17-10-2025
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.
[17-10-2025 14.54] PPM 1: EMR summary from 2020
Age/Gender: 45 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 20/02/2020 03:34 PM
Diagnosis
SLE and portal vein thrombosis
Case History and Clinical Findings
Patient c/o pain abdomen since 1 yr and generalised body pains since 1 yr
patient was apparently asymptomatic 1 yr back then she developed pain abdomen in hypochondrium
insidious in onset, gradually progressive, dull aching type of pain, non-radiating and was admitted in
hospital for which evaluation was done and diagnosed as SLE and portal vein thrombosis with
splenomegaly and she is on treatment since then
h/o fever on and off
intermittent with no chills and rigors
h/o fatigue
h/o rash over back 3 months back
no h/o burning micturition
no h/o loose stools
no h/o vomitings
no h/o headache
not k/c/o DM, HTN, asthma, TB, CVD, CAD
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KIMS HOSPITALS
Not a known alcoholic or smoker
vitals: temp: afebrile, pr:98bpm, bp:110/70 mmmhg, spo2:98% on RA
O/E:
CVS: S1S2 HEARD, NO MURMURS
CNS: NAD
RS: BAE+, NVBS
P/A: SPLEEN PALPABLE UPTO UMBILCUS
Investigation
HEMOGRAM: HB:9.5, TLC:1600, PLTS:40000
BT:2 MIN 30 SEC, CT:4 MIN 30SCE
LFT: TB:2.83, DB:0.50, SGOT:28, SGPT:15, ALP:110, TP:6.5, ALBUMIN:3.8, A/G RATIO:1.42
Treatment Given (Enter only Generic Name)
T PROPRONOLOL 20 MG H/S
T HIQ 200MG H/S
T PREDNISOLONE 5 MG OD
T FOLATE 5 MG OD
T PANTOP 40 MG OD
T SHELCAL 500MG OD
Advice at Discharge
T PROPRONOLOL 20 MG H/S
T HIQ 200MG H/S
T PREDNISOLONE 5 MG OD
T FOLATE 5 MG OD
T PANTOP 40 MG OD
T SHELCAL 500MG OD
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
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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:
For Treatment Enquiries Patient/Attendant 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:20/2/2020 Ward: Unit:2
[17-10-2025 14.59] PPM 1: Recent hemogram done from our college
[17-10-2025 14.59] PPM 1: Today's upper GI endoscopy.
Apparently she had been banded once. @PPM3 @CR can you add the patient advocate's number here?https://youtube.com/shorts/HSBVaaw6yqo?si=yFsCxs4MmU179lCs
[17-10-2025 15.00] PPM 2: Wouldn't she be a good candidate for Splenectomy? Or is the current hypothesis something along the lines of splenectomy worsing GI bleeds?
[17-10-2025 16.44] PPM 4: Would an APLA test be usually sought in this case sir?
[17-10-2025 16.49] PPM 1: In a high resource academic setting yes.
The only utility would be deciding around anticoagulation.
Generally clinically when the patient is suspected to have an ongoing thrombosis we would anyways start anticoagulation hence the APLA may not be very necessary in the clinical decision making perhaps
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