Previous work up links on this project serially placed from past to current:
Introduction
The evaluation of undifferentiated fever often requires dynamic clinical reasoning frameworks to capture and organize evolving phenotypic data. This case centers on a 30-year-old male presenting with a protracted four-month history of abdominal pain, punctuated by a recent onset of high-grade fever, syncope, and shortness of breath. The patient's clinical trajectory underscores the complexities of navigating multisystem involvement, where the differential diagnosis spans severe atypical infection, occult connective tissue disease, and hypercoagulable states.
Methods
A comprehensive, iterative clinical evaluation was conducted across two closely linked hospital admissions. The longitudinal history was mapped against a multimodal diagnostic workup. Initial evaluation focused on acute stabilization following an episode of syncope and utilized basic metabolic panels, hemograms, and arterial blood gas analyses. Given the multisystem presentation, the diagnostic pathways expanded to include extensive cross-sectional imaging (HRCT chest, CTPA, USG abdomen, and MRI of the lumbo-sacral spine and hips). Targeted autoimmune serologies, peripheral blood smears, and multidisciplinary clinical consultations were integrated to evaluate for hemolysis, deep tissue infections, and coagulopathy.
Results
The initial admission revealed a complex triad of sepsis with transient thrombocytopenia (nadir platelets 54,000), right-sided pulmonary thromboembolism (PTE) with bilateral pulmonary infarcts, and mesenteric panniculitis. After initiating therapeutic anticoagulation (enoxaparin) and broad-spectrum antibiotics, the patient left against medical advice, only to return days later.
During the second admission, the patient presented with severe, dragging low back pain, worsening shortness of breath (MMRC Grade III), epistaxis, and hematuria. Hemograms demonstrated a persistent normocytic normochromic anemia (Hb ~6.8 - 8.5 g/dL). Crucially, an ANA blot returned positive for antibodies against the U1-snRNP antigen. MRI of the bilateral hips revealed multiple T1 hypointense and PD hyperintense areas suggestive of extensive bone infarcts involving the acetabulum, ischium, ilium, and femoral necks. Therapeutic interventions during this phase included continued broad-spectrum antibiotics (piperacillin-tazobactam, ceftriaxone, doxycycline), anticoagulation transitioning to an oral direct factor Xa inhibitor (apixaban), and systemic corticosteroids (prednisolone).
Discussion
This case illustrates profound diagnostic and therapeutic uncertainties, necessitating a precision medicine approach to patient management.
Diagnostic Uncertainties: The central diagnostic tension lies in distinguishing a primary infectious process with secondary embolic complications from a primary rheumatologic or prothrombotic syndrome. The concurrent presentation of PTE, widespread bone infarcts, and mesenteric panniculitis strongly suggests a systemic hypercoagulable or vasculitic state. While the initial impression included septic emboli, the positive U1-snRNP antibody introduces Mixed Connective Tissue Disease (MCTD) or a potential overlapping Antiphospholipid Syndrome (APLA) as a unifying etiology. Furthermore, the persistent anemia raises the question of whether occult hemolysis (potentially autoimmune or microangiopathic) is driving the systemic decompensation.
Therapeutic Uncertainties: The management strategy requires delicately balancing opposing pathophysiological risks. Administering therapeutic anticoagulation for life-threatening PTE and extensive osseous infarctions is directly challenged by the patient's bleeding manifestations (epistaxis, hematuria) and recent thrombocytopenia. Additionally, the concurrent use of broad-spectrum antibiotics for presumed sepsis alongside systemic corticosteroids for suspected connective tissue disease creates a distinct therapeutic conflict, risking opportunistic infections while attempting to blunt an autoimmune inflammatory storm.
Socratic Questions for Further Reasoning
How does the isolation of U1-snRNP antibodies shift the diagnostic weight away from septic emboli and toward a unifying rheumatologic or microvascular ontology?
In the presence of simultaneous macrovascular thrombosis (PTE, bone infarcts) and spontaneous mucosal bleeding (hematuria, epistaxis), what dynamic laboratory markers would best guide the real-time titration of anticoagulation?
If treating this presentation as an "n-of-1" clinical trial, how might the rapid integration of deeper phenotypic data—such as specific hemolysis panels, complement levels, or complete antiphospholipid titers—alter the decision to maintain concurrent antimicrobial and immunosuppressive therapies?
Diagnosis
SEPSIS WITH ?VIRAL HEPATITIS THROMBOCYTOPENIA(RECOVERED)
PULMONARY THROMBOEMBOLISM
MESENTERIC PANNICULITIS
?ATYPICAL PNEUMONIA ? ARDS TO R/O CONNECTIvE TISSUE DISORDER
Case History and Clinical Findings
C/O GIDDINESS F/B LOSS OF CONSCIOUSNESS
C/O FEVER WITH CHILLS Since 1 DAY
C/O LOWER BACK PAIN SINCE 1 DAY
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL FRIDAY(YESTERDAY) AFTERNOON THEN
HE SUDDENLY HAD AN EPISODE OF GIDDINESS F/B LOSS OF CONSCIOUSNESS FOR 5 MINS
WHILE WALKING AND FELL DOWN AND WAS ADMITTED IN OUTSIDE HOSPITAL THEN
PATIENT CAME WITH C/O GIDDINESS F/B LOSS OF CONSCIOUSNESS WHICH IS SUDDEN
ONSET,FOR ABOUT 5 MIN. C/O LOW BACK APIN WHICH IS SUDDEN IN ONSET , NON
PROGRESSIVE , Aggravated ON BENDING AND NO Relieving FACTORS PRESENT.
C/O FEVER WITH CHILLS SINCE YESTERDAY WHICH IS HIGH GRADE , INTERMITTENT
RELIEVED ON MEDICATION
C/O GENERALISD BODY PAINS SINCE YESTERDAY
NO H/O INVOLUNTARY MOVEMENTS OF LIMBS,HEADACHE,TRAUMA TO HEAD,CHEST PAIN
,PALPITATIONS,SOB,DECREASED URINE OUTPUT,EAR DISCHARGE,TINNITUS.
PAST HISTORY :. N/K/C/O DM, CVA , HTN , CAD THYROID, TB , EPILEPSY.
PERSONAL HISTORY - MARRIED,MIXED DIET, REGULAR BOWEL AND BLADDER HABITS, NO
ALLERGIES, NO ADDICTIONS , APETITE NORMAL, GENERAL EXAMINATION: NO PALLOR, NO
ICTERUS, NO CYANOSIS, NO CLUBBING, NO LYMPHADENOPATHY, NO PEDAL
EDEMA.;SYSTEMIC EXAMINATION CVS- S1 S2 PRESENT , NO MURMURS. RS-BAE +,
DECREASED BREATH SOUNDS ON RT MAMMARY REGION , PER ABDOMEN- SOFT NON
TENDER,CNS - NFND.;VITALS:- TEMP: 101 F , BP: 130/70MMHG, RR: 16 CPM, PR: 75 BPM,
SPO2: 98% AT RA
DVL REFERRAL WAS DONE ON 1/3/26 I/V/O LESION IN THE INGUINAL AREA
IMPRESSION - TINEA CORPORIS ET CRURIS AND ADVICED - 1. LULICONAZOLE CREAM L/A X
2 WEEKS
2 . EBERNET CREAM L/A OD X 2 WEEKS
OPTHALMOLOGY REFERRAL WAS DONE ON 28/2/26 I/V/O RAISED ICP FEATURE
IMPRESSION : FUNDUS EXAMINATION IS NORMAL NO RAISED ICP FEATURES NOTED
CARDIOLOGY REFERRAL WAS DONE 0N 3/3/26 I/V/O ANTICOAGULATION:
IMPRESSION - ADVICED INJ . CLEXANE 60MG SC/BD FOR 5- 7 DAYS F/B ADD NOAC
DVL REFERRAL WAS DONE ON 4/3/26 ERYTHEMATOUS LESION ON THE LT GLUTEAL
REGION
IMPRESSION - ?Abscess AND ADVICED CEBHYDRA MOISTURIZER LOTION L/A X 1 WEEK
PULMONOLOGY REFERRAL WAS DONE ON 4/3/26 I/V/O ? Pneumonia
IMPRESION - ADVICED INJ. CLEXANE 60 MG S/C BD
COMPRESSION STOCKINGS TO B/L LOWER LIMB
Investigation
27/2/26
PH - 7.40 ,PCO2 - 29.80,PO2 - 136, HCO3 - 18, O2 STAT - 100, O2 COUNT - 13
28/2/26
RFT
BLOOD UREA - 42.00
S. ELECTROLYTES
Na - 139,K - 3.9 ,Cl - 102 ,Ca - 1.05,S. CRAET - 3.90 ,ESR - 13
BLOOD FOR M.P STRIP TEST - NEGATIVE
HEMOGRAM :
HB- 12.5,TLC - 12670,RBC - 4.3,PLT - 1.1,N/L/E/M/B - 92/5/1/2/0
CUE :
COLOUR - YELLOW ; APP- CLEAR ; REACTION - ACIDIC ; S. GRAVITY - 1.0100 ; ALB - TRACE
<3 ; SUGAR - NIL ; PUS CELLS - 2-4 ; EPITHELIAL CELLS - 2-3 ; RBC - NIL ; CASTS - NIL ;
BILESALTS - NIL ; BILE PIGMENTS - NIL
ABG :
PH - 7.453 ,PCO2 - 32,5 ,PO2 - 48.1 ,O2 STAT - 84% ,O2 COUNT - 13
LFT : TB 9.36 DB 6.17 SGPT 57 SGOT 82 ,ALP-336 TP 6.7 ALB -3.76 GLO-2.94 A/G 1.28
1/3/26
HEMOGRAM :
HB - 12.8,TLC - 14200,RBC -4.8,PLTS - 88000,PCV -38.4,N/L/B/E/M - 92/5/0/1/2
RFT
BLOOD UREA - 37.7 ,S. ELECTROLYTES :Na - 138,K - 3.9 ,Cl - 104,S. CRAET - 1
LFT: TB 3.5 DB 2.4 SGPT 50 SGOT 82 ,ALP-334 TP 6.4 ALB -3.4 GLO- A/G 1.14
2/3/26
HB - 12.1,TLC - 15760,RBC -4.0,PLTS - 72000,PCV -35.4,N/L/B/E/M - 90/6/0/0/4
ABG :
PH - 7.461,PCO2 - 26.4,PO2 - 140 ,O2 SAT - 99.4%
PT 17,INR 1.25
3/3/26
HB - 10.8,TLC - 14700,RBC -3.4 ,PLTS - 54000,PCV -30.2
LFT: TB 1.9 DB 1.04 SGPT 41.6 SGOT 84.1 ,ALP-304.9 TP 5.4 ALB -3.1 GLO-2.3 A/G 1.35
PH - 7.561,PCO2 - 33,2,PO2 - 42.9,O2 SAT - 77.4%
BLOOD CULTURE REPORT - NO GROWTH
4/3/26
HB -8.9 ,TLC - 11700,RBC -3.1 ,PLTS - 80000,PCV -27.3
RFT BLOOD UREA - 44.4,S. ELECTROLYTES :Na - 140,K - 3.2 ,Cl - 106 ,S. CRAET - 0.90
PT 18, INR 1.33
LFT: TB 1.8 DB 1 SGPT 41.9 SGOT 80.2 ,ALP-273.9 TP 5.1 ALB -3.1 GLO-2.00 A/G 1.55
PH - 7.496,PCO2 - 32,7,PO2 - 44,O2 SAT - 80.7%
PERIPHERAL SMEAR -
RBC - NORMOCYTIC NORMOCHROMIC
WBC - INCREASED COUNTS ON SMEAR WITH INCREASED NEUTROPHILS
PLATELET SERIES - DECREASED COUNTS ON SMEAR
T3- 0.4,T4- 12.0,TSH - 1,24
5/3/26
ABG :
PH - 7.522,PCO2 - 31.4 ,PO2 - 39.3 ,O2 SAT - 73.8%
S. ELCTROLYTES
SODIUM - 138 ,POTASSIUM -3.2 ,CL - 102
PT - 16 ,INR - 1.11
6/6/26 :
PERIPHERAL SMEAR
RBC - NORMOCYTIC NORMOCHROMIC
WBC - INCREASED COUNTS ON SMEAR WITH INCREASED NEUTROPHILS
PLATELET SERIES - DECREASED COUNTS ON SMEAR
HEMOGRAM :
HB - 7.8 ,TLC - 14000 ,RBC - 2.6 ,PCV - 23.0 ,PLT - 1.20 ,N/E/M/B/L - 75/1/4/0/20
LFT: TB 1.8 DB 1 SGPT 38 SGOT 35 ,ALP-228 TP 5.7 ALB -3.0 GLO-2.70 A/G 1.11
CUE
URINE FOR BLOOD - NEG
BILE SALTS - NEG
BILE PIGMENTS - NEG
S. ELECTROLYTES
SODIUM - 138 ,POTASSIUM -3.4 ,CL - 108 ,ICA - 1.10
ABG :
PH - 7.455 ,PCO2 - 37.1 ,PO2 - 59.5 ,O2 STAT-90
7/3/26
HB - 7.8 ,TLC - 11500 ,RBC - 2.4 ,PCV - 21.8 ,PLT - 1.66
LFT: TB 1.48 DB 0.3 SGPT 40 SGOT 31 ,ALP-210 TP 5.6 ALB -2.9 GLO-2.70 A/G 1.07
RFT BLOOD UREA - 29 ,S. ELECTROLYTES :Na - 138,K - 3.7 ,Cl - 102 ,S. CRAET - 0.70
8/3/26
HB - 6.8 ,TLC - 11800 ,RBC - 2.4 ,PCV - 21.6 ,PLT - 2.49
MRI - LUMBO SACRAL SPINE WITH WHOLE SPINE WAS DONE ON 28/2/26
IMPRESSION - DIFFUSE DISC BULGE AT LEVEL L4-L5 , L5-S1 CAUSING MILD CENTRAL
CANAL STENOSIS , MILD B/L RECESS NARROWING AND MILD FORAMINAL NARROWING
MILD END PALE FATTY CHANGES AT L2 VERTEBRAE
CTPA WAS DONE ON 1/3/26
IMPRESSION - POSITIVE FOR PULMONARY THROMBO EMBOLISM ON RIGHT SIDE WITH
BILATERAL SMALL PULMONARY INFARCTS
HRCT CHEST ON 01/03/26:B/L LOWER LOBES PREDOMINANTLY BASAL SEGMENTS SHOW
GGOs LIKELY INFECTVE/INFLAMMATORY Etiology
USG ANDOMEN PELVIS DONE ON 1/3/26
IMPRESSION - GRADE 1 FATTY LIVER
- SPLENOMEGALY
- FEW ENLARGED MESENTRIC LYMPH NODES IN PERIUMBLICAL REGION AS DESCRIBED
2D ECHO WAS DONE ON 1/3/26
IMPRESSION - TACHYCARDIA DURING STUDY
NO RMWA , TRIVIAL TR+ , NO PAH , NO MR/AR/PR
EF= 58% RVSP2 37 MMHG
GOOD LV/RV SYSTOLIC FUNCTION
IVC SIZE - 1.35 CM COLLAPSING
VENOUS DOPPLER WAS DONE ON 2/3/26
NO E/O ANY HYPERECHOIC FOCI NOTED IN EXAMINED DEEP VEIN
NO E/O ANY SUBCUTANEOUS EDEMA
USG LEFT GLUTEAL REGION WAS DONE ON 4/3/26
IMPRESSION -NO EVIDENCE OF COLLECTION NOTED, NO SONOLOGICAL ABNORMALITY
DETECTED
Treatment Given(Enter only Generic Name)
INTERMITTENT NIV
INJ . PIPTAZ 4.5 ML /IV/QID FOR 6 DAYS
INJ . DOXY 100 MG IV/BD FOR 7 DAYS
INJ . CLEXANE 60 MG /SC/BD FOR 6 DAYS
Page-6
KIMS HOSPITALS,Narketpally
Nalgonda-T.S
6
INJ . NEOMOL 1GM /IV /SOS IF TEMP >101 F
INJ . OPTINEURON 1AMP IN 100 ML NS /IV/OD
INJ . PAN 40 MG /IV/OD
INJ . HYDROCORT 100 MG /IV/BD FOR 5 DAYS
TAB. DOLO 650 PO/QID
TAB . PREGABA - NT 0-0-1
TAB . UDILIV 300 MG 1-1-1
TAB. ACECLO MR 1-1-1
CAP.FLUVIR 75MG 1-0-1 FOR 4 DAYS
SYP.POTKLOR 20 ML /PO/TID
OINT LULLICONAZOLE L/A X-X-N
OINT EBERNET L/A M-X-X
NEB WITH IPRAVENT , BUDECORT - 8TH HRLY
Advice at Discharge
LEAVING AGAINST MEDICAL ADVISE:
Diagnosis
1 SEPSIS WITH THROMBOCYTOPENIA (RESOLVED) WITH ?ARDS?DIC
2 PULMONARY THROMBOEMBOLISM
3 ?SEPTIC EMBOLI WITH MULTIPLE BONY INFARCTS (HIP JOINT)
4 Mesenteric PANNICULITIS
5 TO R/O APLA SYNDROME
6 ANEMIA SECONDARY TO ?HEMOLYSIS
Case History and Clinical Findings
C/O LOW BACK ACHE SINCE 7 DAYS,C/O FEVER SINCE 7 DAYS,C/O SOB SINCE 2 DAYS
PATIENT PRESENTED TO CASUALTY WITH C/O LOW BACK ACHE SINCE 7
DAYS,Aggravated SINCE 2 DAYS,INSIDIOUS ONSET,DRAGGING TYPE,RADIATING TO B/L
LL,Aggravated ON MOVEMENT OR LIFTING WEIGHTS,Relieved ON MEDICATION.C/O
SOB,GRADE III MMRC,SINCE 2 DAYS,A/W H/O INTERMITTENT CHEST PAIN.H/O
HEMATURIA(RESOLVED),H/O EPISTAXIS SINCE 2 DAYS RESOLVED ON ITS OWN.N/H/O
PALPITATIONS,SEIZURES,LOC,
PAST HISTORY: PT WAS ADMITTED WITH SIMILAR COMPLAINTS 7 DAYS BACK,FOR WHICH
HE WAS EVALUATED AND TREATED,BUT PATIENT WENT ON LAMA YESTERDAY AND CAME
FOR READMISSION TODAY.K/C/O PULMONARY THROMBOEMBOLISM TREATED WITH
INJ.CLEXONE 60MG S/C BD X 6 DAYS.N/K/C/O TYPE II DM, CVA , HTN , CAD THYROID, TB ,
EPILEPSY.
PERSONAL HISTORY - MARRIED,MIXED DIET, REGULAR BOWEL AND BLADDER HABITS, NO
ALLERGIES, NO ADDICTIONS , APETITE NORMAL, GENERAL EXAMINATION: PALLOR, NO
ICTERUS, NO CYANOSIS, NO CLUBBING, NO LYMPHADENOPATHY, NO PEDAL
EDEMA.;SYSTEMIC EXAMINATION CVS- S1 S2 PRESENT , NO MURMURS. RS-BAE +, NVBS ,
PER ABDOMEN- SOFT NON TENDER,CNS - NFND.;VITALS:- TEMP: AFEBRILE , BP:
130/70MMHG, RR: 16 CPM, PR: 75 BPM, SPO2: 98% AT RA
ORTHOPEDICS REFERRAL WAS DONE I/V/O LOW BACK ACHE ADVICED REFER TO HIGHER
CENTRE I/V/O BIOPSY
Investigation
HEMOGRAM:(09/03/26 ) HB-6.8, PCV-21.5,TLC-11,510, RBC-2.4, PLT-2.86
HEMOGRAM:(10/03/26 ) HB-7.1, PCV-21.2,TLC-9700, RBC-2.4, PLT-2.75
HEMOGRAM:(11/03/26 ) HB-7.7, PCV-23.2,TLC-9300, RBC-2.63, PLT-3.81
HEMOGRAM:(18/03/26 ) HB-7.1, PCV-22.7,TLC-7180, RBC-2.63 PLT-5.27
HEMOGRAM:(21/03/26 ) HB-8.5, PCV-27.2,TLC-8200, RBC-3.0 PLT-4.62
RBS (09/03/26)- 100MG/DL
SEROLOGY NEGATIVE (HIV,HBSAG,HCV)
RFT:(9/3/26)UREA- 47, CREATININE-1.2, SODIUM-134, POTASSIUM-4.2, CHLORIDE-92
RFT:(10/3/26)UREA- 22, CREATININE-0.9, SODIUM-138, POTASSIUM-3.8, CHLORIDE-
106,CALCIUM (IONIZED)-1.11,PHOSPHORUS-4.
RFT:(11/3/26)UREA- 20, CREATININE-0.9, SODIUM-136, POTASSIUM-3.7, CHLORIDE-
105,CALCIUM (IONIZED)-1.11,PHOSPHORUS-4.
RFT:(21/3/26)UREA- 32, CREATININE-0.7, SODIUM-140, POTASSIUM-4.4, CHLORIDE-
102,CALCIUM (IONIZED)-1.11
LFT:(9/3/26) TB-1.79, DB-1.03 ,SGPT -71 ,SGOT- 24, ALP -180,TP - 6.4, ALB-3.54,A/G RATIO -
1.24
LFT:(10/3/26) TB-1.28, DB-0.41,SGPT -24,SGOT- 23, ALP -176,TP - 5.8, ALB-2.8,A/G RATIO - 0.93
CUE(09/03/26-COLOR:PALE YELLOW, , SUGAR NIL ,PUS 2-3CELLS, EPI: 1-2 CELLS, ALB: NIL ,
RBC: NIL
CUE(21/03/26-COLOR:PALE YELLOW, , SUGAR NIL ,PUS 3-4CELLS, EPI: 2-3 CELLS, ALB:
TRACE LESS THAN 30MG/DL , RBC: NIL
LDH ; (21-03-26) 206.50
ESR(14/3/26)-130
ESR(17/3/26)-140
PT ; 20 SEC INR; 1.40 APTT;41 SEC
ANA PROFILE; ANA BLOT TEST REPORTED POSITVE AS ANTIBODIES WERE DETECTED
AGANIST U1-snRNP ANTIGEN
PERIPHERAL SMEAR-IMPRESSION- NORMOCYTIC NORMOCHROMIC ANEMIA
BLOOD GROUP- O POSITIVE
ECG-NORMAL SINUS RHYTHM ,NO SIGNIFICANT ST T CHANGES
USG GLUTEAL REGION WAS DONE ON 18/3/26 I/V/O GLUTEAL REGION PAIN IMPRESSION
WAS LIKELY EARLY PRESSURE SORE CHANGES.
MRI B/L HIP WAS DONE ON 18/3/26 IMPRESSION IS ALL VISUALISED BONE SHOWS T1
HYPOINTENSE AREAS METABOLIC OR HEMATOLOGICAL CAUSE
MULTIPLE PD HYPERINTENSE AREAS INVOLVING B/L ACETABULUM ,
ISCHIUM,ILIUM,SACRUM AND B/L FEMORAL NECK SOME OF THESE AREAS SHOWING T1
HYPOINTENSE RIM LIKELY SUGGESTIVE OF BONE INFARCTS MILD B/L SACROILLIAC JOINT
EFFUSION L>R MODERATE B/L HIP JOINT EFFUSION LT GLUTEUS SHOWS MILD
INTRAMUSCULAR EDEMA
Treatment Given(Enter only Generic Name)
INJ TRAMADOL 10MG IN 100ML NS STAT
INJ PIPTAZ 4.5 GMS IV/QID (1-1-1-1)
INJ CEFTRIAXONE 1GM IV/BD (1-0-1)
INJ NEOMOL IV/SOS (IF TEMP >101F)
INJ OPTINEURON 1 AMP IN 100ML NS IV (1-0-0)
INJ PAN 40MG IV/OD (1-0-0)
CAP FLUVIR 75MG PO/BD (1-0-1)
TAB DOLO 650MG PO/QID (1-1-1-1)
TAB PREGABA-NT PO/HS (0-0-1)
TAB ACECLO MR PO/BD (1-0-1)
TAB PREDNISOLONE 30MG PO/OD (1-0-0)
TAB APIXABAN 5MG PO/BD (1-0-1)
TAB DOXYCYLIN 100 MG PO/BD
TAB ECOSPRIN 75 PO/HS
SYP POTCLOR 15ML PO/TID (1-1-1)
OINT LULLICONOZOLE L/A OD (0-0-1)
OINT EBERNE L/A (1-0-0)
Advice at Discharge
INJ CEFTRIAXONE 1GM IV/BD (1-0-1)
TAB PAN 40MG IV/OD (1-0-0)
TAB DOLO 650MG PO/QID (1-1-1-1)
TAB PREGABA-NT PO/HS (0-0-1)
TAB ACECLO MR PO/BD (1-0-1)
TAB PREDNISOLONE 30MG PO/OD (1-0-0)
TAB APIXABAN 5MG PO/BD (1-0-1)
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