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.
[02-09-2025 12.35] PPM 1: Reviewing her again in the OPD now. Came alone. Children may not have come due to her strong personality which puts them off perhaps. She went to the dentist and they referred her here looking at her strong comorbidities.
[14-10-2025 12.42] PPM 1: Reviewing her in the OPD and admitting her husband who appears to be having a progressive neurovascular parkinsonism with possible acute frontal lobar bilateral ACA territory infarcts clinically.
Currently complains of NYHA II symptomatic reduced from her previous NYHA III
[18-10-2025 11.14] PPM 1: 
Subjectively has burning urine
Also NYHA 2-3 since many years
Objectively urine cue pus cells 3-6 and albumin 3+
Assessment: chronic heart failure post CAD metabolic syn with possible UTI
Plan:
let's get her urinary culture and 24 hour urine for protein and creatinine @PPM3
[4.56 pm, 22/12/2025] PPM 1: EMR SUMMARY
Age/Gender: 67 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 16/12/2025 10:54 AM
Discharge Date: 17/12/2025 09:26 AM
Diagnosis
?URINARY TRACT INFECTION
K/C/O HEART FAILURE WITH PRESERVED EJECTION FRACTION
K/C/O CORONARY ARTERY DISEASE S/P PTCA 10 YEARS AGO
K/C/O HTN SINCE 10 YEARS
K/C/O TYPE II DM SINCE 10 YEARS
Case History and Clinical Findings
PATIENT CAME WITH C/O BURNING SENSATION OVER THE CHEST SINCE 2 MONTHS,
BURNING MICTURITION SINCE 2 MONTHS, B/L PEDAL EDEMA SINCE 4 YEARS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YEARS AGO THEN SHE DEVELOPED
BURNING SENSATION OVER THE ABDOMEN SINNCE 2 MONTHS ASSOCIATED WITH
CONSTIPATION, BURNING MICTURITION SINCE 2 MONTHS.
NO C/O OLIGURIA, POLYURIA. B/L PEDAL EDEMA (GRADE II PITTING TYPE) SINCE 4 YEARS.
H/O SHORTNESS OF BREATH WHILE WALKING (GRADE III). C/O GENERALIZED BODY PAINS, DECREASED APPETITE, SLEEP DISTURBANCES. C/O PALPITATIONS+, BELCHING+. NO H/O EXCESSIVE SWEATING. NO H/O FEVER, COLD, COUGH, NAUSEA, VOMITINGS. C/O GIDDINESS ON&OFF. APPETITE DECREASED CONSTIPATION SINCE 2 MONTHS
PAST HISTORY: K/C/O CAD S/P PTCA 10 YEARS AGO,
ON TAB CLOPIDOGREL+ATORVASTATIN 75/20MG OD
K/C/O HTN, ON TAB TELMA HYDROCHLORTHIAZIDE 40/125MG PO/OD SINCE 10 YEARS
K/C/O TYPE II DM SINCE 10 YEARS, ON TAB GLIMI M1 PO/OD
TREATMENT HISTORY: 2 PINT PRBC TRANSFUSION DONE 8 YEARS AGO
SURGICAL HISTORY: HYSTERECTOMY, S/P PTCA
Page-2
KIMS HOSPITALS
PERSONAL HISTORY- MARRIED, MIXED DIET, APPETITE DECREASED, REGULAR BOWEL
MOVEMENTS, BURNING MICTURITION+, NO ALLERGIES, NO ADDICTIONS
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA
VITALS: TEMP-AFEBRILE BP-150/80 MMHG PR-86 BPM RR-17CPM GRBS-165MG%
SYSTEMIC EXAMINATION- CVS-S1S2+, NO MURMURS
RS-BAE+, B/L NVBS+
PER ABDOMEN-SOFT, NON TENDER
CNS: NFND
ENT REFERRAL WAS DONE ON 20-12-25 IN VIEW OF HARD HEARING AND WAS ADVISED
PURE TONE AUDIOMETRY
Investigation
HEMOGRAM: (16/12/25) HB-9.5, PCV-30.3, TLC-7500, RBC-3.4, PLT-2.6
SEROLOGY: NEGATIVE HBA1C-6.7% UPCR (18-12-25)-3.30
RFT: (16/12/25) UREA-84, Na-130, K-4.0, Cl-98 (19-12-25): SERUM CREATININE-1.80, Na-141, K-
4.1, Cl-97
LFT:(16/12/25) TB-0.40, DB-0.13, SGPT -12, SGOT-17, ALP-245, TP-6.0, ALB-3.79, GLO-2.21, A/G
RATIO-1.71
CUE:(16/12/25) COLOR-PALE YELLOW, ALB+++, SUGAR+, PUS CELLS 3-6, EPITHELIAL CELLS 2-4, RBC-NIL
(19-12-25): TOTAL URINE VOLUME-2600, 24HR URINE PROTEIN-858, 24HR URINE
CREATININE-1.0
USG (18-12-25): B/L GRADE I RPD CHANGES
2D ECHO (18-12-25): MILD TR+ (ECCENTRIC JET TR) WITH PAH, MILD AR+, TRIVIAL MR+, MILD
PR+, RWMA+ LCX HYPOKINESIA, NO AS/MS. CONCENTRIC LVH, FAIR LV SYSTOLIC
FUNCTION. GRADE II DIASTOLIC DYSFUNCTION, NO LV CLOT
URINE CULTURE & SENSITIVITY (18-12-25): 4-6 PUS CELLS SEEN, COLONY COUNT- 10^5
CFU/ML
Treatment Given (Enter only Generic Name)
1.TAB.DYTOR 10MG PO/BD
2.TAB.TELMA+HYDROCHLORTHIAZIDE 40/12.5MG PO/OD
3.TAB.CLOPIDOGREL+ATORVASTATIN 75/20MG PO/HS
4.TAB.GLIMI M1 PO/OD
5.SYP.CITRALKA 10ML PO/TID 10ML-10ML-10ML
6.TAB.PAN 40MG PO/OD
7.SYP.SUCRAL-O GEL PO/TID 10ML-10ML-10ML
Advice at Discharge
1.TAB.LASIX 80MG PO/BD 1(8AM) --1/2(12PM) --X TO BE CONTINUED
2.TAB.TELMA+HYDROCHLORTHIAZIDE 40/12.5MG PO/ODTO BE CONTINUED
3.TAB.CLOPIDOGREL+ATORVASTATIN 75/20MG PO/HSTO BE CONTINUED
4.TAB.GLIMI M1 PO/ODTO BE CONTINUED
5.SYP.CITRALKA 10ML PO/TID 10ML-10ML-10ML FOR 7 DAYS
6.TAB.PAN 40MG PO/ODFOR 7 DAYS
7.SYP.SUCRAL-O GEL PO/TID 10ML-10ML-10MLFOR 7 DAYS
8.TAB.CIPROFLOXACIN 500MG PO/BD 8AM--X--8PMFOR 7 DAYS
Follow Up
REVIEW TO GM OPD AFTER 2 WEEKS/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/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:20-12-25 Ward: FMW Unit: III
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