24-03-2025
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 PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
MRIs of the 65F patient
Showing the mid brain lesion
EMR summary:
Age/Gender: 65 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 19/03/2025 08:57 PM
Diagnosis
1. ACUTE ISCHEMIC STROKE WITH RIGHT PARAMEDIAN MIDBRAIN INFARCT
2. OSA, HFMEF(EF47%)
3. DENOVO T2DM
4. AIRBORNE CONTACT DERMATITIS
5. HTN SINCE 12 YEARS, H/O CABG 10 YEARS BACK
Case History and Clinical Findings
CHIEF COMPALINTS: C/O GIDDINESS AND DEVIATION OF MOUTH TO RIGHT SIDE SINCE YESTERDAY
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC UPTO YESTERDAY , THEN DEVELOPED GIDDINESS, SUDDEN IN ONSET, ASSOCIATED WITH Deviation OF MOUTH TO RIGHT SIDE, NO Drooling OF SALIVA
With weakness OF left upper and lower LIMBS
PAST HISTORY:
PATIENT IS K/C/O B/L OSTEOARTHRITIS WALKS WITH SUPPORT SINCE 8-9 YEARS
K/C/O HTN SINCE 12 YEARS ON MET X 50MG
H/O CABG 10YEARS BACK GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSUIS, CLUBBING, LYMPHADENOAPTHY BP :140/100
PR:102BPM RR:17CPM TEMP: AFEBRILE
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD, NOMURMURS RS: BAE PRESENT
PA: SOFT AND NON TENDER CNS:
RIGHT LEFT
TONE UL NORMAL LL NORAML NORMAL POWER UL 5/5 5/5
LL 5/5 5/5 REFLEXES B +2 +2
T +2 +2
K +2 +2
A +2 +2
S +2 +2
P +2 +2
DERMATOLOGY REFFERAL DONE I/V/O PIGMENTATION AROUND THE EYES AND NECK ON 21/3/25
ADVICE
1 DESONIDE CREAM L/A OD X 1WEEK
2. MOMATE CREAM L/A OD X 1 WEEK
3. VENUSIA MAX LOTION L/A BD X 1 WEEK
4. TAB TECZINE 5MG PO/OD
2D ECHO CONCLUSION:
CONCENTRIC LVH, POOR ECHOWINDOW
S/P CABG
TRIVIAL MR +/ TR +, MILD AR+/AR-PHT -517M/SEC, NO PR, NO PAH NO AS/MS, CALCIFIED AV, IAS INTACT ANEURYSM, EF =57%
FAIR TO GOOF LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION, NO LV CLOT, NO PE IVC SIZE 1.21CMS COLLAPSING
IVS 1.38CMS EDD 5.48 CMS ESD 3.87CMS DPW 1.35CMS
ALL CHAMBERS Dilated MRI BRAIN PLAIN IMPRESSION
ACUTE INFRACT IN RIGHT SIDE MID BRAIN
BILATERAL CONFLUENT PERIVENTRICULAR Hyper Intensities -FAZEKAS GRADE 3
Investigation
Investigations: Name Value Range
Name Value Range BLOOD UREA 19-03-2025 09:25:PM 21 mg/dl 50-17 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 19-03-2025 09:25:PM SODIUM 143 mmol/L 145-136
mmol/L POTASSIUM 3.9 mmol/L 5.1-3.5 mmol/L CHLORIDE 103 mmol/L 98-107 mmol/L SERUM
CREATININE 19-03-2025 09:25:PM 0.7 mg/dl 1.2-0.6 mg/dl
LIVER FUNCTION TEST (LFT) 19-03-2025 09:25:PM Total Bilurubin 0.69 mg/dl 1-0 mg/ dl Direct Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 19 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0
IU/LALKALINE PHOSPHATASE 259 IU/L 128-56 IU/LTOTAL PROTEINS 6.4 gm/dl 8.3-6.4
gm/dl ALBUMIN 3.90 gm/dl 4.6-3.2 gm/dl A/G RATIO 1.56HBsAg-RAPID 19-03-2025 09:25:PM
Negative Anti HCV Antibodies - RAPID 19-03-2025 09:26:PM Non Reactive
COMPLETE URINE EXAMINATION (CUE) 19-03-2025 09:26:PM COLOUR Pale yellow APPEARANCE Clear Reaction Acidic SP.GRAVITY 1.010ALBUMIN Nil
SUGAR +BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 2- 3EPITHELIAL CELLS 2-3RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
T3, T4, TSH 20-03-2025 02:04:AM T3 0.81 ng/ml 1.87-0.87 ng/mlT4 11.73 micro g/dl 12.23-6.32
micro g/dl TSH 1.8 micro ul /ml SERUM ELECTROLYTES (Na, K, C l) 21-03-2025 12:02:AM SODIUM140 mmol/L145-136 mmol/LPOTASSIUM4.7 mmol/L5.1-3.5 mmol/LCHLORIDE106
mmol/L98-107 mmol/l
HEMOGRAM Provisional Test Result Units Normal Range Method HAEMOGLOBIN 13.0 gm/dl 12.0 -15.0 Colorimetric LOX -PAPTOTAL COUNT 12,700 cells/cumm 4000 - 10000
Impedence NEUTROPHILS 74 % 40 - 80 Light Microscopy LYMPHOCYTES 16 % 20 - 40 Light
Microscopy EOSINOPHILS 02 % 01 - 06 Light Microscopy MONOCYTES 08 % 02 - 10 Light
Microscopy BASOPHILS 00 % 0 - 2 Light Microscopy PCV 38.1 vol % 36 - 46 Calculation M C V 80.0 fl 83 - 101 Calculation M C H 27.3 pg 27 - 32 Calculation M C H C 34.1 % 31.5 - 34.5 Calculation RDW-CV 13.7 % 11.6 - 14.0 Histogram RDW-SD 40.3 fl 39.0-46.0 Histogram RBC COUNT 4.76
millions/cumm 3.8 - 4.8 Impedence PLATELET COUNT 3.57 lakhs/cu.mm 1.5-4.1 Impedence SMEAR RBC Normocytic normochromic Light Microscopy WBC leukocytosis Light Microscopy PLATELETS Adeqaute Light Microscopy HEMOPARASITES No hemoparasites seen Light Microscopy IMPRESSION Normocytic normochromic blood picture with leukocytosis
FBS 209 mg/dl 70 - 110 GOD - POD 21/3/25 HbA1c 7.3 %
Total Cholesterol 196 mg/dl Child: Desirable:<170Borderline high:170-199High: >199Adult
: Desirable:<200Borderline high:200-239High: >239CHOD/PODTriglycerides 275 mg/dl 0 - 150 GPO- POD With ESPASHDL Cholesterol 49.4 mg/dl 40 - 65 Direct Enzymatic LDL Cholesterol 122.2 mg/dl.
0 - 100 Direct Enzymatic VLDL * 55.0 mg/dl 12-40 mg/dl Direct Enzymatic APTT TEST 31 Sec
BLEEDING TIME 2 Min 00 sec 2-7 Mins CLOTING TIME 4 Min 30 sec 1-9 Mins
Prothrombin Time 15 Sec 10-16secINR 1.11
SERUM ELECTROLYTES (Na, K, C l) 21/3/25Test Result Units Normal Range Method SODIUM 140 mmol/L 136 - 145 Ion Selective Electrode POTASSIUM 4.7 mmol/L 3.5 - 5.1 Ion
Selective Electrode CHLORIDE 106 mmol/L 98 - 107 Ion Selective Electrode CALCIUM IONIZED 1.06 mmol/L Cord Blood: 1.30 - 1.602Hrs
FBS 147 mg/dl 70 - 110 GOD - POD 22/3/25
PLBS 216 mg/dl
Treatment Given (Enter only Generic Name)
1. TAB ECOSPIRIN GOLD 75/75/20 PO/HS
2. TAB STROCIT PLUS PO/BD
3. TAB MET XL 50MG PO/OD
4. TAB METFROMIN 500MG PO/OD
5. TAB MODAFINIL 200MG PO/OD AT 7PM
6. TAB TELMA 40MG PO/BD
7. TAB DYTOR PLUS 10/50 HALF PO/OD
8. DESONIDE CREAM L/A OD
9. MOMATE CREAM L/A OD
10. VENUSIA MAX LOTION L/A BD
11. THROMBOPHOBE L/A OVER LEFT HAND
10.PHYSIOTHERAPY OF LEFT UL AND LL COURSE IN THE HOSPITAL
65 YEAR OLD FEMALE KNOWN HYPERTENSIVE AND H/O CABG 10YRS BACK, CAME WITH C/O GIDDINESS AND DEVIATION OF MOUTH TO RIGHT SIDE SINCE YESTERDAY. MRI BRAIN SHOWED ACUTE INFARCTS IN RT PARAMEDIAN MIDBRAIN. STARTED ON DUAL ANTIPLATELETS. DENOVO T2 DM WAS DETECTED AND STARTED ON OHAs. PHYSIOTHERAPY OF LEFT UL AND LOWER LIMB WAS DONE. STARTED ON DIURETICS, ARBs. DERMA REFERERAL WAS DONE AND DIAGNOSED AS AIRBORNBE CONTACT DERMATITIS. PATIET WAS SYPTOMATICALLY AND DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION.
Advice at Discharge
TAB ECOSPIRIN GOLD 75/75/20 PO/HS TO BE CONTINUED TAB STROCIT PLUS PO/BD FOR 1 WEEK
.TAB MET XL 50MG PO/OD AT 8AM TO CONTINUE
TAB METFORMIN 500MG PO/OD AFTER DINNER TO BE CONTINUED TAB MODAFINIL 200MG PO/OD AT 7PM FOR 15 DAYS
TAB TELMA 40MG PO/OD AT 8AM TO CONTINUE TAB DYTOR PLUS 10/50 PO/OD 1/2 TABLET AT 8AM DESONIDE CREAM L/A OD FOR 5 DAYS
MOMATE CREAM L/A ODFOR 5 DAYS VENUSIA MAX LOTION L/A BD FOR 5 DAYS THROMBOPHOBE L/A OVER LEFT HAND PHYSIOTHERAPYOF LEFT UL AND LL STRICT DIBETIC DIET
Follow Up
REVIEW TO GM OPD AFTER 5DAYS ON FRIDAY 28/3/25 REVIEW TO DERMATOLOGY OPD AFTER 1WEEK 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, 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:23/3/25 Ward: FMW Unit: GM III
[24-03-2025 19:06] PPM 1: @~.PA How is she now?
[24-03-2025 23:21] PA: With the support she is slowly walking
[25-03-2025 08:47] PPM 1: That's good to hear! Do keep sharing her daily hourly activities and images
of her food plates daily if possible because we need to cure the root cause of her problems which is
metabolic syn. Here's a link to guide how one can share their daily activities and food plates from our other patient's case report:
[25-03-2025 14:11] PA: Okay sir definitely I'll keep Sharing
[25-03-2025 14:23] PA: Sir from yesterday night drolling of saliva is coming sir
[25-03-2025 14:39] PPM 1: From the left side of the mouth?
[25-03-2025 16:10] PA: Yes sir
[25-03-2025 16:20] PPM 1: Please share her food plates
[25-03-2025 16:21] PA: Ok sir.
[28-03-2025 11.58] PPM 1: Reviewed in OPD:
Better symptomatically
BP: 76/62 mm of hg
On telma 40!
Metoprolol 50 mg od
Dytor plus!
Plan:
Reduce all by 50%
And @~PA will tell us the home BP recordings.
[28-03-2025 16:15] PPM 2: Any history of long term steroids?[28-03-2025 16:16] PPM 1: None but she loves to take alcohol sometimes to the tune of 150 ml while her husband is a teetotaller
[28-03-2025 16:18] PA: Sir and she used to take pain killers everyday sir
[28-03-2025 16:21] PPM 2: Which pain killers? Wysolone?
[28-03-2025 16:21] PPM 2: Please be sure on this one. Looks cushingoid
[28-03-2025 16:21] PPM 2: And she is on a wheelchair because OA?
[28-03-2025 16:24] PPM 1: Left hemiparesis
[28-03-2025 16:24] PPM 1: Please share more details on the pain killers.
Was it for her knee pains?
[28-03-2025 16:49] PA: No sir not for knee pain
[28-03-2025 16:51] PPM 1: Then where was her pain?
Tell us in detail about her past pain.
When was she absolutely alright?
How did all her pain symptoms start in the beginning?
[28-03-2025 17:15] PA: Her pain started 20 yrs back sir so for temporary relief she use to take that pain killers
[28-03-2025 17:17] PA: She is fine before 8yrs sir
[28-03-2025 17:22] PA: And later she is walking by using Walker with out Walker she can't even go
[28-03-2025 17:31] PPM 2: What is the name of pain killer? Brand name or medicine composition?
[28-03-2025 17:51] PA: Prednisolone dispersible tablet
[28-03-2025 17:52] PA: 5mg
[28-03-2025 17:54] PA: Diclofenac sodium, paracetamol and chlorzoxazone tablet
[28-03-2025 17:55] PA: This 2 tablets she is taking since 20yrs Sir
[28-03-2025 19:50] PPM 1: In which part of her body does she have pain?
[28-03-2025 19:53] PPM 1: 👆 amazing photo evaluation @PPM2 👏👏
Which part of this patient's image made you suspect Cushing's? Her arms?
[28-03-2025 19:55] PPM 2: Oh dear for 20 years?!
[28-03-2025 19:55] PPM 2: She is currently in Adrenal insufficiency and hence the low BP!
[28-03-2025 19:57] PPM 2: Supraclavicular fat pads and just the general body habitus.
Also, from my recall most patients who had OA or strokes generally walk around with a stick. Seeing
her in a wheelchair made me think she has Vascular necrosis of both hips.
Just reflexive system 1 here.
[28-03-2025 20:00] PA: Yes sir
[28-03-2025 20:01] PPM 2: Avascular *
[28-03-2025 20:02] PPM 2: Hmm. All her problems are because of the Prednisolone tablet. We have to now start gradually tapering the tablet over several months to years and enable her adrenal (the gland
above the kidney which secretes stress hormones) to wake up and recover.
[28-03-2025 20.02] PPM 1: 👍
[28-03-2025 20:02] PA: Okay sir
[01-04-2025 12.00] PPM 1: @~~PPM3 this is our current stroke patient. @~PPM4 @~PPM5 have met
her onsite and can help you to learn more about how we are trying to improve her illness journey.
[02-04-2025 07:57] PPM 3: Thankyou sir! 👍
[16-06-2025 15.44] PPM 1: Readmitted today right now from OPD with no BP and pulse although apparently in normal sensorium
@~. patient advocate says she's been having regular vomiting since 1 month and not eating but just drinking Eno!
[16-06-2025 15:47] PPM 1: Later the advocate says just red coloured vomitus since last few days!
Inserting ryles tube now! @PPM6 when we found her pulseless and BP less in the Casualty we needed to have explored possible chances of bleed.
TODAY'S ECG 👆
ECG at last admission on 19th March
Came to our OPD pulseless and BP less and started on noradrenaline
[18-06-2025 16:58] PPM 7: Image is blurry sir
could you please re upload it
[18-06-2025 16:59] PPM 1: Captured by phone. On the way to Hyderabad now.
[18-06-2025 16:59] PPM 7: Ohh okay I'll try to read it
[18-06-2025 16:59] PPM 7: I'm weak in reading ECG sir, please teach me
[18-06-2025 17:00] PPM 1: Just observe the two closely for any differences
[18-06-2025 17:00] PPM 7: Image quality is low sir
[18-06-2025 17:01] PPM 7: I recently argued with chatgpt as it misread ECG of my friend
[18-06-2025 17:01] PPM 7: So I wanted to learn it
[18-06-2025 17:01] PPM 1: Give this to chatGPT again and share what it says
[18-06-2025 17:01] PPM 7: I saw some biswas chatgpt prior thought it was u 😅
[18-06-2025 17:02] PPM 7: Week back
[18-06-2025 17:02] PPM 1: You are an MBBS doctor. You already know it. Rest everyone has to learn lifelong
[18-06-2025 17:02] PPM 7: I get confused reading it sir
[18-06-2025 17:02] PPM 7: Like there are so many inputs and I get lost
[18-06-2025 17:05] PPM 1: The first step to learning to read ECG or MRI is to realise that it's the patient which is more important and everything is biased to be interpreted with what the patient presents with and not the other way around.
Most people take quite a few years to realise this and hence a lot of valuable learning lessons are lost.
So look at this ECG in the patient's context
[18-06-2025 17:06] PPM 7: yeah😅
we need to study all the history
and then make a proper diagnosis
[18-06-2025 17:06] PPM 7: With empathy
[18-06-2025 17:07] PPM 1: 90% history
5% examination
2% tests only for confirmation
[18-06-2025 17:10] PPM 7: yeah
[18-06-2025 17.11] PPM 1: Bedside clinical imageology in this 65F patient of Metabolic syn phenotype, current presentation with shock with presentation as cerebral infarction in mid brain at March 2025.
Note the Hfpef
[18-06-2025 17:14] PPM 7: Uncontrolled hypertension
DM
might have caused blocks in vessels and
caused ischemic attack
and then paresis
[18-06-2025 17:15] PPM 7: that could be due to bad life style
or stress or
no compliance in medication
[18-06-2025 17:15] PPM 7: Or other family or financial issues
[18-06-2025 17:16] PPM 7 I deleted it sir since I felt I'm not trusting myself
[18-06-2025 17:16] PPM 7: A week back
[18-06-2025 17:16] PPM 7: I felt im doubting myself so i deleted it to build confidence
[18-06-2025 17:21] PPM 7: Could u please explain me this 2d echo sir.
[18-06-2025 17.21] PPM 1: Check out the ECG changes here since admission @PPM10 Please inform their unit SR to change the Mx accordingly and share a note on her file to that effect.
[18-06-2025 17:23] PPM 1: To understand the abnormal you have to also look at the normal.
The best way to understand is to keep looking at a lot of echo videos but anyone would feel bored to do that unless one is at the bedside also looking at the patient in 3D
[18-06-2025 17:23] PPM 7: Yeah
[18-06-2025 17:25] PPM 7: Also since she is a 65F
she lost the protective function of oestrogen
and that might have added to the final Effect
[18-06-2025 17:31] PPM 10: Ok sir.
[19-06-2025 19:43] PPM 1: Today's update?
[19-06-2025 20:02] PPM 10: Today: Vomitings subsided sir. Subjectively feeling better
Tapered NORAD and stopped .pyuria subsided...
Tomorrow plan for upper GI endoscopy..in view of hematemesis.
[19-06-2025 22:01] PPM 1: 19/3/25 was her previous admission ECG? @PPM9
[19-06-2025 22:02] PPM 9: Yes sir
[20-06-2025 09:43] PPM 1: 👆@PPM9 can you share yesterday's and today's ECG?
[20-06-2025 09:56] PPM 9: I'll try and send it to you
[20-06-2025 21:52] PPM 1: What about the subsequent ECG changes @PPM10?
[20-06-2025 22:51] PPM 10: Today ECG was not done sir...due to some issues in shifting the patient.
And she was also discharged Today.
[21-06-2025 07:17] PPM 1: Yesterday's ECG?
[21-06-2025 07:17] PPM 1: Can you pm me her IP number so that I can collect the EMR summary
[21-06-2025 08:26] +91 80086 71890: Ok sir.
[21-06-2025 10:20] PPM 1: @CR EMR summary from 20/6/25👇
Age/Gender: 65 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 16/06/2025 12:57 PM
Name of Treating Faculty
(AP), (SR)
Diagnosis
SEPTIC SHOCK SECONDARY TO CHRONIC UTI
CHRONIC GASTRITIS SINCE 1 MONTH
CAP S/P CABG 12YRS AGO
H/O CVA-LEFT HEMIPARESIS 3 MONTHS AGO
K/C/O HYPERTENSION, TYPE II DIABETES MELLITUS
Case History and Clinical Findings
PATIENT CAME IN A DROWSY STATE
C/O WEAKNESS SINCE 1 DAY
C/O VOMITINGS SINCE 1 MONTH
C/O BURNING SENSATION IN CHEST SINCE 1 MONTH
HOPI: PATIENT WAS APPARENTLY ASYMPOMATIC 3 MONTHS BACK, AFTER WHICH SHE
DEVELOPED ACUTE ISCHEMIC STROKE SINCE THEN SHE WAS BEDRIDDEN
H/O VOMITINGS SINCE 1 MONTH AFTER 10MINS OF CONSUMPTION OF FOOD. WITH BLOOD
CLOTS IN VOMITINGS SINCE 4 DAYS
H/O CHESTPAIN SINCE 1 MONTH, BURNING TYPE, INSIDIOUS IN ONSET, GRADUALLY
PROGRESSIVE, AGGRAVATED WITH FOOD INTAKE RELIEVED WITHENO.
NO H/O PALPITATIONS, SOB, ORTHOPNEA, PND.
NO H/O BURNING ICTURITIN, OLIGURIA, NOCTURIA, POLYURIA.
APPETITE DECREASED, EATING ONLY ONE BANANA A DAY
H/O B/L KNEE PAIN SINCE 2YRS, WALKING WITH WALKER.
PAST ILLNESS: K/CO CVA SINCE 3 MONTHS ON ECOSPRIN GOLD 75/75/20, STOPED
MEDICATION SINCE 1MONTHKIMS HOSPITALS
K/C/O HTN SINCE 12YRS, USED TELMA 40MG OD BUT NON COMPLIANT TO MEDICATION
SINCE 1 MONTH
K/C/O DM-II SINCE 3 MONTHS, USED METFORMIN 500MG PO/OD BUT NON COMPLIANT TO
MEDICATION SINCE 1 MONTH.
S/P CABG 10YRS BACK, ON TAB.METXL 50MG OD
N/K/C/O THYROID DISORDERS, ASTHMA
PERSONAL HISTORY: MIXED DIET, APPETITE NORMAL, REGULAR BOWEL MOVEMENTS,
MICTURITION NORMAL, NO KNOWN ALERGIES AND ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT
GENREAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION
VITALS: - TEMP: AFEBRILE, BP: 110/50 MMHG, RR: 20CPM, PR: 76 BPM, SPO2: 98% AT RA,
GRBS 70 MG%
SYSTEMIC EXAMINATION: - CVS, RS, P/A: NORMAL
CNS: - HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT
TONE- RIGHT LEFT
UL NORMAL
LL NORMAL
POWER- RIGHT LEFT
UL 5/5 4/5
LL 5/5 2/5
REFLEXES:
BICEPS +2 +1
TRICEPS +1 +1
SUPINATOR + +
KNEE - -
ANKLE - -
PLANTAR WITHDRAWAL
CARDIOLOGY REFERRAL WAS DONE ON 16/6/25
2D ECHO: RWMA IN LAD TERRITORY
APEX SEPTUM HYPOKINESIA
MODERATE LV DYSFUNCTION
TREATMENT ADVISED: 1) TAB.ECOSPRIN GOLD 20OMG 2) INJ.NORAD 5ML/HR
Page-2KIMS HOSPITALS
GASTRENTEROLOGY OPINION WAS TAKEN ON 20/6/25 I/V/O UPPER GI BLEED: PATIENT WAS SEEN AND ENDOSCOPY WAS SUGGESTED BUT THE PATIENT WAS NOT COMPLIANT TO IT.
COURSE IN HOSPITAL:
PATIENT PRESENTED TO CASUALTY IN A DROWSY STATE, BP AND PULSE WERE NOT
RECORDABLE .200ML FLUID BOLUS WAS GIVEN AND NORAD STARTED @5ML/HOUR AFTER TAKING CARDIOLOGIST OPINION AND AFTER PATIENT WAS STABILISED, DETAILED
HISTORY AND EVALUATION WAS DONE, PATIENT WAS DIAGNOSED WITH SEPTIC SHOCK
SECONDARY TO CHRONIC UTI, CHRONIC GASTRITIS WITH? UGI BLEED, HFMEF
SECONDARY TO OLD CAD, CAP S/P CABG 12YRS AGO H/O CVA-LEFT HEMIPARESIS 3
MONTHS AGO. K/C/O HYPERTENSION, TYPE II DIABETES MELLITUS. TEATMENT WAS
STARTED SYMPTOMATICALLY. IV FLUIDS, IV ANTIBIOTICS, ANTACIDS, ANTIEMETICS,
VITAMIN SUPPLEMENTS AND OTHER SUPPORTIVE TREATMENT WAS GIVEN.
PATIENT IMPROVED CLINICALLY WITH THE TREATMENT, SO IS BEING DISCHARGED IN A
HEMODNAICALLY STABLE STATE.
Investigation
ON 16/6/25
HAEMOGLOBIN 9.7 gm/dl TOTAL COUNT 12,400 cells/cumm NEUTROPHILS 70
%LYMPHOCYTES 17 % EOSINOPHILS 03 % MONOCYTES 10 % BASOPHILS 00 % PCV 27.3 vol% M C V 77.3 fl M C H 27.5 pg M C H C 35.5 %RDW-CV 18.5 % RDW-SD 52.6 fl RBC COUNT 3.53
millions/cumm PLATELET COUNT 2.82 lakhs/cu.mm SMEAR: RBC Normocytic normochromic
WBC: Increased in count, PLATELETS: Adeqaute, No hemoparasites seen
IMPRESSION: Normocytic normochromic Anemia with Leukocytosis
COMPLETE URINE EXAMINATION COLOUR Pale yellow APPEARANCE Cloudy REACTION
Acidic SP.GRAVITY 1.010ALBUMIN ++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS Loaded EPITHELIAL CELLS 0-2 RED BLOOD CELLS 0-2CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Bacteria Present
BLOOD UREA: 27 mg/dl, SERUM CREATININE: 1.1 mg/dl
SERUM ELECTROLYTES SODIUM 128 mmol/L POTASSIUM 3.4 mmol/L CHLORIDE 96 mmol/L
LIVER FUNCTION TEST Total Bilurubin 1.42 mg/dl Direct Bilurubin 0.51 mg/dl SGOT(AST) 56 IU/L SGPT(ALT) 20 IU/L ALKALINE PHOSPHATASE 193 IU/L TOTAL PROTEINS 5.5 gm/dl ALBUMIN 2.7 gm/dl A/G RATIO 1.01
Anti HCV Antibodies - RAPID: Non Reactive ; HBsAg-RAPID: Negative
BLOOD UREA: 27 mg/dl; SERUM CREATININE :1.5 mg/dl
SERUM ELECTROLYTES SODIUM 130 mmol/L POTASSIUM 3.6 mmol/L CHLORIDE 96 mmol/L
TROPONIN-I 4.8 pg/ml
URINE FOR KETONE BODIES: NEGATIVE
Page-3KIMS HOSPITALS
SERUM FOR OSMOLALITY :254mOSM/kg
ON 17/6/25 HAEMOGLOBIN 8.7 gm/dl TOTAL COUNT 11,000 cells/cumm NEUTROPHILS 58 %
LYMPHOCYTES 26 % EOSINOPHILS 06 %MONOCYTES 10 % BASOPHILS 00 % PCV 26.0 vol
%M C V 81.0 flM C H 27.0 pg M C H C 33.4 % RDW-CV 21.5 %RDW-SD 64.2 fl RBC COUNT 3.2
millions/cumm PLATELET COUNT 2.9 lakhs/cu.mm SMEAR: RBC: Normocytic normochromic,
WBC: normal, PLATELETS: Adeqaute, No hemoparasites seen IMPRESSION: Normocytic
normochromic anemia
SERUM ELECTROLYTES SODIUM 133 mmol/L POTASSIUM 3.4 mmol/LCHLORIDE 98 mmol/L
ON 19/6/25
FBS 70 mg/dl; HbA1c 6.4 %
HAEMOGLOBIN 8.1 gm/dl TOTAL COUNT 9,800 cells/cumm NEUTROPHILS 60 %
LYMPHOCYTES 24 % EOSINOPHILS 06 % MONOCYTES 10 % BASOPHILS 00 %PCV 22.7 vol
%M C V 76.9 fl M C H 27.5 pg M C H C 35.7 % RDW-CV 19.7 % RDW-SD 55.1 fl RBC COUNT 2.95 millions/cumm PLATELET COUNT 2.8 lakhs/cu.mm SMEAR: RBC : Normocytic normochromic WBC: normal, PLATELETS Adequate, No hemoparasites seen
IMPRESSION : Normocytic normochromic anemia
STOOL FOR OCCULT BLOOD - POSITIVE
2D ECHO IMPRESSION:
1) TRIVIAL TR; NO PAH; NO MR/AR/PR
2)NO RWMA; MILD LVH; NO AS/MS, SCLEROTIC AV
3)GOOD LV SYSTOLIC FUNCTION
4)GRADE I DIASTOLIC DYSFUNCTION; NO PE; NO LV CLOT
USG ABDOMEN AND PELVIS DONE ON 16/6/25
IMPRESSION: NO SONOLOGICAL ABNORMALITIES
GRADE II FATTY LIVER
Treatment Given (Enter only Generic Name)
IVF NS/DNS @ 50ML/HR PO/HS
INJ.NORAD AT 2 AMP IN 46ML NS @0.16MG /ML 3.5ML/HR AND TAPERED ACCORDINGLY
INJ.ZOFER 4MG IV/TID
INJ.PAN40MG IV/OD
INJ.PIPTAZ 4.5GM IV STAT FOLLOWED BY INJ. PIPTAZ 2.25GM IN/TID FOR 5 DAYS
INJ.NEOMOL 1GM IV/SOS
INJ.OPTINEURON 1 AMP IN 100ML NS IV/OD
INJ.LASIX 20MG IV/SOS
Page-4KIMS HOSPITALS
INJ.HAI S/C TID
INJ.TRANEXEMIC ACID 500MG IV/TID
INJ.ZOFER 4MG IV/TID
TAB.ECOSPRIN GOLD 75/75/20 PO/HS
SYP.ALKASTONE-B6 10ML IN 1/2 GLASS OF WATER /TID
SYP.SUCRAL-O-GEL 10ML PO/TID
SYP.CREMAFFIN 20ML PO/HS
Advice at Discharge
TAB.AMOXICLAV 625MG PO/BD FOR 5DAYS
TAB.PAN40MG PO/OD FOR 5DAYS
TAB.ATORVAS 20MG PO/OD AT 9PM TO CONTINUE
TAB.ZOFER 4MG PO/SOS
SYP.SUCRAL-O-GEL 10ML PO/TID FOR 3 DAYS
SYP.ALKASTONE-B6 10ML IN 1/2 GLASS OF WATER /TID FOR 3 DAYS
PHYSIOTHERAPY OF LEFT LOWER LIMB
ENCOURAGE MOBILISATION
TO WITH HOLD ANTIHYPERTENSIVES AND OHAS FOR 1 WEEK
Follow Up
REVIEW TO GM OPD AFTER 1 DAYS/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:
08682279999 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:20/6/25
Page-5KIMS HOSPITALS
Ward: FMW
Unit: I
Page-6
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