34M Imbalance 1 year WB PaJR

 

THIS IS AN 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.

[27-06-2025 13.16] PPM 1: Second long distance 34M patient under @PPM3 @PPM4

Worked as mason specialized in creating iron frameworks of homes that functions as a cast for pouring cement in Kerala for 9 years but is currently without a job and living again in his hometown 2500 kms from Kerala because of feeling unwell where he feels like when he's cycling he's flying and when he's walking he's swimming and in general admits to a lack of balance.

On examination CNS normal

@PPM3 please get a psy opinion. @PPM6 can you give us an appointment for a convenient time when the patient advocate can call you?

[27-06-2025 13:23] PPM 6: Yes Sir, @PPM3 can get in contact with me at 6.30 pm today

[27-06-2025 15:10] PPM 1: @PPM7 it appears that @PPM3 has transferred the patient under your care. Please send him to psy ASAP now

[27-06-2025 15:32] PPM 7: Ok sir

[27-06-2025 20:12] PPM 1: Thanks

I guess they missed today

Will make his PaJR group and coordinate with the patient advocate.

[27-06-2025 20.17] PPM 1: @PA please get the telephone appointment from @PPM6

[30-06-2025 10.48] PPM 7: 

EMR SUMMARY

Age/Gender: 34 Years/Male

Address:

Discharge Type: Relieved

Admission Date: 26/06/2025 10:04 PM

Name of Treating Faculty

(AP), (SR)

Diagnosis

ANXIETY NOT OTHERWISE SPECIFIED

Case History and Clinical Findings

CC:C/O HEADACHE SINCE 3MONTHS

HOPI

PATIENT WAS APPARENTLY ASSYMPTOMATIC 3MONTHS AGO THEN DEVELOPED

HEADACHE ON AND OFF IN LEFT PARIETAL REGION PRICKING TYPE NO PRECIPITATING

FACTORS ASSOCIATED WITH GIDDINESSNOT ASSOCIATED WITH NAUSEA, VOMITING

H/O INADEQUATE SLEEP (DIFFICULTY FALLING ASLEEP) SINCE 3 MONTHS 3-4 HOURS OF

SLEEP/DAY NO DAYTIME SLEEP

H/O GIDDINESS WHILE GETTING DOWN FROM BIKE, WHILE WALKING

H/O RECENT FALL FROM BIKE 2MONTHS BACK

H/O STRESS FACTORS PRESENT

H/O PALPITATIONS PRESENT

NO H/O HEAD TRAUMA,

NO H/O BLURRING OF VISION, DROWSINESS ON GEETTING UP FROM BED

NO H/O CHESTPAIN, SHORTNESS OF BREATH, ORTHOPNEA, PND.

NO H/O OLIGURIA, NOCTURIA, POLYURIA.

PAST ILLNESS: N/K/C/O DM-II, HTN, TB, ASTHMA, THYROID, CVA, CAD

PERSONAL HISTORY: MARRIED, FAEMER BY OCCUPATION, MIXED DIET, APPETITE

NORMAL, REGULAR BOWEL MOVEMENTS, MICTURITION NORMAL, NO KNOWN ALERGIES

ADDICTIONS ALCOHOL OCCASIONAL STOPPED 3 MONTHS AGO, SMOKING ALSO STOPPED

3 MONTHS AGO

KIMS HOSPITALS

FAMILY HISTORY: NOT SIGNIFICANT

GENREAL EXAMINATION:

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION

VITALS: - TEMP: 98.7F, BP: 110/70 MMHG, RR: 17CPM, PR: 79 BPM, SPO2: 98% AT RA

SYSTEMIC EXAMINATION: - CVS, RS, CNS, P/A : NORMAL

PSYCHIATRY REFRRAL WAS DONE ON 28/6/25

DIAGNOSED AS ANXIETY NOS AND TOBACCO HARMFUL USE

ADVICE:

Investigation

COMPLETE URINE EXAMINATION (CUE) COLOUR Pale yellow APPEARANCE Clear REACTION

Acidic SP.GRAVITY 1.010ALBUMIN Nil SUGAR Nil 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

LIVER FUNCTION TEST (LFT)Total Bilurubin 1.35 mg/dl Direct Bilurubin 0.57 mg/dl SGOT(AST) 22

IU/L SGPT(ALT) 27 IU/L ALKALINE PHOSPHATASE 148 IU/L TOTAL PROTEINS 7.2 gm/dl

ALBUMIN 4.52 gm/dl A/G RATIO 1.69BLOOD UREA 23 mg/dl

SERUM CREATININE 0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l) SODIUM 138 mmol/L

POTASSIUM 3.8 mmol/L CHLORIDE 102 mmol/L

Anti HCV Antibodies - RAPID Non ReactiveHBsAg-RAPID Negative

Treatment Given (Enter only Generic Name)

TAB PAROXETINE 12.5 MG PO/HS

TAB CLONAZEPAM 0.5 MG PO /HS

NICOTINE GUMS 2MG PO/SOS

Advice at Discharge

TAB PALOXETINE 12.5MG PO/OD + TAB CLONAZEPAM 0.5MG PO/OD CONTINUE FOR 1

MONTH AND THEN TAKE HALF TAB FOR ANOTHER 1 MONTH

NICOTINE GUMS 2MG PO/SOS

Follow Up

REVIEW TO PSYCHIATRY OPD AFTER 2 MONTHS/SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

** Tentative Date Page-2

KIMS HOSPITALS

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: 2/7/25

Ward:MMW

Unit:1