1041 : Mr.

Afreen Siddique (38y, Male) - 9145374931

Date : 11-Dec-2023

Complaints: F/UP CASE OF IBS D , NOW SINCE DECREASED MEDICATION - 2-3 STOOLS / DAY , LOOSE , STARTED LIBRAX -
BETTER , SINCE SUNDAY LOOSE STOOLS + MUCUS , HAD ACUTE INFECTIVE DIARRHEA - TREATED WITH ANTIBIOTICS , ATER
THAT WAS BETTER BUT AFTER HAVING PANNEER KI SABJI - AGAIN SYMPTOMS , MAROD AND LOOSE STOOLS , CRP 7.85 ,
CBC 11.4/6100/64000 , ESR 28 , STOOL R/E 1-2 PUS CELLS , REVIEW 26 SEPT - NOT WELL , LOOSE STOOLS , WATER ,
MUCUS , GAINS WEIGHT WHEN EATS , NOW NOT EATING , VIDEO REVIEW 16 NOV 22 : WEIGHT 40 KG , CBC CRP : NORMAL
, REVIEWED 5 DEC VIDEO CALL : HAS BECOME PREGNANT , SAFETY OF PROTHIADEN / RAMOSETRON AND CINITAPRIDE IS
NOT ESTABLISHED IN PREGNANCY , ADV TO STOP CINTODAC / IBSET / PROTHIADEN / LIBRAX , DISCUSSED WITH PATIENT :
DOESNT WANT T CONTINUE PREGANCY - ADVISE TO CONSULT A GYNAECOLOGIST AT THE EARLIEST FOR MTP , VIDEO
CONSULT : 13 FEB 23 : REVIEWED UNDERWENT MTP : IX CBC 12.9/5500/193 , ESR 14 , GLYCO HB 5.7 , TSH 3.80 ,
STOPPED MEDICATION X 15 DAYS - REMAINED STABLE , SINCE TUESDAY - MUCUS + STOOL , REVIEWED 11 APR : LIFTED
HEAVY WEIGHT - 5 KG , SINCE THEN MAROD IN ABDOMEN , MUCUS IN ABDOMEN , STOOL 2 /DAY , REVIEWED 9 SEPT 23 :
WEIGHT GAIN 46 KG , HAS DYSURIA / INCREASED FREQUENCY , HAD CONSTIPATION , TSH 3.78 , LFT / KFT : NORMAL ,
STOOL NORMAL , CBC 11.9/7200/115 , REVIEWED 11 DEC 23 : OK COLICKS IN ABDOMEN , INTERMITTENT FEEL OF LOOSE
STOOLS
Diagnosis: IBS D, THROMBOCYTOPENIA - RESOLVED

Medicine Dose Timing - Freq. - Duration

1 TAB CINTODAC 1—0—0 Before Food - daily

Composition : CINITAPRIDE 3 MG + PANTOPRAZOLE 40 MG

2 TAB IBSET 1—0—0 After Food - daily

Composition : RAMOSETRON 5 MCG

3 TAB LIBRAX / BENIZEP / CIZASPA-X 1—0—1 After Food - daily

Note: / SOS

4 TAB PROTHIADEN 25 MG 0—0—1 After Food - daily

Composition : DOTHIEPIN 25 MG

5 CAP EFEGUT 1—0—0 After Food - daily

Composition : BACILLUS MESENTERICUS 15 MILLION CELLS + CLOSTRIDIUM BUTYRICUM 15 MILLION C...
6 CAP ZONYO CAL (CALCIUM 0—0—1 After Food - alternate day
CARBONATE 1250 + VIT D 1000 +
VIT B 12 1500)

7 TAB PRACTIN 4 MG 1—0—1 After Food - daily

Powered by HealthPlix EMR. www.healthplix.com

 1041 : Mr.Afreen Siddique (38y, Male) - 9145374931
Date : 11-Dec-2023

Composition : CYPROHEPTADINE 4 MG
8 TAB MEDIGAS / ESPUMISAN GOLD 1—0—1 After Food - daily - 20 Days
Composition : SIMETHICONE 140 MG
Note: BLOATING

Tests Prescribed: CBC ESR CRP

Next Visit: 2 months

DR.NISHANT NAGPAL

Powered by HealthPlix EMR. www.healthplix.com