30-11-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DEIDENTIFIED 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 THOS PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[7.16 pm, 30/11/2025] PPM 1: @PPM3 please share her events timeline, clinical images, radiology, electrophysiology etc.
Last admission EMR summary:
Age/Gender: 74 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 01/11/2025 12:55 PM
Discharge Date: 06/11/2025 11:37 AM
Diagnosis
ACUTE FEBRILE ILLNESS (no fever charting done after admission to see if she actually had fever?)
Progressive anemia on repeat hemograms
CKD(STAGE-4)
Case History and Clinical Findings
PT CAME WITH C/O COUGH SINCE 30 DAYS AND BREATHLESSNESS SINCE 30 DAYS,
HOPI: PT WAS APPARENTLY ASYMPTOMATIC 30 DAYS BACK AGO THEN SHE DEVELOPED COUGH- WITH SPUTUM, WHITISH MUCOID, SCANTY, NON FOUL SMELLING, NON BLLOD STAINED
- A/W SOB GRADE II-III SINCE 10 YEARS, H/O FEVER SINCE 15 DAYS CONTINOUS A/W
CHILLS.H/O DECREASED APPETITE, GENERALISED WEAKNESS, BLOATING+, BELCHING+, NAUSEA+, CONSTIPATION-HARD STOOLS-PASSES DAILY.
NO H/O DECREASED URINE OUTPUT, FACIAL PUFFFINESS.H/O PEDAL EDEMA-ON AND
OFF,
PAST HISTORY: -NO SIMILAR COMPLAINTS IN THE PAST.
PERSONAL HISTORY: -MARRIED, FARMER.
MIXED DIET; DECREASED APPETITE; BOWEL MOVEMENTS-CONSTIPATION, NO BURNING
MICTURITION, NO ALLERGIES; NO ADDICTIONS,
FAMILY HISTORY: -NOTSIGNIFICANT,
GENERAL EXAMINATION: -PT IS C/C/C,
VITALS TEMP: AFEBRILE, BP:110/70MMHG, RR:20 CPM, PR:72BPM, SPO2:98 % AT RA .NO PALLOR, CYANOSIS, CLUBBING OF FINGERS, ICTERUS, LYMPHADENOPATHY. B/L PEDAL EDEMA PRESENT.
SYSTEMIC EXAMINATION:
CVS: S1S2+, S4 + IN TRICUSPID AREA, NO MURMURS, RS: B/L NVBS
HEARD, P/A: SOFT NON TENDER; CNS: NO FOCAL NEUROLOGICAL DEFICIT
SURGERY REFFERAL WAS DONE ON 4/11/25 I/V/O CHOLELITHIASIS.
TREATMENT: USG FINDING IS INCIDENTAL FINDING
PT CAN BE OPERATED IF SYMPTOMATIC, ELSE WAIT AND WATCH
ENT REFFERAL WAS DONE ON 4/11/25 I/V/O RINGING SENASATION, EAR PAIN IN LT EAR:
ADVICE: PTA, IMPEDENCE AUDIOMETRY
RX: R/A REPORTS TO ENT OPD
Investigation
HEMOGRAM (1/11/25): - HB-8.3, PCV-25.5, TLC-12700, RBC-3.1, PLT-5.2, ESR-130
HEMOGRAM (3/11/25): - HB-8.0, PCV-25.0, TLC-12300, RBC-3.0, PLT-5.3
HEMOGRAM (4/11/25): - HB-7.6, PCV-22.8, TLC-12500, RBC-2.6, PLT-4.6
HEMOGRAM (6/11/25): - HB-7.3, PCV-21.6, TLC-12300, RBC-2.5, PLT-4.2
RFT (1/11/25): UREA 47MG/DL, CREATININE 2.5 MG/DL, SODIUM 141 MG/DL, POTASSIUM
4.8MG/DL, CHLORIDE 101 MG/DL
RFT (2/11/25): UREA 34MG/DL, CREATININE 2.2 MG/DL, SODIUM 144 MG/DL, POTASSIUM
4.7MG/DL, CHLORIDE 102 MG/DL
RFT (6/11/25): UREA 57MG/DL, CREATININE 2.7 MG/DL, SODIUM 134 MG/DL, POTASSIUM
4.4MG/DL, CHLORIDE 97 MG/DL
LIVER FUNTION TEST (1/11/25): TOTAL BILIRUBIN 0.73 MG/DL, DIRECT BILIRUBIN 0.18 MG/DL, SGOT 36 MG/DL, SGPT 38 MG/DL, ALKALINE PHOSPHATASE 264 IU/L, TOTAL PROTEINS 6.5 G/L, ALBUMIN 2.7 G/DL, GLOBULIN 3.8 G/DL, A/G RATIO 0.71
CUE
(1/11/25): ALB-+30MG/DL, SUGAR-NIL, PUS CELLS-2-4, EPITHELIAL CELLS-2-3
ABG
(2/11/25):PH-7.400, PCO2-25.8, PO2-77.6, HCO3-15.7
ABG
(4/11/25):PH-7.286, PCO2-25.0, PO2-38.9, HCO3-11.5
USG WAS DONE ON 3/11/25
IMPRESSION: CHOLELITHIASIS
2D ECHO WAS DONE ON 3/11/25
IMPRESSION: MILD MR, TRIVIAL TR, NO PAH, NO PR/AR
NO RWMA, NO AS/MS, SCLEROTIC AV
GOOD LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION +, NO PE/LV CLOTS
AFB SMEAR (2/11/25):NO ACID-FAST BACILLI SEEN
SPUTUM CULTURE AND SENSITIVITY (2/11/25): NORMAL
OROPHARYNGEAL FLORA GROWN
Treatment Given (Enter only Generic Name)
1.TAB.AMOXICLAV 625 MG PO/BD
2.TAB.AZITHROMYCIN 500 MG PO/OD 1--X--X
3.TAB.PANTOP 40 MG PO/OD 1--X--X
4.TAB.PULMOCLEAR PO/BD 1--X--1
5.TAB.NODOSIS 1GM PO/OD
5.INJ.NEOMOL 1GM IV/TID
6.SYP.ASCORIL-LS PO/TID 10ML--10ML--10ML
7.NEBS WITH IPRAVENT -6TH HRLY
BUDECORT-12TH HRLY
Advice at Discharge
1.TAB.AMOXICLAV 625 MG PO/BD FOR 1--X--1 5 DAYS
2.TAB.AZITHROMYCIN 500 MG PO/OD 1--X--X FOR 5 DAYS
3.TAB.PANTOP 40 MG PO/OD 1--X--X FOR 5 DAYS
4.TAB.PCM 650 MG PO/TID 1--1--1 FOR 5 DAYS
4.TAB.PULMOCLEAR PO/BD 1--X--1 FOR 5 DAYS
5.TAB.NODOSIS 1GM PO/OD 1-X-X FOR 15 DAYS
6.SYP.ASCORIL-LS PO/TID 10ML--10ML--10ML FOR 5 DAYS
Follow Up
REVIEW TO GM OPD WITH HRCT CHEST REPORT
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: 6/11/25
Ward: FMW
Unit: GM IV
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