42M Palpitations intermittent 3 years CG PaJR

Patient Advocate: Hello
Chest Mein Halka Sa pen Hai Aur kamjori Bhi lag raha hai sir Ke Piche gardan Mein Thoda Sa Halka Dard Hai
Pichhle 2 Hafte se एक-एक ghante mein urin ho raha hai
Pichhle 2 sal pahle Aisa Hi chest pen hokar Dil Ki Dhadkan 28 bar per minut ho gaya tha same Vaisa hi Abhi Bhi lag raha hai
Jiska treatment hyderabad Hospital mein kiya gaya tha

Participant: Patient getting slight pain in chest, feeling week, back if the neck also there is pain and discomfort

Participant: Last 2 weeks patient is getting urge for urinations

PaJR PHR Moderator: Uska discharge summary share kijiye taki IP number dikhe par patient ka naam na dikhe

Participant: 2 years back patient has same symptoms hear rate came down

Patient Advocate: Sar vah do sal pahle admit hua tha to uska discharge paper mil Nahin raha hai main aaj dhundhne ka koshish kiya tha

PaJR PHR Moderator: He needs to collect his 24 urine volume as well as the total 24 hour water he's taking and share it with us

Participant: Patient visited hyderabad hospital then

PaJR PHR Moderator: Kal subah yahan yaad dilana. Hum college computer mein dhoondenge

Patient Advocate: Okay sar

Participant: Aap paani kitna pee rahe hai ek din me

Participant: Andaaz se

Patient Advocate: Subah Se Raat Tak 3 litre Pita hun

Participant: Patient is a sub contractor working on hill top he is experiencing dryness of throat, urge to drink water, low heart beat, dizziness

PaJR PHR Moderator: Pyas aane par peete hain ya waise hi?

Patient Advocate: Sirf Pyas lagne per Hi Pita hun

PaJR PHR Moderator: Kal subah sahi se 24 ghanta naap kar peejiyega aur pishab bhi naap kar batayiyega 24 ghante ka

Patient Advocate: 👍

Participant: 👍

Patient Advocate: Sar ismein Jo medicine likha injection usko lena hai ki nahin

Participant: Nahin abhi nahin

PaJR PHR Moderator: Nahin

Patient Advocate: Ji

Patient Advocate: Sir koi bat hai kya
Sar cardiologist ko jode kya

PaJR PHR Moderator: Locally dikha sakte hain cardiologist ko

Patient Advocate: Sir yahan nahi hai ya to raipur me hai

PaJR PHR Moderator: Thik hai. Raipur mein hi dikha lijiye

Participant: Sir patient waiting for you near OPD 🙏

PaJR PHR Moderator: Yes saw him
Saw him for the first time as a patient's relative in 2019
Then in early 2020 after he had a head trauma and was admitted here
He had taken loan for his treatment (possibly before getting admitted with us) and the loan sharks forced him to again get admitted in 2021 with stress! Perhaps seen by @Paticipant at that time.
This time also similar symptoms suggestive of stress with no organic objective findings

PaJR PHR Moderator: Complains of nuchal and shoulder pains since 2 months.

Participant: please send him to physiotherapy for neck, shoulder and back strengthening exercises

Participant: Ok sir

PaJR PHR Moderator: Let's see his yesterday's interview details from the psy. Please ask someone to send his file to the OPD @Participant

Participant: Ok sir

Patient Advocate: 👏

Psy 2: they missed his head injury history! @Participant remember the head injury paper you wrote with them?

LFT Report

11/26/24

PaJR PHR Moderator: Finally it all boils down to addiction psychiatry! @Paticipant

Should have added @Narmeen Shah here earlier as she could have prepared this case report also by talking to this patient telephonically @Patient Advocate
@Participant may be able to share all that has transpired in this group

Patient Advocate: Sir chest paine ke liye bhi dawai likhwadona

PaJR PHR Moderator: @Participant can add tablet amitriptyline 10 mg one hour before dinner in his discharge

Participant: Ok sir

PaJR PHR Moderator: @Participant didn't share the older discharge from 2020 yet. @Participant please collect his signed informed consent for the case report by @Narmeen Shah before he leaves. The forms are in ICU or with Participant.

PaJR PHR Moderator: This is the EMR summary for this admission written by Participant 👇

Age/Gender : 42 Years/Male

Discharge Type: Relieved

Admission Date: 24/11/2024 05:29 AM

Diagnosis:

ACID PEPTIC DISEASE TINEA CRURIS

TOBACCO DEPENDENCE SYNDROME

Case History and Clinical Findings 

C/O CHEST PAIN SINCE 3 DAYS 

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED CHEST PAIN INSIDIOUS ONSET BURNING TYPE NON RADIATING ASSOCIATED WITHJ CHEST HEAVINESS

NO C/O PROFUSE SWEATING,SOB NOT A/W NAUSEA,VOMITING

H/O BELCHING NO H/O TRAUMA

NO H/O HEAVY WEIGHT LIFTING

NO H/O WEIGHT LOSS/WEIGHT GAIN

H/O SIMILAR COMPLAINTS 3 YEARS AGO PAST ILLNESS:

N/K/C/O DM,HTN,CVA,CAD,EPILEPSY,TB,THYROID DISORDERS PERSONAL HISTORY:

APPETITE: NORMAL

 BOWEL AND BLADDER: REGULAR ALLERGIES: NONE

ADDICTIONS: ALCOHOL OCCASIONALLY

GENERAL EXAMINATION:

NO PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY OEDEMA BP: 110/70 MMHG

PR:56 BPM RR: 18 CPM

TEMPERATURE:98 F SPO2: 98% AT RA GRBS:101 MG/DL

CVS: NO THRILLS, S1S2 +, NO MURMURS NO ADDITIONAL SOUNDS HEARD

APEX BEAT FELT AT LEFT 5TH ICS JUST LATERAL TO MID CLAVICULAR LINE RS:

CHEST SHAPE SYMMETRICAL

NO SINUS,DISCHARGES,SCARS,SKIN CHANGES BAE+,NVBS, NO ADDED SOUNDS

PER ABDOMEN: SOFT, NON TENDER, NO ORGANOMEGALY, NO ABDOMEN DISTENSION CNS : NFND

PSYCHIATRY REFERRAL DONE ON 25/11/24 I/V/O STRESS DIAGNOSED AS TOBACCO DEPENDENCE SYNDROME ADVISED:NICOTINE GUMS 2MG PO TID/SOS

T. CLONAZEPAM MO 0.5MG PO/SOS

DERMATOLOGY REFERRAL DONE ON 25/11/24 I/V/O ITCHY SKIN LESIONS ON B/L BUTTOCKS DIAGNOSED AS TINEA CRURIS

ADVISED: CAP. ALCROS 100MG PO BD X 2WEEKS LULIFIN CREAM L/A BD X 2 WEEKS

TAB. TECZINE 5MG PO OD X 1 WEEKS KETO SOAP

Investigation

SERUM ELECTROLYTES (Na, K, C l)SODIUM 137 mmol/L POTASSIUM 4.2 mmol/L CHLORIDE

102 mmol/L CALCIUM IONIZED 1.18 mmol/L Serum Creatinine 0.7 mg/dl

HEMOGRAM

HAEMOGLOBIN 12.4 gm/dl TOTAL COUNT 5,700 cells/cumm NEUTROPHILS 56 % LYMPHOCYTES 34 %EOSINOPHILS 02 % MONOCYTES 08 % BASOPHILS 00 % PCV 38.3 vol % M C V 96.2 fl M C H 31.2 pg M C H C 32.4 %RDW-CV 11.2 % RDW-SD 40.2 fl RBC COUNT 3.98millions/cumm

PLATELET COUNT 2.30 lakhs/cu.mm SMEAR

RBC Normocytic normochromicWBC With in normal limitsPLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seenIMPRESSION Normocytic normochromic bloodpicture

LIVER FUNCTION TEST (LFT)Total Bilurubin 1.00 mg/dlDirect Bilurubin 0.20 mg/dl SGOT(AST) 21 IU/LSGPT(ALT) 21 IU/L ALKALINEPHOSPHATASE88 IU/LTOTAL PROTEINS 6.8 gm/dlALBUMIN

4.68 gm/dlA/G RATIO 2.21RBS 130 mg/dl

2D ECHO: TRIVIAL TR ,NO PAH,TRIVIAL AR,NO MR NO RWMA. NO AS/MS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC FFUNCTION,NO PE/LV CLOT

Treatment Given(Enter only Generic Name)

T. PAN 40MG PO OD

TAB TEIZINE 10MG PO OD LULIFIN CREAM L/A BD

SYP. SUCRAL O 10ML PO TID NICOTINE GUMS 2MG PO TID/SOS MONITOR VITALS AND INFORM SOS

Advice at Discharge

T. PAN 40MG PO OD

T. AMITRIPTYLINE 10MG 1 HR BEFORE DINNER TAB TECZINE 10MG PO OD

SYP. SUCRAL O 10ML PO TID NICOTINE GUMS 2MG PO TID/SOS CAP. ALCROS 100MG PO BD X 2WEEKS LULIFIN CREAM L/A BD X 2 WEEKS TAB. TECZINE 5MG PO OD X 1 WEEKS KETO SOAP

Follow Up

FOLLOW UP TO GM AND DERMATOLOGY OPD AFTER 2 WEEKS

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/Attendent 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: 26/11/24 Ward: MMW Unit:III

PaJR PHR Moderator: This is his previous admission EMR summary that will also go into the case report:

AGE: 42Y/M

DOA:28/06/2022; 

08:41 AM

Diagnosis 

1.MICRO VASCULAR ANGINA WITH GENERALISED ANXIETY DISORDER . 

2.NON ULCER DYSPEPSIA . 

3.TOBACCO POUCH KERATOSIS ON LEFT LOWER VESTIBULAR REGION WITH CHRONIC GENERALISED GINGIVITIS WITH LOCALISED PERIODONTITIS. 

Case History and Clinical Findings

PATIENT CAME WITH C/O RETRO STERNAL CHEST PAIN SINCE 4 DAYS . 

HOPI: Patient WAS APPARENTLY ASYMPTOMATIC 2YR BACK AND HAD A INJURY TO RT TEMPORAL REGION DUE TO FALL FOR WHICH CT BRAIN WAS DONE AND SHOWED AN HEMORRHAGE FOR WHICH HE TOOK MEDICATION TAB .TeGRETOL 100MG FOR 3 MONTHS AND STOPPED.NOW SINCE 4 DAYS BACK AND DEVELOPED CHEST VPAIN WHICH CRUSHING TYPE NON RADIATING AND DOESNT RELIEVE ON MEDICATION .INCREASES ON ACTIVITY .RELIEVES ON REST .ANXIETY +NT .NO PALPITATION ,DYSNEA,VOMITINGS,SWEATING. 

PAST HISTORY : NOT K/C/O HTN /DM/CVA/CAD/ASTHAMA. 

PERSONAL HISTORY : DIET -MIXED 

APPETITE NORMAL 

SLEEP ADEQUATE 

BOWEL AND MICTURITION -NORMAL . 

ADDICTION-PATIENT HAD AN HABIT OF CHEWING THAMBAKU AND PAN SINCE 12YRS .

FAMILY HISTORY :NOT SIGNIFICANT

SYTEMIC EXAMINATION: O/E PT C/C/C 

AFEBRILE 

PR 78BPM 

BP 120/70MMHG

CVS- S1S2+ 

RS -BAE + 

CNS- NAD 

P/A- SOFT AND NON TENDER.

COURSE IN THE HOSPITAL: PATIENT CAME WITH C/O CHEST PAIN ,ECG AND BASIC INVESTIGATION WAS DONE.ECG SHOWED NORMAL SINUS RHYTHM AND WAS MANAGED CONSEREVATIVELY .PATIENT WAS KEPT ON OBSERVATION AND VITALS MONITERED . 2D ECHO WAS DONE ,NO RWMA DETECTED,GOOD LV/RV FUNCTION ,EF 65%. PT HAD FOOD LODGEMENT IN TOOTH AND ULCER IN MOUTH AND YELLOWISH DISCOLOURATION OF TEETH . PATIENT WAS REFFERED TO DENTIST I/V/O ORAL ULCER AND YELLOWISH DISCOLOURATION OF TEETH .DENTIST HAS REVEWIED THE CASE AND INVESTIGATION HAVE BEEN DONE. PROVISOINAL DIAGNOSIS OF TOBACCO POUCH KERATOSIS ON LEFT LOWER VESTIBULAR REGION WITH CHRONIC GENERALISED GINGIVITIS WITH LOCAL PERIODONTITIS WAS DONE AND MANAGED CONSERVATIVELY.DEEP SCALING DONE ON 1/7/22 AND ADVICED TO REVIEW AFTER 15 DAYS TO DENTAL OPD .

Investigation: ECG NORMAL SINUS RHYTHM

Treatment Given(Enter only Generic Name) 

TAB .ULTRACET 1/2 TAB QID

 TAB.CLONAZEPAM 0.2 MG PO/BD 

OINT.RETINOL A 0.025% ON LESION

 Advice at Discharge:

1.TAB .ULTRACET 1/2 TAB QID FOR 4DAYS 

2.TAB. CLONAZEPAM 0.2MG PO/BD FOR 7DAYS

3.OINT . RETINOL A 0.025% ON LESION FOR 15DAYS

 4.HEXIDINE MOUTH WASH 

5.STOLIN GUM PAINT 

6.THERMOCELE PASTE 

Follow Up:

REVIEW AFTER 15 DAYS TO DENTAL OPD FOR FURTHER FOLLOWUP

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/Attendent 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 

S      IGNATURE OF PG/INTERNEE 

SIGNATURE OF ADMINISTRATOR 

SIGNATURE OF FACULTY 

Discharge Date Date:4/7/2022 Ward:male medical ward Unit: 5