SINCE BIRTH

H/O DIFFICULTY IN MIXING FOOD,EATING,BUTTONING

NO H/O PALPITATIONS, BREATHLESSNESS, ORTHOPNOEA, PND NO H/O COUGH, COLD, FEVER

NO H/O PEDAL EDEMA, PROFUSE SWEATING, GIDDINESS, DECREASED URINE OUTPUT NO H/O PAIN ABDOMEN, VOMITTINGS, LOOSE STOOLS

PAST ILLNESS:

N/K/C/O DM, HTN, THYROID DISORDERS, EPILEPSY, CAD, CVA

PERSONAL HISTORY:

APPETITE: NORMAL

BOWEL AND BLADDER: REGULAR ALLERGIES: NONE ADDICTIONS:NO

 

FAMILY HISTORY: INSIGNIFICANT

GENERAL EXAMINATION PT IS C/C/C

BP: 120/90 MMHG PR: 76 BPM

RR: 19 CPM TEMP: AFEBRILE SPO2: 98% AT RA GRBS: 101MG/DL

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY CVS: S1S2+ NO MURMURS

RS: BAE+

P/A: SOFT, NT, BS+ CNS: NFND

COURSE: A MALE PT OF AGE 20 YEAR OLD CAME WITH C/O CHEST PAIN SINCE 3 YEARS. VITALS: BP: 120/90MMHG, PR: 74 BPM, RR: 17 CPM, SPO2: 98% AT RA, GRBS: 101 MG/DL. ON FURTHER EVALUATION WAS DIAGNOSED AS SUPPORTIVE TREATMENT WAS GIVEN. PATIENT WAS IMPROVED CLINICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION

Investigation HEMOGRAM: 19/12/24 HB- 15.3

TLC- 8300

RBC- 5.14

PLT COUNT- 2.71COMPLETE URINE EXAMINATION (CUE) 19-12-2024 04:12:PMCOLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN Nil SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS NilAMORPHOUS DEPOSITS Absen tOTHERS Nil

RFT 19-12-2024 04:13:PMUREA 20 mg/dl CREATININE 1.0 mg/dl uric ACID 3.4 mmol/LCALCIUM

9.7 mg/dl PHOSPHOROUS 3.5 mg/dl SODIUM 139 mmol/L POTASSIUM 4.4 mmol/L. CHLORIDE 98

mmol/L HBsAg-RAPID 19-12-2024 04:13:PM Negative

Anti HCV Antibodies - RAPID 19-12-2024 04:13:PM Non Reactive

 

Treatment Given(Enter only Generic Name)

TAB MVT PO/OD

Advice at Discharge

TAB MVT PO/OD X 10 DAYS

Follow Up

REVIEW TO GM OP AFTER 1 WEEK OR SOS.

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DO NOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date Date:21/12/24 Ward: AMC

Unit: II