30-05-2025
THIS ISAN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS 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.
[30-05-2025 13.24] PPM 1: Another 53M patient today with fascinating OPLL which presented since one year back when he developed gradual onset of paralysis and stiffness and was bed ridden for a month before our neurosurgery team did a laminectomy for him following which he is walking but currently presented with bi pedal edema.
[30-05-2025 13.25] PPM 3: 
[30-05-2025 13.25] PPM 1: 
EMR SUMMARY
Age/Gender: 53 Years/Male
Address:
Discharge Type: Relieved
Admission Date: 10/02/2025 10:59 AM
Date of Operation: 12/02/25
C2-C5 POSTERIOR STABILIZATION + LAMINECTOMY
Name of Treating Faculty
Diagnosis
C2-C5 CERVICAL MYELOPATHY
Case History and Clinical Findings
CHIEF COMPLAINTS:
C/O OF PAIN IN NECK SINCE 1 YEAR
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK, THEN DEVELOPED PAIN IN THE NECK WHICH IS INSIDIOUS IN ONSET, CONTINUOUS, DRAGGING TYPE, AGGRAVATED WITHMOVEMENTS AND NOT RELIEVED WITH REST AND MEDICATION, RADIATING TO BOTH UPPER LIMBS, TINGLING PRESENT, NUMBNESS ABSENT
NO H/O LOC/ENT BLEED
NO H/O FEVER
NO H/O TRAUMA/BURNING MICTURITION/ BOWEL AND BLADDER INCONTINENCE.
PAST HISTORY:
K/C/O HTN SINCE 2 YEARS
N/K/C/O DM/HTN/HYPOTHYROID/CVA/CAD
ON GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, EDEMA
TEMP:98.4 F
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KIMS HOSPITALS
PR:82BPM
RR:19CPM
BP:110/80MMHG
SPO2: 98%@RA
CVS- S1,S2 HEARD NO MURMURS
RS-BAE +NVBS
PA- SOFT, NON TENDER
CNS-NFND
LOCAL EXAMINATION OF LS SPINE
ATTITUDE: NORMAL
SKIN: NORMAL
SWELLING: ABSENT
TENDERNESS:C2-C5
DEFORMITY: ABSENT
NO LOCAL RISE OF TEMPERATURE
RIGHT LEFT
SLRT 90 90
HIP 5/5 5/5
KNEE F AND E 5/5 5/5
HIP F AND E 5/5 5/5
ANKLE DF AND PF 5/5 5/5
SENSATION - INTACT INTACT
DISTAL PULSES- PRESENT PRESENT
Investigation
COMPLETE BLOOD PICTURE (CBP) 13-02-2025
TOTAL COUNT 14600 cells/Cumm NEUTROPHILS 92 %LYMPHOCYTES 06 %EOSINOPHILS 01
%MONOCYTES 01 %BASOPHILS 00 %PLATELET COUNT 2.18SMEAR Normocytic normochromic with neutrophilic leucocytosis
RFT 30-01-2025 06:43:PM UREA 31 mg/dl CREATININE 0.7 mg/dl URIC ACID 4.5mmol/LCALCIUM, 9.5 mg/dl phosphorous 3.5 mg/dl SODIUM 138 mmol/L POTASSIUM 4.1 mmol/L.CHLORIDE 104mmol/L
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KIMS HOSPITALS
LIVER FUNCTION TEST (LFT) 30-01-2025 06:43:PM Total Bilurubin 0.54 mg/dl Direct Bilurubin 0.18mg/dl SGOT(AST) 50 IU/L SGPT(ALT) 134IU/L ALKALINE PHOSPHATASE 160 IU/L TOTALPROTEINS 6.5 gm/dl ALBUMIN 4.17 gm/dl A/G RATIO 1.79HBsAg-RAPID
30-01-2025 06:43:PM
Negative
Anti HCV Antibodies - RAPID
30-01-2025 06:43:PM Non Reactive
RBS: 81 MG/DL
BGT: A POSTIVE
BT:2MIN
CT:5MIN
APTT :33 SEC
PT:17 SEC
INR:1.2
ESR :20 MM/1ST HOUR
Treatment Given (Enter only Generic Name)
PATIENT WAS CLINIRADIOLOGICALLY DIAGNOSED AS C2-C5 CERVICAL MYELOPATHY, PAC DONE, C2-C5 POSTERIOR STABILIZATION + LAMINECTOMY WAS DONE ON 12/2/25
UNEVENTFUL PROCEDURE, SHIFTED TO POST OP UNDER HEMODYNAMICALLY STABLE
CONDITION, COMPLETE SUTURE REMOVALDONE ON 22/2/25.DURING THE COURSE OF
HOSPITAL STAY PT WAS TREATED WITH IVF, ANTIBIOTICS, ANTACIDS, ANALGESICS, MULTIVITAMINS.PATIENT IS NOW BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION
Advice at Discharge
1.TAB CEFTAS CL 200 MG PO/BD X 1 WEEK
2.TAB PAN 40 MG PO/OD X 1 WEEK
3.TAB XYKAA 1 GM PO/BD X 1 WEEK
4.TAB SHELCAL CT PO/OD X 15 DAYS
5.TAB LIMCEE 500 MG PO BD X 15 DAYS
6.TAB TRIGABANTINE 100 MG PO/HS
7.TAB EVION CC PO BD X 15 DAYS
Follow Up
REVIEW TO ORTHO OPD AFTER 2 WEEKS OR INFORM SOS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.
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KIMS HOSPITALS
Drugs
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 prescribedand 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
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KIMS HOSPITALS
Drug-Dosage Drug-Dosage Drug-Dosage
3WAY STOP COCK 100CM - MEDIKIT- ABHAY-TOX - 0.5 ML- ABSORBENT COTTON WOOL - 400 GMACEPRA - TAB(ACECLOFENAC)- ADULT DIAPER(MEDIUM)- ALINFEC - 500MG - INJ(AMIKACIN)-
AMLOHOM - 5MG TAB(AMLODEPIN)- ANIMGABA- PLUS- 100MG
TAB (gabapentin-methylcobalamin)-
AQSOLVE 1-0 R/C (AM 2534)-
ATROMED - INJ (ATROPINE)- BACLOGEN - 20ER - XL TAB- BACTIGERM -5GM
OINT MUPIROCIN)-
BLOOD SET (LIFE LINE)- CALITROL- CAP- CALVIC -D TABLET(CALCIUM)-
CEFIXM-200 MG TAB- CENTISILK - 0- R/C5037- CENTIWAX -CW810- [BONE WAX]-
CORTIBEST -100MG
INJ(HYDROCORTISONE)-
DICLOVEN INJ (DICLOFENAC)- DISPOVAN SYRINGES - 10 MLDISPOVAN SYRINGES - 2 ML- DISPOVAN SYRINGES - 5 ML- DYNOPLASTER (MEDIGRIP) )-
ECG LEADS (EASY TRODE)- EVIGOD LC TAB (VITAMIN E- L
CARNITINE)-
EVIKEM - LC TAB (L-CARNITINE -VIT -E)-
EVMOL - 650MG TAB(PARACETAMOL)- FERIRAS - XT - TAB (FERROUS
&FOLICZINCFLEXO METAL REINFORCED TRACHEAL
TUBE CUFFED - NO:7.5MMFLEXO METALIC REINFORCED
TRACHEAL TUBE CUFFED-6.0
(ROMSONS)-
G2K-40MG INJ(PANTOPRAZOLE)- GDOMOL - INJ(TRAMADOL)-
HANDYSEPT PVP -5%-100ML (
POVINANZ) SOLUTIONHME FILTERS- HYDROGEN PEROXIDE - 100 MLIFLURANE - 30ML ISOFLURANE)- IGNIUM - 1ML INJ(NEOSTIGMINE)- IO DRAPE - VISI POVI - MEDIUM
(35CMX35CM)-
IV CANNULA - 20G - MEDIKIT- IV CANNULA -18G- MEDIKIT- IV DNS -500ML (PUNISKA)-
IV NS - 100 ML [ACULIFE]- IV NS - 500ML (PUNISKA)- IV RL - 500ML - (PUNISKA)-
IV SETS [POLYMED)- JETROL - CZ -
TAB(CALCIUM+CALCITRIOL)-
JODDY PLUS GEL (DICLOFENAC GEL)-
KENAZ -TAB(ACECLOFENAC&PCM)- LIMCEE CHEW TAB- METRONIDAZOLE - 100ML -PUNISKANAPRO-MIDA 10ML INJ(MIDAZOLAM)- NEBULIZER MASK ADULT (LIFE LINE
SYSTEM0-
OLPID -5MG TAB (ZOLPIDEM)-
ONDABETA - MD4 MG TAB- ONDANSETRON - 2ML INJ- OXYGEN MASK ADULT - (LIFE O LINE)-
PANRAS - 40MG TAB(PANTOPRAZOLE)- PARACIP - 100ML (PARACETAMOL)- POLYSOLVE- 1 R/C 2421-
PROPAQUE - 1% -10ML. INJ(PROPOFOL)- PYROLATE - 1 ML- Q-METH -1GM
INJ(METHYLPREDNISOLONE)-
QVEC -4MG INJ(VECURONIUM)- ROLLER BANDAGES - 6'- ROMOVAC SET - NO. 16-
RUSCH FOLEYS CATHETER - NO:14
[2WAY]-
SHAVING SET -PREPARATION BLADE- SHERCEF - 1GM INJ(CEFTRIAXONE)-
SILKUS - 5037 0 R/C TRUSILK- SKIN STAPLER (AQMEN)- SOFT ROLL PADS - 6'-
SPONGILUS GELSPON - STERILE WATER - 10 ML- SUCCITHEM -
10ML(SUCCINYLCHOLINE)VAILSUCTION CATHTER - 14FG - MEDIKIT- SUPRATEL 40 MG TAB- SURGICAL BLADE - NO. 11 -
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KIMS HOSPITALS
SURGICAL BLADE - NO. 22- SURGICAL BLADE NO-15- SURGICAL GLOVE - NO - 7-5
[SURGICARE]-
SURGICAL GLOVE - NO:7-0
[SURGICARE]-
SURGICAL GLOVE -6.5 -(AQMAX)- SURGICAL GLOVE -7.0 -(AQMAX)-
SURGICAL GLOVE -7.5 -AQMAX)- SURGICAL SPIRIT - 100 ML- TAMPASID - 40MG TAB
(PANTOPRAZOLE)-
THEMIDRINE -30MG/1ML(EPHEDRINE)-
EFIPRESTHIAMAK - 2ML INJ - TUCIN - AM - 100ML SYRPURINE BAG ADULT - MEDIKIT- ZINKOVITA - SYP 200ML- ZOCALM - 0.25MG TAB(ALPRAZOLAM)-
Discharge Date
Date:22/2/2025
Ward: MOW
Unit: I
[30-05-2025 16:49] PPM 1: Current issues:
Pedal edema since few weeks evaluated by @PPM4 in the OPD today
[30-05-2025 17:11] PPM 1: 👍
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