[13/09, 11:59] PPM 1: @Genau PaJR CEO CFHE IIT do you have the previous records shared here? As
his case report wasn't made and I changed my phone I'm unable to see any of the previous records
shared here
2004 started with blood in sperms
Reduced with ofloxacin
On silodosin since then
Also put on statins
And has been asymptomatic since then and gets scared with repeated ultrasound measurements
informing him that his prostate is this enlarging!
[13/09, 12:03] PPM 1: Also whenever the cardiologist sees his ECG he is asked if he feels faint because
he has LBBB. He hasn't brought his ECG today. @Genau PaJR CEO CFHE IIT check if it was shared
in the group earlier
[13/09, 12:09] PPM 1: Sensitive information:
Also in 2014 his spouse had a problem at her workplace and since then has developed anxiety, panic
attacks, claustrophobia and is often found in the terrace at midnight when he automatically wakes up at
night from sleep.
[13/09, 12:10] PPM 1: 👆This appears to be the main problem for which we shall take a telephonic
appointment with @PPM3 Psychologist
[13/09, 12:10] PPM 1: Low back ache since 2 years.
EMR summary:
Age/Gender: 61 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 13/09/2024 11:53 AM
Diagnosis
BPH (GRADE II PROSTATOMEGALY) MIXED ANXIETY AND DEPRESSION
FOLLICULITIS +? POST INFLAMMATORY PIGMENTATION+? PHOTO-MELANOSIS K/C/O HYPERTENSION SINCE 20 YEARS
Case History and Clinical Findings
C/O LOWER BACKACHE SINCE 4 YEARS
HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YEARS BACK AND THEN HE DEVELOPED LOWER BACK ACHE 4 YEARS AGO, PRICKLING TYPE OF PAIN, INTERMITTENT TYPE, NON RADIATING, Aggravating ON WORKING, AND RELIEVING ON REST
PAST ILLNESS
N/H/OFEVER, COLD,COUGH,CHESTPAIN, PALPITATIONS, SWEATING, SOB, ABDOMINAL PAIN, NAUSEA, VOMITING, LOOSE STOOLS, PEDAL EDEMA
H/O GRADE II PROSTATOMEGALY WITH MINIMAL RESIDUAL URINE SINCE 20 YEARS H/O RIGHT EPIDIDYMAL CYST SINCE 2YRS
H/O ANXIETY AND DEPRESSION SINCE 10 YEARS AND ON T.PAROXETINE 25MG/HS K/C/O HYPERTENSION SINCE 20 YEARS
N/K/C/O DM2, ASTHMA, CVD,EPILEPSY, TB, THYROID DISORDERS GENERAL EXAMINATION
PERSONAL HISTORY:
DIET- MIXED
APPETITE- NORMAL SLEEP- ADEQUATE BOWEL- REGULAR BLADDER- NORMAL ADDICTIONS: NO DEHYDRATION - NO GENERAL EXAMINATION:
NO PALLOR
NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY VITALS ON ADMISSION:
TEMP:98.8 PR: 80BPM, RR: 18CPM,
BP: 130/80MMHG, SPO2: 98% ON RA GRBS 211
SYSTEMIC EXAMINATION-
CVS: S1 S2 HEARD, NO THRILLS, NO MURMERS RESP: BAE+, NVBS HEARD
PER ABDOMEN: SOFT, NON TENDER CNS: NAD, NORMAL
GCS: E4V5M6
DEMATOLOGY REFFERAL DONE I/V/O HYPERPIGMENTATION ON 14/9/24
DIAGNOSIS-FOLLICULITIS +? POST INFLAMMATORY PIGMENTATION+? PHOTOMELANOSIS RX,
T.TECZINE 5MG PO/ODX 1 WEEK FUDIC CREAM L/A BD X 1 WEEK LIQUID PARAFFIN L/A BD X 2 WEEKS
PHOTOBAN AQUAGEL SPF 30 L/A TID X 4 WEEKS
PSYCHIATRY REFFERAL DONE I/V/O ANXIETY AND DEPRESSION SINCE 10 YEARS ADVICE
COUNSELLED AND SUGGESTED RELAXATION AND DIVERSION TECHNIQUES REGULAR FOLLOW UPS
T.PAROXETINE 25 MG PO/OD
OPHTHALMOLOGY REFERAL WAS DONE -IMPRESSION: MILD HYPERTENSIVE RETINOPATHY CHANGES NOTED
COURSE IN THE HOSPITAL: A 61 YEAR MALE K/C/O HYPERTENSION SINCE 20 YEARS CAME WITH C/O LOWER BACKACHE SINCE 4 YEARS. ALL NECESSARY INVESTIGATIONS WERE SENT.
PATIENT WAS DIAGNOSED AS BPH (GRADE II PROSTATOMEGALY) MIXED ANXIETY AND DEPRESSIONFOLLICULITIS +? POST INFLAMMATORY PIGMENTATION+? PHOTOMELANOSIS.PATIENT WAS TREATED ACCORDINGLY WITH ANTIHYPERTENSIVES, ANALGESICS, ANTI DEPRESSANTS, VITALS MONITORING.PATIENT IS BEING DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation
SERUM CREATININE 14-09-2024 01:11:PM 0.9 mg/dl 1.3-0.8 mg/dl
LIVER FUNCTION TEST (LFT) 14-09-2024 01:11: PMTotal Bilurubin 0.73 mg/dl 1-0 mg/dl direct Bilurubin 0.14 mg/dl 0.2-0.0 mg/dl SGOT(AST) 20 IU/L 35-0 IU/LSGPT(ALT) 28 IU/L 45-0
IU/LALKALINE PHOSPHATASE 184 IU/L 119-56 IU/LTOTAL PROTEINS 7.1 gm/dl 8.3-6.4
gm/dl ALBUMIN 4.42 gm/dl 4.6-3.2 gm/dl A/G RATIO 1.65 2D ECHO DONE ON 14/9/24
IMPRESSION
MILD TR WITH PAH; MILD MR; TRIVIAL AR; PR NO RWMA, NO AS.MS, SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION
GRADE 1 DIASTOLIC DYSFUNCTION NO LV CLOT
Treatment Given (Enter only Generic Name) CAP.SIDALOSIN 8MG+DURASTERIDE 0.5MG PO/OD 9PM T.AMLONG 2.5MG PO/OD 7AM
T.PAROXETINE 25MG PO/OD T.TECZINE 5MG PO/ODX 1 WEEK FUDIC CREAM L/A BD X 1 WEEK LIQUID PARAFFIN L/A BD X 2 WEEKS
PHOTOBAN AQUAGEL SPF 30 L/A TID X 4 WEEKS
Advice at Discharge
CAP.SIDALOSIN 8MG+DURASTERIDE 0.5MG PO/OD 9PM T.AMLONG 2.5MG PO/OD 7AM
T.PAROXETINE 25MG PO/OD
T.TECZINE 5MG PO/ODX 1 WEEK FUDIC CREAM L/A BD X 1 WEEK LIQUID PARAFFIN L/A BD X 2 WEEKS
PHOTOBAN AQUAGEL SPF 30 L/A TID X 4 WEEKS
Follow Up
REVIEW TO GM OPD 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, 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:18/9/24 Ward:MMW Unit:II
[13-03-2025 16.30] PPM 1: Repeat
Fasting Triglycerides (only)
Fasting blood sugar and in that same day please share:
2 hours post meal blood sugar after breakfast
2 hours post meal blood sugar after lunch
2 hours post meal blood sugar after dinner
[13-03-2025 16:31] PA: Here’s the previous report
[13-03-2025 16:32] PPM 1: I need to see his previous case report link (if it was made) and signed
informed consent (if taken). If not available don't worry.
[19-03-2025 19:45] PA: Rat a laboratory bondho hoye jai! After Dinner test ta kivabe korbo ???
Translation - "The laboratory closes at night! How will I do the after-dinner test???"
[19-03-2025 19:47] PPM 1: Glucometer diye amader ashikansho patient ra koren tabe apnar khetre
bortomane mone hocche shob bhalo ebong na korleo cholbe
Translation - "Most of our patients use a glucometer, but in your case, it seems everything is fine, and
it's okay if you don't do it."
tobe ar korchi na after dinner test ta
Translation - "I don't have a glucometer, so I'm not doing the after-dinner test."
[19-03-2025 20:16] PPM 1 : Soptahe ek din BP ta 10 bar mepe janaben jemon ekhane janano hoyeche👇
Translation - Weekly once check your BP one day 10 times and share here like in this below patient's case report. 👇
https://24fpatient.blogspot.com/2024/12/63m-metabolic-syn-dyspnea-2-years-wb.html?m=1
[19-03-2025 20:17] PA: Amar kono sharirik kosto hocha na.
Translation - I'm not experiencing any physical discomfort."
[19-03-2025 20.17] PPM 1: 👍
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