23F Benign Intracranial Hypertension Nasal Sym 2022, Backache 2018, Teeth Stains 2019 WB PaJR

 

10-03-2025

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.

[10-03-2025 20:07] PPM 1: Benign intracranial hypertension is one possibility. CSF

 pressure Manometry is required to confirm the diagnosis

https://pmc.ncbi.nlm.nih.gov/articles/PMC7385768/

[10-03-2025 21:03] PA: Ok sir!

[13-03-2025 16.56] PPM 1: CSF manometer pressure?

[13-03-2025 17.05] PA: They said its 11cmH2O

[13-03-2025 17:08] PPM 1: 👍So, the patient doesn't have intractable hypertension assuming the test

 has good sensitivity specificity

[13-03-2025 17:09] PA: Yes!

[13-03-2025 17:09] PA: So whats the cause of papilliedema?

[14-03-2025 20:19] PPM 1: It may not be papilledema?

[17-03-2025 23:14] PA: Ok sir!

[24-03-2025 15.23] PA: Should I take the medicine? @ PPM 1

[24-03-2025 16:51] PPM 1: It's for chronic headache.

Does the patient have that?

It can reduce the frequency and duration of the headache

[24-03-2025 18:01] PA: No not much sir

[24-03-2025 19:23] PPM 1: If none then it may not be necessary

This is her earlier data when she was admitted with us last year:

EMR summary:

Age/Gender: 24 Years/Female

Address:

Discharge Type: Relieved

Admission Date: 13/09/2024 11:54 AM

Diagnosis

MODERATE DEPRESSION WITH ANXIETY SYMPTOMS PITYRIASIS CAPITIS AND XEROSIS CUTIS

PRIMARY DYSMENORRHEA

Case History and Clinical Findings C/O LOWER BACKACHE SINCE 2 YEARS 

HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO AND DEVELOPED LOWER BACK ACHE SINCE 2 YEARS, PAIN+,TENDERNeSS NON RADIATING; AGGRAVATING ON WORK; RELIEVING BY TAKING REST AND PAIN IS INTERMITTENT

PAST ILLNESS

N/H/O FEVER, COLD, COUGH, ALLERGIES, CHEST PAIN, PALPITATIONS, SWEATING, SOB ABD.PAIN, NAUSEA, VOMITINGS, LOOSE STOOLS, DECREASED URINE OUT PUT, PEDAL EDEMA

H/O SCOLIOSIS SINCE 2 YEARS

N/K/C/O HTN, DM2, TB, EPILEPSY, ASTHMA, CVA, CAD, THYROID GENERAL EXAMINATION

PERSONAL HISTORY: DIET- MIXED APPETITE- NORMAL SLEEP- ADEQUATE BOWEL- REGULAR

 

BLADDER- NORMAL ADDICTIONS : NO DEHYDRATION - NO GENERAL EXAMINATION:

MILD PALLOR

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY  VITALS ON ADMISSION:

TEMP:98.8 PR: 80BPM, RR: 18CPM,

BP: 130/80MMHG, SPO2: 98% ON RA GRBS 132

SYSTEMIC EXAMINATION-

CVS: S1 S2 HEARD, NO THRILLS, NO MURMERS RESP: BAE+, NVBS HEARD

PER ABDOMEN: SOFT, NON TENDER CNS: NAD, NORMAL

GCS: E4V5M6

OBG REFFERAL DONE ON 14/9/24 I/V/O DYSMENORRHEA RX,

REASSURANCE

T.MEFTAL SPAS PO/OD FROM D1-D2 OF CYCLE

OPHTHALMOLOGY REFERRAL WAS DONE - IMPRESSION: GRADE 1 PAPILLEDEMA NO ACTIVE INTERVENTION IS REQUIRED

COURSE IN THE HOSPITAL: A 24 YEAR FEMALE CAME WITH C/O LOWER BACKACHE SINCE 2 YEARS. ALL NECESSARY INVESTIGATIONS WERE SENT.PATIENT WAS DIAGNOSED MODERATE DEPRESSION WITH ANXIETY SYMPTOMS PITYRIASIS CAPITIS AND XEROSIS CUTISPRIMARY DYSMENORRHEA. PATIENT WAS TREATED ACCORDINGLY WITH ANALGESICS, ANTIDEPRESSANTS. VITALS MONITORING.PATIENT IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE

Investigation

COMPLETE BLOOD PICTURE (CBP) 16-09-2024 10:29: AM HAEMOGLOBIN 12.1 gm/dl 15.0-12.0

gm/dl TOTAL COUNT 10200 cells/cumm 10000-4000 cells/cumm NEUTROPHILS 69 % 80-40

%LYMPHOCYTES 25 % 40-20 %EOSINOPHILS 01 % 6-1 %MONOCYTES 05 % 10-2

%BASOPHILS 00 % 2-0 %PLATELET COUNT 1.60SMEAR Normocytic normochromic blood picture

Treatment Given (Enter only Generic Name) T.METFHAL SPAS PO BD FROM D1 -D2 OF CYCLE OF SOS T.FOLLIHAIR PO OD X 1 MONTH

T.DESVENLAFAXINE 50MG PO/OD T.ETIFOXINE 50MG PO/OD T.CLONAZEPAM MD 0.5MG PO/SOS

SCALP-E SHAMPOO L/A TWICE WEEEKLY X 4 WEEKS CEBHYDRA MOISTURISING LOTION L/A BD

Advice at Discharge

T.MEFTHAL SPAS PO BD FROM D1 -D2 OF CYCLE OF SOS T.FOLLIHAIR PO OD X 1 MONTH

T.DESVENLAFAXINE 50MG PO/OD T.ETIFOXINE 50MG PO/OD T.CLONAZEPAM MD 0.5MG PO/SOS

SCALP-E SHAMPOO L/A TWICE WEEEKLY X 4 WEEKS CEBHYDRA MOISTURISING LOTION L/A BD

Follow Up

REVIEW TO GM OPD

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, DONOT 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:16/9/24 Ward:MMW Unit:II

[29-03-2025 00.35] PA: 

[29-03-2025 09.00] PPM 1: 👍