18-12-2025
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 PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[8.58 pm, 19/12/2025] PPM 1: Patient had a sudden slurring of speech on 14th December evening and they started bringing her to Hyderabad the next morning on 15th when she had a seizure on the way and they decided to get admitted here.
[9.03 pm, 19/12/2025] PPM 1: @PPM3 @PPM4 please share the serial sodium values and her MRI
[11.34 am, 26/12/2025] PPM 1: EMR summary
Age/Gender: 79 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 15/12/2025 01:35 PM
Discharge Date: 22/12/2025 09:18 AM
Diagnosis
CEREBROVASCULAR Accident- ACUTE ISCHEMIC STROKE ACUTE INFARCTS IN RIGHT
HEMIPONS AND LEFT OCCIPITAL LOBE.
HYPOTONIC HYPONATREMIA SECONDARY TO? SIADH (RESOLVED)
CHRONIC KIDNEY DISEASE
? ASPIRATUION PNEUMONIA
K/C/O CORONARY ARTERY DISEASE S/P CABG 30YRS AGO S/P PTCA 15YRS AGO
K/C/O HTN SINCE 30YEARS
K/C/O DM II SINCE 30 YEARS
Case History and Clinical Findings
C/O DEVIATION OF MOUTH TOWARDS LEFT SIDE SINCE YESTERDAY EVENING, WEAKNESS OF RIGHT UPPER AND LOWER LIMB.
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY EVENING THEN SHE DEVELOPED DEVIATION OF MOUTH TOWARDS LEFT SIDE, WEAKNESS TOWARDS RIGHT UPPER AND LOWER LIMB, NOT ASSOCIATED WITH TINGLING AND NUMBERNESS,
INVOLUNTARY MOVEMENTS. HISTORY OF SLURRING OF SPEECH SINCE EVENING. NO
HISTORY OF CHEST PAIN, PALPITAIONS, ORTHOPNEA, PND.
K/C/O CORONARY ARTERY DISEASE S/P CABG 30YRS AGO ON TAB. ECOSPRINE GOLD
PO/DIS
K/C/O HTN SINCE 30YEARS ON TELMA 40MG PO/OD
K/C/O DM II SINCE 30 YEARS ON INJ LANTUS SC BD 40U-40U
NO OTHER COMORBIDITIES
PERSONAL HISTORY - MARRIED, MIXED DIET, REGULAR BOWEL AND BLADDER HABITS, NO ALLERGIES, Appetite NORMAL, NO ADDICTIONS
GENERAL EXAMINATION: NO PALLOR, NO ICTERUS, NO CYANOSIS, NO CLUBBING, NO
LYMPHADENOPATHY, NO PEDAL EDEMA.
SYSTEMIC EXAMINATIONCNS:
RIGHT LEFT
POWER UL 0/5 5/5
LL 3/5 5/5
TONE UL DECREASED NORMAL
LL DECREASEDNORMAL
REFLEXES
BICEPS - +
TRICEPS - +
SUPINATOR - +
KNEE - +
ANKLE - -
PLANTAR EXTENSOR FLEXOR
CVS- S1 S2 PRESENT, NO MURMURS. RS-BAE +, NVBS, PER ABDOMEN- SOFT NON
TENDER,
VITALS: - TEMP: AFEBRILE, BP: 140/90MMHG, RR: 18 CPM, PR: 98BPM, SPO2: 97% AT RA.
OPTHALMOLOGY REFERRAL WAS DONE AND FUNDUS WAS NORMAL AND NO
RETINOPATHY CHANGES PRESENT.
Investigation
HEMOGRAM:(15/12/25) HB- 10, PCV-29.7, TLC-11400, RBC-3.5, PLT-3.2
(16/12/25) HB- 11.5, PCV-34.8, TLC-14900, RBC-4.1, PLT-3.6
(17/12/25) HB- 11.3, PCV-34.3, TLC-15400, RBC-4.0, PLT-3.6
(18/12/25) HB- 9.9, PCV-30.3, TLC-11600, RBC-3.6, PLT-3.3
(19/12/25) HB- 9.4, PCV-28.1, TLC-10600, RBC-3.3, PLT-3.1
RFT:(15/12/25) UREA-47, CR-1.60, NA-138, K-4.4, CHLORIDE-101
(16/12/25) UREA-51, CR-1.60, NA-135, K-4.3, CHLORIDE-98
(17/12/25) UREA-75, CR-1.90, NA-129, K-4.6, CHLORIDE-96
(18/12/25) UREA-87, CR-1.600, NA-133, K-3.8, CHLORIDE-94
(19/12/25) UREA-86.6, CR-1.600, NA-135, K-4.2, CHLORIDE-97
** Tentative Date Page-3
KIMS HOSPITALS
(20/12/25) UREA-77.1, CR-1.400, NA-136, K-4.3, CHLORIDE-98
(21/12/25) UREA-87, CR-1.40, NA-134, K-4.3, CHLORIDE-98
(22/12/25) UREA-82, CR-1.20, NA-135, K-4.0, CHLORIDE-98
HBA1C: 6.2
LFT:(15/12/25) TB-0.57, DB-0.17, SGPT -13, SGOT-13, ALP -167, TP-6.6, ALB-4.0, GLO-2.60, A/G
RATIO-1.54
CUE:(15/12/25) COLOR PALE YELLOW, ALB-++, SUGAR NIL, PUS 3-4 CELLS, EPITHELIAL
CELLS 2-3
THYROID PROFILE (15/12/25) T3: 0.9, T4:12.2, TSH: 5.74
SEROLOGY NEGATIVE
BLOOD CULTURE AND SENSITIVITY: (18/12/25) NEGATIVE
2D ECHO (22/12/2025): CONCENTRIC LVH+, RVH+, NORWMA, MILD TR+, NO PAH, TRIVIAL
MR=/PR=, MILD AR=, MILD CALCIFIED AV, NO MS, MILD AS+, EF 54% FAIR LV SYSTOLIC
FUNCTION, GRADE I DIASTOLIC DYSFUNCTIONS. IVC SIZE (0.7CMS) COLLAPSING, IAS
INTACT, MINIMAL PE+, NO LV CLOT
CAROTID DOPPLER (20/12/25): DOPPLER INDICES ARE WITHIN NORMAL LIMIT. MULTIPLE
TINY PLAQES NOTED IN B/L CCA AND LEFT ICA FEW SHOWING CALCIFICATIONS
MDCT SCAN BRAIN PLAIN: (16/12/25) HYODENSE AREA MEASURING APPROXIMATELY 36MM IN LEFT OCCIPITAL LOBE- S/O ACUTE INFARCT. CHRONIC LACUNAR INFARCT IN BODY OF LEFT CAUDATE NUCLEUS. HYPODENSE FOCI MEASURING 5MM IN RIGHT CORONA RADIATA- ACUTE INFARCT. FEW DISCRETE AND MULTIPLE CONFLUENT HYPODENSITIES ARE PRESENT IN BILATERAL FRONTAL, PARIETAL PERIVENTRICULAR AND DEEP WHITE MATTER, CORONA RADIATA, CENTRUM SEMI-OVALE S/O CHRONIC SMALL VESSEL WHITE MATTER ISCHEMIA. MILD DIFFUSE CEREBRAL ATROPHY. MODERATE MUCO-PERIOSTEAL THICKENING RIGHT SPHENOID SINUS WITH HYPERDENSE MATERIAL- CHRONIC SINUSITIS
WITH SUPERIMPOSED? COLORIZED MYCETOMA.
X-RAY CHEST (AP VIEW): (19/12/25) DIFFUSE HAZINESS INVOLVING THE LEFT LUNG FIELD?
CONSOLIDATION SUGGESTED CLINICAL CORRELATION, APPARENT CARDIOMEGALY, LEFT PLEURAL EFFUSION.
USG (16/12/25): GALL BLADDER CALCULUS, RIGHT SMALL KIDNEY WITH GRADE III RPD
CHANGES RT KIDNEY: 5.2X3.5CM LEFT KIDNEY: 9.6X4.1CM, GRADE I FATTY LIVER.
Treatment Given (Enter only Generic Name)
1. RYLES TUBE FEEDING
2. INJ. MONOCEF 1GM IV/BD 8AM-X-8PM
3. INJ HAI S/C TID
4. INJ OPTINEURON 1AMP IN 100ML NS IV/OD
** Tentative Date Page-4
KIMS HOSPITALS
5. TAB. NICARDIA RETARD 20MG RT/TID 7AM-1PM-7PM
6. TAB. MET-XL 50MG RT/OD/10AM
7. TAB. ECOSPRIN AV 75/20MG PO/HS
8. TAB. TICAGRELOR90MG RT/BD 8AM-X-8PM
9. TAB. LEVIPILL 500MG RT/OD X-1-X
10. TAB. NODOSIS 1000MG RT/BD 1-X-1
11. TAB PULMOCLEAR 600MG RT/BD 8AM-X-8PM
12. NEB WITH IPRAVENT, BUDECORT 6TH HOURLY
13. PHYSIOTHERAPY OF RT UPPERLIMB AND LOWERLIMB
14. SYP CREMAFFIN 20ML PO/STAT
Advice at Discharge
1. RYLES TUBE FEEDING
2. INJ HAI S/C TID 8U(8AM)-8U(1PM)-8U (8 PM) TO CONTINUE
3. TAB. NICARDIA RETARD 20MG RT/TID 7AM-1PM-7PMTO CONTINUE
4. TAB. MET-XL 50MG RT/OD/10AMTO CONTINUE
5. TAB. ECOSPRIN AV 75/20MG PO/HSTO CONTINUE
6. TAB. TICAGRELOR90MG RT/BD 8AM-X-8PMTO CONTINUE
7. TAB. LEVIPILL 500MG RT/OD X-1-XTO CONTINUE
8. TAB PULMOCLEAR 600MG RT/BD 8AM-X-8PM 3 DAYS
9. PHYSIOTHERAPY OF RT UPPERLIMB AND LOWER LIMB
Follow Up
REVIEW TO GM OPD AFTER 1 WEEK/SOS WITH FBS, PLBS
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: 22/12/25
Ward: FMW
Unit: III
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