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 15.49] PPM 1: 3rd long distance patient 39M
One day 2 years back, he found all of a sudden a catch in his back while shifting a heavy machine in his ration shop.
Since then he is having severe whole body stiffness since early mornings everyday and has to rub his lower limb planter areas for half an hour before getting out of bed.
Also showed in AIG since last two months for throat and abdominal tightness diagnosed as globus in AIG
He also complains of assymetric nail changes in his feet.
[27-06-2025 15.49] PPM 1: Evaluated by PPM3.
[30-06-2025 11.56] PPM 1: @PPM3 update on this patient?
We are reviewing him again in the OPD now.
What other test had we discussed on Saturday which you promised to do?
[30-06-2025 11:57] PPM 3: Sir MRI spine Venkat sir is not accepting sir
[30-06-2025 11:57] PPM 3: So we did not do MRI brain
[30-06-2025 11:57] PPM 3: We are more interested in the clinical findings
What is our localisation? Where are we expecting to find the lesion in MRI
[30-06-2025 11:59] PPM 3: Hemogram creatinine
[30-06-2025 12:00] PPM 1: Can you help us by examining his shoebers test here in OPD?
[30-06-2025 12:01] PPM 3: Ok sir I am coming
[30-06-2025 12:06] PPM 3: Sir patient went outside I will get him to ICU at 2 o clock sir
[30-06-2025 12:16] PPM 1: Patient is waiting with us in OPD!
[30-06-2025 12:23] PPM 3: Ok sir I am coming
[30-06-2025 13:07] PPM 1: Chest expansion is 3-4 cm and shoebers test is 19 cm suggesting objective evidence for reduced spinal flexibility due to ligamental fibrosis.
Chief complaint is inability to bend down and lift objects due to pain that aggravates while doing so
@PPM3 please share his deidentified x-rays and orthopedic notes and ask them to review the patient
[30-06-2025 13:07] PPM 3: Ok sir
[30-06-2025 17:03] PPM 1: Please share his x-rays and the Orthopedic note
[30-06-2025 17:06] PPM 3: Ok sir
[30-06-2025 17:41] PPM 3: Ortho refferal sir
[30-06-2025 17:41] PPM 3: Review ortho refferal.
[30-06-2025 21:37] PPM 1: Tell them they have come from 2000 kms away and can't come back in 3 weeks and they have taken all these pain killers since 2 years
[30-06-2025 21:37] PPM 3: Ok sir
[04-07-2025 08:30] PA: Aj chuti kariye dean sir
[04-07-2025 09:02] PPM 1: @PPM3 share the deidentified discharge EMR summary ASAP on text here
[04-07-2025 16:39] PPM 3: Ok sir
[09-08-2025 12.19] PA: Report as on 23/08/2025
EMR SUMMARY
Patient Details
Age/Gender: 39 years / Male
Admission Date: 26/06/2025, 10:03 PM
Discharge Type: Relieved
Department: General Medicine
Faculty: (Professor), (SR), (PGY2), PGY1)
Diagnosis
Primary: Spondyloarthropathy (initially written as ankylosing spondylosis)
MRI: Lumbar spine done
History & Symptoms
Lower back pain for 1 year
Tingling & numbness over right side for 15 days
No history of chest pain, palpitations, orthopnea, PND, shortness of breath, headache, giddiness, vomiting, pedal edema, fever, cough, or abdominal discomfort
Past History
No known history of hypertension, diabetes, asthma, epilepsy, stroke, coronary artery disease, TB, or hypothyroidism
Personal History
Appetite normal, bowel & urination normal
No known allergies or addictions
No significant family history
General Examination
No pallor, icterus, cyanosis, lymphadenopathy, finger clubbing, or pedal edema
Vitals at Admission
Temperature: Afebrile
PR: 80 bpm
RR: 22 cpm
BP: 110/80 mmHg
SpO₂: 98% (room air)
GRBS: 128 mg/dl
Systemic Examination
RS: BAE+, NVBS
P/A: Soft, non-tender
CVS: S1 S2+, no murmurs, no thrills
CNS: Normal tone, power 5/5 in all limbs, normal reflexes
Investigations
Urine: Pale yellow, clear, no abnormal findings
Liver Function Tests: Mildly raised alkaline phosphatase (146 IU/L), rest normal
Kidney Function: Blood urea 23 mg/dl, serum creatinine 1.0–1.1 mg/dl
Electrolytes: Na 138 mmol/L, K 3.7 mmol/L, Cl 102 mmol/L
HBsAg & Anti-HCV: Negative
Treatment at Discharge
Tab Ultracet (QID, tapering dose)
Tab Amitriptyline 10 mg PO/HS
Tab Hifenac MR PO/BD
Tab Gabapentin 100 mg PO/HS
Tab Pan 40 mg PO/OD
Physiotherapy: Back strengthening exercises
Advice
Avoid self-medication
Don’t miss medications
Contact hospital in case of emergency
Preventive care & follow-up explained
[11-09-2025 09.27] PA:
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