A 56 YEAR OLD MALE WITH NASO FACIAL PAIN AND SWELLING

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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

A 50 year old male,farmer by occupation,from garudapally  presented in the opd with complaints of painful fluid filled lesion on nose since 3 days followed by periorbital edema since 3 days

No c/o fever/decreased hearing/ear discharge/itching.

? H/o pneumonia 20 days back.

4 years ago he had hemiparesis and slurred speech for which he used medications and stopped.

He was diagnosed with HTN and DM 4 Years ago and on Tab.ISRYL M2 PO/OD and Tab.VOGLIBOSE M2 PO/OD

He has normal appetite,mixed diet,regular bowel and bladder movements,no allergies and takes alcohol occassionally and also smokes 5-6 beedis per day.

On examination patient is conscious, coherent and cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema

Vitals:

Temp-98.2 degrees F

PR-81Bpm

RR-18 Cpm

BP-110/80 mm Hg

Spo2-99%

CVS-S1S2+

RS-BAE+;NVBS+

CNS-NFD

P/A- Soft,non tender

Local examination:

Day 1:

day 3:

INVESTIGATIONS:

FBS-246 mg/dl

HbA1c-7.3%

Hemogram:

Hb-12.6

Tlc-12,800

MCV-77.2

MCH-25.9

ptc-3.32 

Normocytic normochromic with leucocytosis

Blood group-A positive

CUE:

Albumin-trace

Sugar-++++

Pus cells-3-6

Epithelial cells-2-4

LFT:

T.bil-0.60

D.bil-0.20

AST-22

ALT-40

ALP-204

TP-7.4

Albumin-4.0

A/G-1.21

RFT:

Urea-16 mg/dl

Creatinine-1.2 mg/dl

Na-136

K-3.7

Cl-94

C-reactive protein-positive(1.2 mg/dl)

HIV-negative

HCV-negative

HBsAg-negative

ECG:

Opthalmology referral:

dermatology referral:

TREATMENT:

1)T.VALCYCLOVIR 1000 MG PO/BD

2)T.ULTRACET/PO/BD

3)T.PAN 40 MG PO/OD

4)T.PCM 650 MG PO/SOS

5)LUBREX EYE DROPS

6)OINT.T BACT FOR L/A FOR 1 WEEK

7)GRBS CHARTING 4TH HOURLY

8)BP/PR/SPO2 MONITORING

9)INJ.HAI S/C TID ACCORDING TO SLIDING SCALE