Wednesday, August 14, 2024

First admission September 2022, 20F with Lupus deidentified Horcrux EMR

 September 27, 2022

Intern 2016 batch 

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

Presentation 

20 year female came to casualty with chief complaints of 

-Hyperpigmented macules since 15 days

-b/l pedal edema since 15 days 

Fever 15 days back

-abdominal distension since 8 days 

-cough(dry) since 7 days 

-Sore throat since 7 days 

-decreased appetite since 7 days 

-decreased urine output since 3 days 

-constipation since 3 days 

-SOB since 5 days

HOPI 

20 year old female came with c/o of b/l pitting type pedal edema extending till knees since 15 days to which she got medical health checkup and prescribed some medication (unknown) then her pedal edema got resolved along with fever she developed Hyperpigmented macules on face later they stopped medications after 2 days she again had a complaints of b/l pedal edema  and fever abdominal distension associated with dry cough and decreased appetite she also has a complaints of DECREASED urine output and constipation since 3 days passing stools once in 3 to 4 days  

N/k/c/o HTN DM THYROID DISORDER CAD EPILEPSY TB












Personal history: 

Mixed diet 

Appetite lost 

Non veg diet 

Bowel and bladder movements are decreased 

Family history :

No significant family history 

O/E :

Pt was c/c/c 

On admission vitals are 

Bp 110/70 

PR 79 

RR 19 

Temp 98.8 


CVS- apex beat replaced laterally palpable thrills and s1 s2 heard mild s3

RS - BAE decreased rt infra scapular crepts present

P/a umblicus is everted

CNS 

MMSE 



Investigations:



30/9/22 




28/09/22


Pleural tap


Cerebral infarcts 














ANA PROFILE





28/9/22
ICU BED NO. 2
B/l pedal edema SOB 
Fever spikes 
O
Pt c/c/c 
Bp - 120/70 
PR - 142 
RR- 29
Temp-99.5
Spo2 - 94 at room air 
A
Post streptococcal glomerulonephritis..??
IGA nephropathy..??
Infective endocarditis..??
P
1)INJ Augmentin 1.2gm iv BD
2)INJ lasix 40mg iv BD
3) NEB Duolin, Budocort 6th hourly
4) INJ neomol 1gm/iv/sos
5) TAB Azithromycin 500mg po bd 
6) Betadine gargles tid

29/9/22

ICU BED NO. 2

B/l pedal edema SOB 

Fever spikes 

O

Pt c/c/c 

Bp - 120/70 

PR - 142 

RR- 29

Temp-99.5

Spo2 - 94 at room air 

A

Post streptococcal glomerulonephritis..??

IGA nephropathy..??

Infective endocarditis..??

P

1)INJ Augmentin 1.2gm iv BD

2)INJ lasix 40mg iv BD

3) NEB Duolin, Budocort 6th hourly

4) INJ neomol 1gm/iv/sos

5) TAB Azithromycin 500mg po bd 

6) Betadine gargles tid 

30/9/22

ICU BED NO. 2

Fever spikes +

Stools not passed 

O

Pt c/c/c 

Bp - 1110/70 

PR - 128

RR- 29

Temp-100.6

Spo2 - 94 at room air 

A

Post streptococcal glomerulonephritis..??

IGA nephropathy..??

Infective endocarditis..??

Polyserositis 2' to SLE

P

1)INJ Augmentin 1.2gm iv BD

2)INJ lasix 40mg iv BD

3) NEB Duolin, Budocort 6th hourly

4) INJ neomol 1gm/iv/sos

5) tab prednisolone 50mg po bd 

6) Betadine gargles tid

7) inj pan 40 mg iv bd 

1/10/22

ICU BED NO. 2

B/l pedal edema subsided

COUGH +

O

Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

infective endocarditis

Drug induced 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLY



2/10/22

ICU BED NO. 2

Action tremors +

FEVER SPIKES +

O

Pt c/c/c 

Bp - 120/70 

PR - 101

RR- 22

Temp-99.5

Spo2 - 94 at room air 

A

FLARE UP SLE WITH 

LUPUS NEPHRITIS 

CNS LUPUS VASCULITIS 

P

1) Iv fluids NS @30ml/hr 

2) inj methyl Prednisone 750mg in 100ml NS IV OD 

3) INJ. CEFTRIAXONE 1GM IV/BD

4) INJ. PAN 40 MG IV/OD

5) INJ. LASIX 40 MG IV OD

6) INJ.NEOMOL 1GM IV/SOS

7) INJ. DERIPHYLLIN 100MG IV/BD

8) INJ. TRAMADOL 100MG IN 100 ML NS IV/BD 

9) TAB HCQ 200 MG PO/OD

10) TAB. PREDNISOLONE 30MG/PO/BD

11) TAB. DOLO 650 MG PO/TID

12) NEB . BUDECORT P/N 12TH HRLY

13) BP, PR, TEMP, 4TH HRLY CHARTING 


3/10/22

ICU BED NO. 2

B/l pedal edema subsided

COUGH +


Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLYSolved 

8) IV fluids NS @50 ml/hr 

9) inj methyl Prednisone IV OD 

10) tab hcq200mg po od 

11) oint t bact l/a bd 

12) neosporin powder for l/a 

4/10/22

ICU BED NO. 2

B/l pedal edema subsided

COUGH +


Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLYSolved 

8) IV fluids NS @50 ml/hr 

9) inj methyl Prednisone IV OD 

10) tab hcq200mg po od 

11) oint  t bact l/a bd 

12) neosporin powder for l/a

08/10/22


No fever spikes 


Pt c/c/c 

Bp - 120/90 

PR - 74 

RR- 16

Temp-98

Spo2 - 98 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)TAB. PAN 40 MG PO OD 

2)TAB. MCQ 200MG/PO/OD

3) TAB PREDNISOLONE 20 MG PO BD

4) TAB. AZORAN 50 MG PO BD 

5) TAB. WARFARIN 5MG PO OD 

6) TAB. WARFARIN 5MG PO OD 

6) SYP. DULPHALAC 15 ML / PO/ TID 

7) OINT - T - BACT L/A BD 

8) CEBHYDRA LOTION L/A BD 

9) NEOSPORIN POWDER L/A







Discussion around the patient
1. Supranuclear bulbar paralysis, a rather more accurate term, is due to an upper motor lesion caused by bilateral disturbance of the corticobulbar tracts. The corticobulbar tracts exert supranuclear control over brainstem motor nuclei and are involved in the muscular movement of the head and neck. They originate from pyramidal cells (Betz cells) in the motor cortex and terminate at cranial nerve nuclei within the brainstem. These nuclei control mastication, deglutition, and speech. Pseudobulbar palsy is characterized by dysarthria, dysphagia, facial and tongue weakness, and emotional lability.[1][2] Any condition which damages bilateral corticobulbar pathways can cause pseudobulbar palsy.
Many pathological conditions can lead to pseudobulbar palsy. These include traumatic brain injury, neoplasm, vascular lesions, metabolic abnormality, or neurological disease. Pseudobulbar palsy is one of the severe complications of cerebrovascular diseases.[2][3]
Rare causes : 
Central pontine myelinolysis
Methotrexate
B/L thalamic infarcts
Neurocysticercosis
PML
Cerebral malaria
Bacterial Endocarditis

Loss of cerebellar modulation (cortico-pontocerebellar pathways) causing emotional dysmetria and disinhibition owing to lesions of corticobulbar volitional pathways are the main pathogenesis explained for pseudobulbar apathy
5. The sequelae reported after viral encephalitis can involve cognitive impairments, motor dysfunction, and epilepsy.Studies of patients who had been diagnosed with viral encephalitis due to HSE have demonstrated sequelae such as speech disorders, memory, and cognitive impairment, personality disorders, and epilepsy (Sellner and Trinka, 2012; Fruchter et al., 2015; Klein et al., 2017). It is vital to notice that the development of epilepsy has been reported 8 years after the onset of the encephalitis, and in nearly 60% of the patients infected with HSV(Sellner and Trinka, 2012; Bonello et al., 2015).









Brisk jaw jerk in pseudobulbar palsy


Glucocorticoid in SLE

"The activation of the non-genomic pathway starts at doses >100 mg/day of prednisone or equivalent. This pathway is especially sensitive to methylprednisolone (MP) and dexamethasone, which have non-genomic effects up to five times more potent than genomic ones [8]. "

We'll change to Methylpred sir?


"The “classical” standard 1 mg/kg/day prednisone dose is not supported by either basic pharmacology or clinical evidence (Figure 1) [19,20]. It is unlikely that anti-inflammatory effects increase significantly after prednisone doses have reached 30–40 mg/day, since such doses already result in a saturation of almost 100% of the genomic pathway [12,19]. Recent data suggest that higher initial doses of prednisone are associated with higher cumulative doses [21] with the well proven result of increasing damage accrual [1,22,23,24,25]. "

Have to I guess.

"The “Rituxilup” schedule, which consisted of rituximab and MP, followed by maintenance treatment with mycophenolate mofetil and no oral steroids, resulted in 72% of patients with LN class III, IV, or V eventually achieving complete remission within a median period of 36 weeks [32]. "

"In 2018, Danza et al. compared the efficacy and rates of infections among patients with several autoimmune conditions, including SLE, treated with MP pulses, for a total dose over three days ≤1500 mg, <1500 to ≤3000 mg and >3000 mg [19]. No differences among the different doses were seen in patients achieving complete response, partial response, or no response. No patients in the ≤1500 mg group suffered infections, vs. 9.1% in the high dose group. " 

Or dexa if there are affordability constraints. 

Unfortunately there aren't many trials with dexa comparing this cheaper alternative with expensive MP



First admission discharge summary

Age/Gender : 21 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 27/09/2022 04:57 PM
Diagnosis
SYSTEMIC LUPUS ERYTHEMATOSUS WITH GLOMERULONEPHRITIC FLARE UP OF LUPUS NEPHRITIS ?CATASTROPHIC APLA SECONDARY TO SLE [LIBMAN SACKS ENDOCARDITIS
,CNS THROMBO EMBOLISM, AND RENAL FAILURE]
Case History and Clinical Findings
20 YR OLD FEMALE CAME ITH C/O B/L PEDAL EDEMA SINCE 15 DAYS HYPERPIGMENTED MACULES SINCE 15 DAYS
FEVER SINCE 15 DAYS
ABDOMINAL DISTENSION SINCE 8 DAYS DRY COUGH SINCE 7 DAYS
SORE THROAT SINCE 7 DAYS DECREASED APPETITE SINCE 7 DAYS SOB SINCE 5 DAYS
DECREASED URINE OUTPUT SINCE 3 DAYS CONSTIPATION SINCE 3 DAYS
HOPI -20 YEAR OLD FEMALE CAME WITH C/O OF B/L PEDAL EDEMA EXTENDING TILL THE KNEES PITTING TYPE SINCE 15DAYS
 

FOR WHICH SHE GOT MEDICAL HEALTH CHECKUP AND PRESCRIBED SOME MEDICATION [UNKNOWN] THEN HER PEDAL EDEMA GOT RESOLVED ALNG WITH FEVER SHE DEVELOPED HYPER PIGMENTED MACULES ON FACE LATER THEY STOPPED MEDICATIONS AFTER 2 DAYS SHE AGAIN HAD A COMPLAINT OF B/L PEDAL EDEMA AND FEVER ABDOMINAL DISTENSION ASSOCIATED WITH DRY COUGH AND DECREASED APPETITE SHE ALSO HAS COMPLAINTS OF DECREASED URINE OUTPUT AND CONSTIPATION SINCE 3 DAYS
PASSING STOOLS ONCE IN 3-4 DAYS N/K/C/O HTN DM THYROID CAD EPILEPSY TB

PERSONAL HISTORY DIET MIXED APPETITE LOST
BOWEL AND BLADDER MOVEMENTS DECREASED


FAMILY HISTORY NOT SIGNIFICNT

O/E-
PT WAS C/C/C
ON ADMISSION VITALS BP 110/70 MMHG
PR-79 BPM RR-19 CPM TEMP -98.8 F
CVS- APEX BEAT DISPLACED LATERALLY PALPABLE THRILL IN MITRAL AREA
LOUD S2 HEARD IN ALL AREAS NO S3 HEARD
PAN SYSTOLIC MURMUR AT MITRAL AREA


RS-
BAE DECREASED
RT INFRA SCAPULAR CREPTS PRESENT P/A-
 

SOFT NON TENDER WITH EMBILICUS NORMAL SHAPE AND INVERTED XIPHI UMBILICAL LENGTH 15 CM
UMBILICO PUBIC LENGTH 12 CM
ON PALPATION NO ORGANOMEGALY


CNS -B/L UPPER LIMB AND LOWER LIMB
HYPER TONIA WITH EXAGERATED DTR ,ABSENT ANKLE REFLEX PATELLAR CLONUS-
RT SIDE 4+
LT SIDE 3+
MOTOR POWER- 4/5 4/5
4/5 4/5


1/10/22
MMSE - DONE ON 1/10/22 ORIENTATION -
ORIENTED TO DAY,MONTH ,SEASON ,DATE -2 FLOOR ,HOSPITAL,DISTRICT,STATE ,COUNTRY-4 RECALL-2/3
ATTENTION AND CALCULATION-3/4 LANGUAGE -2 OBJECTS-2 SENTENCE-1
3 STAGE COMMAND -3 READING CLOSE YOUR EYES WRITING A SENTENCE -0

MODERATE COGNITIVE IMPAIRMENT COURSE IN HOSPITAL
28/09/22-
NEPHRO REFERAL I/V/O ELEVATED RENAL PARAMETERS AND ANASARCA
REFERAL NOTES-LVTS-,OBSTRUCTION -,HEMATURIA-,PYURIA-,YELLOWIS DISCOLORATION-
,NSAID ABUSE -,NATIVE MEDICATION - ADVICED TO CONTINUE THE SAME TREATMENT 28/09/22-
 

PULMO REFERAL I/V/O WHEEZE ,XRAY CHANGES [BL PLEURAL EFFUSION] ADVICED -INJ AUGMENTIN 1.2 GM IV/TID
INJ.LASIX 40 MG IV/BD NED DUOLIN
BUDECORT 6TH HOURLY IMJ NEOMOL 1GM IV/SOS BETADINE GARGLING TAB AZITHROMYCIN

GENERAL SURGERY REFERAL I/V/O BED SORE [1/10/22]
LE- TWO SMALL ULCERS NOTED EITHER SIDE OF INTERGLUTEAL CLEFT MEASURING 1X1 CM EACH
NO ACTIVE DISCHARGE
FLOOR -GRANULATION TISSUE,NO SLOUGH
EDGE SLOPING EDGES NO SURROUNDING INDURATION MARGINS -BLACKISH
ADVICED -TO MAINTAIN HYGEINE AND KEEP THE AREA DRY OINT T BACT FOR LA
NEOSPORIN POWDER FOR LA FREQUENT POSITION CHANGE AIR BED

29/09/22-
ENT REFERRAL WAS TAKEN I/V/O DYSPHONIA REFRAL NOTES-
O/E OF ORAL CAVITY- MUCOSA PALE TONGUE IS COATED
OROPHARYNX-BL GRADE 2 TONSILLAR HYPERTROPHY ,NO CONGESTION NECK-TRACHEA CENTRAL
LARYNGEAL FRAMEWORK NORMAL LARYNGEAL CREPITUS+
NOSE-
EXTERNAL FRAMEWORK NORMAL CAUDAL DISLOCATION-LEFT ANTERIOS MILD DNS -RIGHT
 

B/L NASAL MUCOSA -PALE TURBINATES AND FLOOR -NORMAL ROOMY NASAL CAVITIES
OE EAR-
B/L TYMPANIC MEMBRANE INTACT .,COL+ DIAGNOSIS-DYSPHAGIA UNDER EVALUATION NO ACTIVE ENT INTERVENTION
30/09/22-
REVIEW NEPHRO REFERAL-
USG KUB SHOWING BULKY LT KIDNEY WITH ALTERED ECHOTEXTURE ADVICED TAB AUGMENTIN
TAB PAN 40 MG OD TAB DOLO 650 MG TID 4/10/22-
DVL REFERAL I/V/O HYPERPIGMENTED MACULES NOTED OVER CHEEKS AND FOREHEAD
,NOSE ,CHIN EAR LOBULE ,RETROAURICULAR REGION [CONCHA SPARED], BOTH FOREARMS,BACK,UPPER CHEST
ORAL CAVITY- N
MULTIPLE HYPERPIGMENTED MACULES NOTED OVER BOTH THE PALMS DIAGNOSIS -POST INFLAMMATORY HYPERPIGMENTATION
ADVICED -CEBHYDRA LOTION LA/BD
REVIEW ENT REFERAL I/V/O DYSPHONIA [13/10/22]
ADVICED TO CONTINUE MEDICATION AS ADVICED BY PHYSICIAN WAIT AND WATCH
FOLLOWED BY SPEECH THERAPY


01/10/2022-
20 F WITH ANASRCA BL PEDAL EDEMA ,PLEURAL EFFUSION ,AND PERICARDIAL EFFUSION - RESOLVING
+RASH HEALED +FEVER
SKIN- HEALED RASHES +PAINLESS EMBOLI LIKE LESIONS [JANEWAY LESIONS] PT APPEARS COMFORTABLE
FEVER SPIKES PERSIST -FEVER CHART ANALYSIS-SEPTIC PTTERN ACTION TREMOR+B/L
 

REDUCTION IN TACHYCARDIA[HR 148->112] LIDLAG
HEALING BEDSORE ON BACK [BUTTOCK AREA]


ON 02/10/22-
ANA PROFILE -ANTI dsDNA +++
ANTI HISTONE ,ANTINUCLEOSOME,ANTI KU AG++
MRI BRAIN- MULTIPLE HYPERINTENSITIES IN BRAIN PARENCHYMA F/S/O-VASCULITIS? USG ABDOMEN -MODERATE ASCITES

SLE DAI SCORE-30 POINTS S/O ACTIVE DISEASE


ON 3/10/22-
TACHYPNEA AND TACHYCARDIA SUBSIDED ACTION TREMOR DECREASED

0N 4/10/22
INJ UNFRACTIONATED HEPARIN 5000IU /IV/STAT
FOLLOWED BY INJ UNFRACTIONATED HEPARIN 5000 IU /SC/QID FOR 3 DAYS[GIVEN FOR 3 DAYS [TILL 6//10/22]]
TAB WARFARIN 5MG /PO/OD IS STARTED


TAB LASIX 40MG PO/BD STARTED ON 12/10/22


BLOOD TRANSFUSION WAS DONE ON 13/10/22
ONE PINT OF A+VE BLOOD WAS TRANSFUSED AFTER DOING THE BLOOD GROUPING AND TYPING AND CROSS MATCHING
TRANSFUSION STARTED AT 7;30 PM AND WAS COMPLETED BY 11;20 PM
HALF AND HOURLY MONITORING OF VITALS WAS DONE DURING THE PROCESS OF TRANSFUSION
PRE TRANSFUSION VITALS AND POST TRANSFUSION VITALS WERE MONITORED,PT WAS STABLE AND NO CHILLS,RIGORS,FEVER,MYALGIA DURING THE TRANSFUSION
 

Investigation
USG IMPRESSION[28/09/2022] MODERATE PERICARDIAL EFFUSION BILATERAL PLEURAL EFFUSION GROSS ASCITES

MRI BRAIN PLAIN WITH CSPINE SCREENING[ON 3/10/22] IMPRESSION-
DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY
MULTIPLE SMALL ACUTE INFARCTS IN BOTH CEREBRAL HEMISPHERES-EMBOLIC SCREENING OF CERVICAL AND DORSAL SPINE APPEARS NORMAL
Treatment Given(Enter only Generic Name)
1] INJ AUGUMENTIN 1.2 GM IV/BD FOR 2 DAYS
2] INJ LASIX 40 MG IV/BD FOR 9 DAYS
3] NEB WITH DUOLIN BUDECORT
4] INJ NEOMOL 1GM IV/SOS
5] TAB AZITHROMYCIN 500 MG PO/OD FOR 2 DAYS
6] BETADINE GARGLES /TID
7] INJ DERIPHYLLINE 100 MG IV /BD FOR 7 DAYS
8] TAB PREDNISOLONE 50 MG PO/BD FOR 3 DAYS[STARTED ON 29/9/22 TO 1/10/22] TAB PREDNISOLONE 30 MG PO/BD FOR 1 DAY[STARTED ON 2/10/22 ]
TAB PREDNISOLONE 20 MG PO/BD FOR 11 DAYS[STARTED ON 3/10/22 ] 9]INJ PAN 40 MG IV/OD
10] INJ CEFTRIOXONE 1 GM IV/BD FOR 7 DAYS
11] INJ TRAMADOL 1 AMP IN 100 ML NA/IV/BD
12] INJ METHYL PREDNISOLONE 750 MG IN 100 ML NS/IV /OD FOR 3 DAYS[2/10/22 TO 4/10/22]
13] TAB HCQ 200 MG PO/OD[STARTED ON 2/10/22]
14] TAB DOLO 650 MG PO/TID
15] OINT T BACT FOR LA /BD
16] NEOSPORIN POWDER FOR LA
17] TAB AZORAN 50 MG PO/BD
18] SYP DULPHALAC 15 ML PO/TID
19] INJ UNFRATIONATED HEPARIN 5000 IU/SC/QID FOR 3 DAYS
20] TAB WARFARIN 5MG /PO/OD
 

21] CEBHYDRA LOTION LA /BD
Advice at Discharge
1] TAB HCQ 200 MG PER ORAL ONCE DAILY
2] TAB PREDNISOLONE 20 MG PER ORAL TWICE DAILY
3] TAB AZORAN 50 MG PER ORAL TWICE DAILY
4] TAB LASIX 40 MG PER ORAL TWICE DAILY
5] SYP SUCRALFATE 10 MLTHRICE DAILY
6] SYP DULPHLAC 15 ML PER ORAL THRICE DAILY
7] OINT TBACT LOCAL APPLICATION TWICE DAILY
8] CEBHYDRA LOTION LOCAL APPLICATION TWICE DAILY
9] NEOSPORIN LOCAL APPLICATION
Follow Up
REVIEW TO GM OPD ON TUESDAYS OR SOS
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:13/10/2022 Ward:AMC Unit:GM 2



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