60 M HTN PERIANAL ABSCESS D12- L1 INFECTIVE SPONDYLODISCITIS
CHIEF COMPLAINTS
60YEARS OLD MALE DRIVER BY OCCUPATION CAME WITH COMPLAINTS OF LOW BACKPAIN SINCE 3 MONTHS RADIATING TO RIGHT LOWER LIMB
HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK AND THEN DEVELOPED LOW BACK PAIN WHICH IS INSIDIOUS IN ONSET, PROGRESSIVE AGGRAVATING ON WALKING, SQUATTING AND ON STANDING AND NOT RELEIVED ON USING MEDICATION.PAIN IS RADIATING TO RIGHT LOWER LIMB AND ASSOCIATED WITH TINGLING OF RIGHT THIGH REGION.
PERSONAL HISTORY
BOWEL AND BLADDER MOVEMENTS ARE REGULAR
APPETITE NORMAL
EX ALCOHOLIC EX SMOKER STOPPED 3 YEARS AGO
PAST HISTORY:
HISTORY OF SURGERY FOR RENAL CALCULI ONE AND ONE N HALF MONTH BACK
HISTORY OF CVA
USED ALTEPLANE STATUSING MEDICATION TAB. ATORVASTATIN, TAB ASPIRIN, TAB ESMOPRAZOLE, TAB RIFAMPICIN SINCE ONE AND HALF MONTH
KNOWN CASE OF TYPE II DM SINCE 2 YEARS USING TAB.METFORMIN 500MG PO BD
K/C/O HYPERTENSION SINCE 2 YEARS USING TELMA 40MG, TAB HYDROCHLORTHIAZIDE
GENERAL EXAMINATION
BP:120/80
O/E
BP:120/80MMHG
PR:89BPM
RR: 16CPM
TEMP:AFEBRILE
L/E OF SPINE:NO DEFORMITY
SKIN NORMAL
NO SWELLING AND NO LOCAL RISE OF TEMPERATURE
TENDERNESS PRESENT
SYSTEMIC EXAMINATION :-
CVS- S1S2 HEARED NO MURMURS
RS- BAE +, NVBS
CNS NFND
LOCAL EXAMINATION :-
SKIN - NORMAL
NO DEFORMITY
TENDERNESS ABSENT
LOCAL RISE OF TEMPERATURE - ABSENT
LOWER LIMB :- RIGHT LEFT
LRF 60 60HIP 5/5 5/5
KNEE 5/5 5/5
ANKLE 5/5 5/5
EHL 5/5 5/5
FHL 5/5 5/5
SENSATIONS - INTACT INTACT
DISTAL PULSES + +RIGHT LEFT
SHOULDER 5/5 5/5
ELBOW 5/5 5/5
WRIST 5/5 5/5
FINGER GRIP 5/5 5/5
REFLEXES RIGHT LEFT
KNEE ****
ANKLE ++ ++
PLANTAR FLEXOR FLEXOR
GENERAL SURGERY REFERRAL DONE ON 30/1/24 I/V/O USG ABDOMEN AND PELVIS REORT FINDINGS:MILD BULKY PANCREAS, GRADE 1 FATTY LIVER, LEFT RENAL CALCULI,RIGHT RENAL EXOPHYTIC CYST AND THEY ADVISED
TAB.DROTIN PO BD FOR 5 DAYS
SYP• ALKASTONE B6 15ML IN HALF GLASS OF WATER FOR 3 MONTHS
TAB.PCM 650MG PO SOS
TAB.ZOFER 4MG PO SOS
DERMATOLOGY REFERRAL DONE ON 2/2/24 I/V/O ITCHING REACTION FOR ATT
DIAGNOSIS:SENILE XEROSIS
ADVISED:
LIQUID PARAFFIN L/A BD FOR 2 WEEKS
TAB TECZINE 5 MG OD FOR 1 WEEK
GENERAL SURGERY REFFERAL DONE ON 4/2/24 I/V/O PAIN IN PERIANAL REGIOI
DIAGNOSIS:FISSURE IN ANO ADVISED:
HIGH FIBRE DIET
PLENTY OF ORAL FLUIDS
SYP CREMAFFIN 15ML PO/HS OINT SMOTH FOR LIA
SITZ BATH WITH BETADINE/TID
GENERAL MEDICINE REFERRAL DONE ON 7/2/24 I/V/O RECURRENT EPISODES OF VOMITINGS
DIAGNOSIS:DRUG INDUCED VOMITINGS
ADVISED INJ.ZOFER 4 MG IV/SOS
TAKE AKT 4 AFTER BREAKFAST
NEUROLOGY REFERRAL DONE ON 8/2/24 I/V/O CVA AND FOR FITNESS OF SURGERY ADVISED:
TO STOP ATORVASTATIN FOR NOW
TO RESTART ANTIPLATELETS AS POSSIBLE POSTOPERATIVELY
UROLOGY REFERRAL DONE ON 9/2/24 I/N/O BURNING MICTURITION AND DECREASED
URINE FLOW
IMPRESSION:NEUROGENIC BLADDER ADVISED:
T. TAMSULOSIN 0.4MG PO HS FOR 1 MONTH
SYP ALKASTONE B6 15ML IN HALF GLASS OF WATER FOR 3 MONTHS
GENERAL MEDICINE REFERRAL DONE ON 9/2/24 I/V/O REVIEW WITH REPORTS ADVISED TO CONTINUE SAME TREATMENT
ENT REFERRAL DONE ON 13/2/24 I//O POSITIONAL VERTIGO
ADVISED TAB VERTIN 16MG PO BD
AVOID SUDDEN MOVEMENTS TO RIGHT SIDE
GENERAL MEDICINE REFERRAL DONE ON 15/2/24 INIO LOOSE STOOLS AND NAUSEA
ADVISED SECOND HOURL ORAL FLUIDS OR RT
INJ ZOFER 4MG IV/TID
INJ PAN 40MG IV/OD
TAB SPOROLAC DS PO/TID
TAB REDOTIL 100 MG PO /BD
STOP METFORMIN 500MG
IV FLUIDS NS 500ML/HR
GENERAL MEDICINE REFERRAL DONE ON 16/2/24
DIAGNOSIS:HYPOGLYCEMIA SECONDARY TO ABSCESS ADVISED:
IV FLUIDS @50ML/HR
INJ 25D INFUSION @30ML/HR
INJ PANTOP 40MGIV OD
INJ ZOFER 4MG IV SOS
TAB PCM 650MG PO SOS
GENERAL SURGERY REFERRAL DONE ON 21/2/24 IN VIEW OF PERIANAL ABSCESS
ADVISED REGULAR DRESSINGS SITZ BATH WITH BETADINE QID
DIAGNOSIS
D12-L1 INFECTIVE SPONDYLODISCITIS
TREATMENT GIVEN DURING HOSPITAL STAY
Treatment Given(Enter only Generic Name)
PATIENT DIAGNOSED AS RIGHT SIDED PERIANAL ABSCESS, EMERGENCY INCISION AND DRAINAGE WAS DONE
UNDER ASEPTIC CONDITIONS AND SEDATION, PATIENT AND PATIENT PARTS PAINTED AND DRAPED .
CRUCIATE INCISION GIVEN OVER SUMMIT OF ABSCESS .300ML PUS DRAINED.LOCULATIONS ARE CLEARED.THOUGH WASH GIVEN WITH BETADINE AND H202.HAEMOSTASIS SECURED.CAVITY PACKED WITH 3 BETADINE SOAKED GUAZE AND ASD DONE
INJ PIPTAZ 4.5GM IV TID
INJ PAN 40MG IV OD
TAB AKT4 PO OD
TAB BENADON FORTE 20MG PO OD
TAB ASPIRIN150MG PO OD
TAB DROTIN P PO/OD
INJ NEOMOL 1GM IV TID
TAB SPOROLAC DS PO TID
TAB TAMSULOSIN 0.5MG PO HS
SYP ALKASTONE 15 ML IN 1 GLASS OF WATER PO TID
TAB VERTIN 16MG PO/OD
TAB REDOTIL 10MG PO/BD
TAB BACTRIM DS PO BD
ADVICE AT DISCHARGE
TAB PAN 40MG PO OD X 5 DAYS
TAB AK4 PO OD CONTINUE
OTE ALKASTONE 15 ML IN 1 GLASS OF WATER PO TI TAB VERTIN 16MG PO/OD
TAB REDOTIL 10MG PO/BD
TAB BACTRIM DS PO BD
Advice at Discharge
TAB PAN 40MG PO OD X 5 DAYS
TAB AKT4 PO OD CONTINUE
TAB BENADON FORTE 20MG PO OD
TAB ASPIRIN150MG PO OD
TAB DROTIN P PO/OD
TAB SPOROLAC DS PO TID
TAB TAMSULOSIN 0.5MG PO HS
SYP CREMMAFIN 15ML IN GLASS OF WATER
TAB METRONIDAZOLE 400MG
OINT ANOBLISS L/A
SYP ALKASTONE 15 ML IN 1 GLASS OF WATER PO TID
TAB VERTIN 16MG PO/OD
TAB REDOTIL 10MG PO/BD
TAB BACTRIM DS PO BD
SITZ BATH DAILY QID WITH BETADINE
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