19M Chronic Otitis media WB PaJR

Age/Gender : 19 Years/Male

Address :

Discharge Type: Relieved

Admission Date: 22/10/2024 12:50 AM

Diagnosis

BILATERAL CHRONIC OTITIS MEDIA MUCOSAL TYPE QUIESCENT STAGE WITH BILATERAL CHL WITHOUT COMPLICATIONS WITH ADENOIDITIS.

Case History and Clinical Findings

C/O DECREASED B/L HEARING LOSS SINCE 12 YEARS HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 12 YEARS BACK AFTER WHICH HE DEVELOPED DECREASED B/L HEARING OF FAR VOICES BUT NOT NEARBY VOICES A/W EAR DISCHARGE (CLEAR FLUID), ITCHING AGGRAVATED DURING WINTER SEASON RELEIEVED ON MEDICATIONS

NO C/O FEVER, COUGH, COLD, SOB, CHEST PAIN, CHEST TIGHTNESS NO C/O PAIN ABDOMEN, NAUSEA, VOMITING

NO H/O PEDAL EDEMA, FACIAL PUFFINESS

H/O USAGE OF MEDICATIONS 5 YEARS BACK FOR 3 MONTHS PAST HISTORY:

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

APPETITE - NORMAL , NON VEGETARIAN DIET , REGULAR BOWEL &BLADDER, NORMAL MICTURITION, NO KNOWN ALLERGIES AND ADDICTIONS

 

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT COOPERATIVE WELL ORIENTED TO TIME PLACE AND PERSON

NO PALLOR,ICTERUS,CLUBBING, CYANOSIS, LYMPHADENOPATHY TEMPERATURE-AFEBRILE

PULSE RATE- 90 BPM RESPIRATORY RATE-18 CPM BP-100/60 MG HG

SPO2 98%@RA GRBS-141 MG/DL

SYSTEMIC EXAMINATION:

CVS- S1, S2+, NO MURMURS

RS-BAE+,NVBS+, NO ADVENTITIOUS SOUNDS

PER ABDOMEN- SOFT, NON TENDER, NO ORGANOMEGALY CNS- CONSCIOUS, PUPILS-NSRL

GCS-15/15 E4V5M6

ENT REFERRAL WAS DONE ON 22-10-24 IN VIEW OF DECREASED BILATERAL HEARING LOSS ASSOCIATED WITH EAR DISCHARGE OCCASIONALLY AND THEY ADVISED PTA(R- 30dBHL AND L-36.6dBHL) AND DNE AND WAS DIAGNOSED ASBILATERAL CHRONIC OTITIS MEDIA MUCOSAL TYPE QUISCENT STAGE WITH BILATERAL CHL WITHOUT COMPLICATIONS WITH ADENOIDITIS. AND WAS ALSO ADVISED FOR LEFT TYMPANOPLASTY UNDER GA

Rx:

TAB LEVOCET 5 MG HS PO 0-0-1 FOR 5 DAYS TAB AMOXICLAV 625 MG BD FOR 5 ADYS TAB.ESMOPRAZOLE 40 MG FOR 5 DAYS

CIPLOX EAR DROPS 3 DROPS 3 TIMES A DAY5 DAYS. AVOID MANIPULATION OF NOSE

AVOID HARD BLOWING OF NOSE STEAM INHALATION

Investigation

CUE:

 

COLOUR Pale yellow Pale Yellow PhysicalExaminationAPPEARANCE Clear Clear PhysicalExaminationREACTION Acidic 5.0-9.0 Reagent StripSP.GRAVITY 1.010 1.001-1.035 Reagent StripALBUMIN + Negative Reagent StripSUGAR Nil Negative Reagent StripBILE SALTS Nil Negative Reagent StripBILE PIGMENTS Nil Negative Reagent StripPUS CELLS 3-4 0-5/HPF Light MicroscopyEPITHELIALCELLS2-3 0-5/HPF Light MicroscopyRED BLOODCELLSNil 0-2/HPF Light MicroscopyCRYSTALS Nil Nil Light MicroscopyCASTS Nil Nil Light MicroscopyAMORPHOUSDEPOSITSAbsent Nil Light MicroscopyOTHERS Nil Nil Light Microscopy

HEMOGRAM:

HAEMOGLOBIN 14.9 gm/dl 13.0 - 17.0 ColorimetricTOTAL COUNT 9,500 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 73 % 40 - 80 Light MicroscopyLYMPHOCYTES 16 % 20 - 40 Light

MicroscopyEOSINOPHILS 01 % 01 - 06 Light MicroscopyMONOCYTES 10 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 42.7 vol % 40 - 50 CalculationM C V 69.8 fl

83 - 101 CalculationM C H 24.3 pg 27 - 32 CalculationM C H C 34.9 % 31.5 - 34.5 CalculationRDW-

CV 14.5 % 11.6 - 14.0 HistogramRDW-SD 36.1 fl 39.0-46.0 HistogramRBC COUNT 6.12

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 1.50 lakhs/cu.mm 1.5-4.1 ImpedenceSMEARRBC microcytic hypochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Microcytic hypochromic bloodpictureFBS:103 MG/DL

Treatment Given(Enter only Generic Name)

TAB LEVOCET 5 MG HS PO 0-0-1 TAB AMOXICLAV 625 MG BD

TAB.ESMOPRAZOLE 40 MG (30 MINUTES BEFORE FOOD) CIPLOX EAR DROPS 3 DROPS 3 TIMES A DAY BUTROCLOT NASAL DROPS/SOS

Advice at Discharge

TAB LEVOCET 5 MG HS PO 0-0-1 FOR 5 DAYS TAB AMOXICLAV 625 MG BD FOR 5 ADYS

TAB.ESMOPRAZOLE 40 MG FOR 5 DAYS(30 MINUTES BEFORE FOOD) CIPLOX EAR DROPS 3 DROPS 3 TIMES A DAY5 DAYS.

AVOID MANIPULATION OF NOSE AVOID HARD BLOWING OF NOSE STEAM INHALATION

Follow Up

REVIEW TO ENT OPD FOR LEFT TYMPANOPLASTY UNDER GA

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: 08682279999 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:25-10-24

Ward:MMW Unit:GM V

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

The PHR, patient journey record PaJR transcripts below reflect the therapeutic uncertainties around the patient and their resolution through team based learning :

Here's the rest of the discussions not yet updated in the case report 👇

[10/30, 7:47 AM] +PA: Hi

[10/30, 7:48 AM] PA:  স্যার আমি কি কানের মেডিসিন আর ড্রপ গুলো নিবো

[10/30, 7:54 AM] PA: বাঁদিকের কান টা একটু ব্যাথা করে আর মাঝে মাঝে ডানদিকের কান টা অল্প ব্যাথা করে আর কান দুটো চুলকায় | আমি কি তাহলে মেডিসিন গুলো নিবো |

[10/30, 8:23 AM] PaJR PHR Moderator: @⁨PAJR TRAINEE ⁩ let's share his prior PaJR, paper and EMR data here

[10/30, 8:26 AM] PAJR TRAINEE: Ok