14-05-2025
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.
[14-05-2025 15.46] PPM 1: Afternoon session
52F with metabolic syn altered sensorium, TIA and Hypertension, Diabetes for 10 years along with anxiety attacks for 5 years being managed by @PPM3
EMR SUMMARY
Age/Gender: 52 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 12/05/2025 04:44 PM
Name of Treating Faculty (ASST PROF) (SR)
(PGY3) (PGY3)
(PGY2) (PGY1) (PGY1)
Diagnosis
1. TRANSIENT ISCHEMIC ATTACK
2. HYPERTENSION ENCEPHALOPATHY- RESOLVED
3. K/C/O HTN SINCE 10 YEARS
4. K/C/O DM TYPE II SINCE 7 YEARS
5. HBsAg POSITIVE
Case History and Clinical Findings
COMPLAINTS AND DURATION
PATIENT WAS BROUGHT TO THE CASUALTY WITH ALTERED SENSORIUM SINCE PAST 30 MINS.
HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 3:30 PM IN THE EVENING THEN SHE DEVELOPED UNCONCIOUSNESS FOR 10MINS WHICH WAS FOLLWOED BY WEAKNESS OF RIGHT UPPER AND LOWER LIMBS, INSIDIOUS IN ONSENT AND NON PROGRESSIVENO H/O DROOLING OF SALIVA, DEVIATION OF MOUTH
NO H/O SEIZURES, TRAUMA
NO H/O INVOLUANTARY MICTURITION OR DEFECATION
NO C/O CHEST PAIN, PALPITATIONS, DYSPNEA, ORTHOPNEA, PND
PAST HISTORY:
K/C/O HTN SINCE 10 YEARS ON MET-XL 50MG OD AND CINOD 10 MG OD K/C/O TYPE II DM SINCE 7 YEARS ON GLIMI- M2 BD
NOT A KNOWN CASE OF THYROID, ASTHMA, TB, CVA, CAD H/O ANXIETY
PERSONALHISTORY:
MARRIED, CONSUMES MIXED DIET, APPETITE NORMAL, NORMAL MICTURITION, REGULAR BOWEL MOVEMENTSNO KNOWN ALERGIES AND ADDICTIONS
FAMILY HISTORY: NOT SIGNIFICANT
GENERAL EXAMINATION:
NOPALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA OF FEET VITALS:
TEMP: 97.2 F,
PR: 92 BPM,
BP: 240/150 MMHG, RR: 20 CPM,
SPO2: 98% AT ROOM AIR. GRBS: 305 MG/DL
SYSTEMIC EXAMINATION:
CVS- S1 S2 HEARD, NO MURMURS
RS- NORMAL VESICULAR BREATH SOUNDS PRESENT, BILATERAL AIR ENTRY PRESENT P/A - SOFT, NON TENDER, NO ORGANOMEGALY
CNS- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT
TONE- RIGHT LEFT
UL INCREASED NORMAL
LL INCREASED NORMAL POWER- RIGHT LEFT
UL 4/5 5/5 LL 4/5 5/5 REFLEXES BICEPS _ + TRICEPS _ _
SUPINATOR _ _
KNEE _ _ ANKLE _ _
PLANTAR EXTENSION EXYENSION
PSYCHIATRIC OPINION WAS TAKEN ON 15/05/25 DIAGNOSIS:
MILD DEPRESSIVE DISORDER WITH PANIC DISORDER TREATMENT:
1. TAB SERTRALIN 25MG X- X- 1 FOR 7 DAYS
2. TAB. CLONAZEPAM 0.25MG PO/SOS
3. PATIENT AND ATTENDER COUNSELLED BRIEFLY
OPHTHAMOLOGY OPINION WAS TAKEN ON 13/05/2025 NORMAL FUNDUS
NO RAISED ICT CHANGES
Investigation
HEMOGRAM 12-05-2025
HAEMOGLOBIN 12.4 gm/dl TOTAL COUNT 10,200 cells/cumm NEUTROPHILS 61
%LYMPHOCYTES 30 %EOSINOPHILS 02 %MONOCYTES 07 %BASOPHILS 00 %PCV 33.6 vol
%M C V 79.6 flM C H 29.4 pgM C H C 36.9 %RDW-CV 12.4 %RDW-SD 36.6 fl RBC COUNT 4.22
millions/cumm PLATELET COUNT 1.81 lakhs/cu.mm SMEARRBC NORMOCYTIC NORMOCHROMICWBC With in normal limits PLATELETS Adeqaute HEMOPARASITES No hemoparasites seen IMPRESSION NORMOCYTIC NORMOCHROMIC BLOOD
LIVER FUNCTION TEST (LFT) 12-05-2025Total Bilurubin 0.64 mg/dl Direct Bilurubin 0.19 mg/dl SGOT(AST) 29 IU/LSGPT(ALT) 25 IU/LALKALINE PHOSPHATASE 223 IU/LTOTAL
PROTEINS 7.4 gm/dl ALBUMIN 4.2 gm/dl A/G RATIO 1.32
RFT 12-05-2025UREA 44 mg/dl CREATININE 1.3 mg/dl URIC ACID 5.5 mmol/LCALCIUM 9.7
mg/dl PHOSPHOROUS 2.4 mg/dl SODIUM 134 mmol/LPOTASSIUM 3.0 mmol/LCHLORIDE 102
mmol/L
COMPLETE URINE EXAMINATION (CUE) 12-05-2025COLOUR Pale yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN Trace SUGAR ++++BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
ABG 12-05-2025PH 7.543PCO2 11.4PO2 149HCO3 9.8St.HCO3 14.9BEB -11.9BEecf -12.8TCO2 20.6O2 Sat 99.7O2 Count 10.7
HBsAg-RAPID 12-05-2025 PositiveAnti HCV Antibodies - RAPID 12-05-2025 Non Reactive SERUM ELECTROLYTES (Na, K, C l) 12-05-2025SODIUM 133 mmol/L 145-136
mmol/LPOTASSIUM 3.7 mmol/L 5.1-3.5 mmol/LCHLORIDE 106 mmol/L 98-107 mmol/L
ABG 13-05-2025 02:19:PMPH 7.47PCO2 20.2PO2 97.4HCO3 14.7St.HCO3 18.9BEB -6.9BEecf -
8.3TCO2 29.2O2 Sat 98.5O2 Count 16.7
SERUM ELECTROLYTES (Na, K, C l) 14-05-2025SODIUM 133 mmol/LPOTASSIUM 3.6
mmol/LCHLORIDE 104 mmol/L
HBA1C: 8.0 %12-05-2025
LIPID PROFILE 13/05/2025
Total Cholesterol 194mg/dl Triglycerides 216 mg/dl HDL Cholesterol 41.7 mg/dl
LDL Cholesterol 111.6 mg/dl. VLDL- 43.2mg/dl
2D ECHO:
IMPRESSION: TRIVIAL AR+ - NO MR/ PR/TR- NO PAH NO RWMA. NO AS/MS. SCLEROTIC AV
GOOD LV SYSTOLUC FUNCTION
GRADE 1 DIASTOLIC DYSFUCTION, NO LV CLOT
CAROTID DOPPLER:
IMPRESSION: ATHEROSCLEROTIC CHANGES NOTED IN BILAYERAL CAROTID VESSELS DOPPLER INCICES WITH IN NORMAL LIMITS.
MRI BRAIN:
IMPRESSION- NO ABNORMALITY DETECTED IN THE BRAIN MDCT SCAN BRAIN:
IMPRESSION- NO ABNORMALITY DETECTED IN THE BRAIN
Treatment Given (Enter only Generic Name)
1. TAB. TELMA 400 MG PO/OD 1- X- X
2. TAB. ECOSPIRIN GOLD 75/75/20 PO/HS X- X- -1
3. TAB NAXDOM 250MG PO/SOS
4. TAB. METFORMIN 500MG PO/BD 1- X- 1
5. TAB GLIMIPERIDE 8MG PO/ OD BEFORE FOOD 1- X- X
6. TAB.GLIMIPERIDE 1MG PO/ OD BEFORE FOOD X- X- 1
7. TAB. LEVOCET 5MG PO/HS X- X- 1
8. SYP. ASCORYL- D PO/TID 10ML - 10ML- 10ML
9. SYP. CREMAFFIN 15ML PO/HS
10. TAB. AMLIODIPINE 10MG PO/OD X- X- 1
11. TAB MET- XL 25MG PO/OD 8AM
12. PHYSIOTHERAPY OF RIGHT UPPER LIMB
13. TAB SERTRALIN 25MG X- X- 1 FOR 7 DAYS
14. TAB. CLONAZEPAM 0.25MG PO/SOS
Advice at Discharge
1. TAB. TELMA 40 MG PO/OD 1-X- X 8 am TO CONTINUE
2. TAB. ECOSPIRIN GOLD 75/75/20 PO/HS X- X- -1 to continue
3. TAB NAXDOM 250MG PO/SOS
4. TAB. METFORMIN 500MG PO/BD 1- X- 1 to continue
5. TAB GLIMIPERIDE 8MG PO/ OD BEFORE FOOD 1-X- X to continue
6. TAB.GLIMIPERIDE 1MG PO/ OD BEFORE FOOD X- X- 1 to continue
7. TAB. LEVOCET 5MG PO/HS X-X- 1 x 3 days
8. SYP. ASCORYL- D PO/TID 10ML - 10ML - 10ML x 3 days
9. SYP. CREMAFFIN 15ML PO/HS x 3 days
10. TAB. AMLIODIPINE 10MG PO/OD X-X- 1 8pm
11. TAB MET- XL 25MG PO/OD 8AM
12. PHYSIOTHERAPY OF RIGHT UPPER LIMB
13. STRICT DIABETIC DIET AND LOW SALT DIET
Follow Up
REVIEW IN GENERAL MEDICINE OPD AFTER 1 WEEK WITH FBS, PLBS REPORTS REVIEW IN PSYCHIATRY OPD AFTER 1 WEEK / 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:15-05-2025
Ward: AMC Unit: 1
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