P. D. HINDUJA NATIONAL HOSPITAL & MEDICAL RESEARCH CENTRE {Established and managed by the National Health & Education Society) ‘EER SAVARKAR ARG, MATIN NOMBAT «00076, NOTA DISCHARGE SUMMARY / CARD ‘Name : SIVAMI JAY PATAKA ‘Age: 59 Sex. HH No 1029139 ‘Agmission No 1088226 ‘Admission Date 20/10/2008 Discharge Date Location 5No FINAL DIAGNOSIS: Ponte nemormage Diabetes Hypertension Heptats C Pancylopenia Early ewonc liver disease. CHIEF COMPLAINT AND HISTORY: ‘The patients 59-year-old male, 2 known case of hypertension since 4-6 yts on regular medications {or the same. Known case of ciabetes since one year on medications, Past history of @ neck injury approximately 20jrs ago tha requires surgery and tracheostomy for @ short period of tme. Comes ‘now with complaints of sudden onset change in sensocum since 2.30 am on 23/%0I08. relatives ‘noticed the patent calling for help inthe maraing fold by altered senaortum. The patent was fonly drowsy responding partly ta verbal commands Thers mx pa history nf vomiting or eenvulsan NNohistory of chest pain or breathlessness, PERTINENT PHYSICAL FINDINGS: On examination Patent was drowsy Responding only @ paefl stimuli Pulse 80min BP -220/110mmHg RR24Imin {IVP was normal ‘No edema feet (CNS examination Patient had eye opening to painful stimu and was moving al four mb PIA~ Soft CChest~ Bilateral bronchospasm with basal crepts (Cvs ~ S182 norma (COURSE IN THE WARD ‘The patient was admitted wit these complaint into the ICU. ‘The patent underwent CT scan brain plan on 23/1008. A centr ‘surrounding edema and intraventrculat extension into. the hematoma is also seen in the right external capsule region, In View of these findings and the patients G-CSF was ETNGV'. In view of these patent was elecivly intuboted and ventlated in view of the long tem requirement of ventilation and surgical tracheostomy was done on 30/102008 by Or A Shukla The patient remained in the ICU, he had uliple episodes of sepsis which was treated with anttiotes as per te culture reports, had icy weaning fom the vetlator due to lel ioworlbe collapse, Opin of chest physician Or 2 F Udwacia was taken who advised a conservative management intial and just advised chest Physiotherapy slong with inhalers. The patent on investgaton was found 10 have decreasing ‘counts. Opinion of Or Bhave, Hematoloist was taken. Patient recowed GICSF. WAC count remained approximately around 1800. The pation improved on conservative treatment inthe ICU ine hematoma with Fe venticle. ‘A smallerP. D. HINDUJA NATIONAL HOSPITAL & MEDICAL RESEARCH CENTRE (Established and managed by the National Health & Education Society) EER SRARRAR NANG. HARI MOWEAT—aG0Te IIR PRONE Daag 1815, 2e45 een 244e 9190 FAK 2044 9181 Patent was start on aT piece tral and inay was put on RT feeds andthe patent erated the RR feeds well and gradually started orally. The pabent was found to be HCV postive and was valid forthe same. HCV wal lad on 5/12I08 was found tobe 7 lac interatnal units perm Fis UrT done showed marginal elevated enzymes and a marginally low albumin Reference was taken ftom the GI team and decision was taken to treat the HCV after the patent Was sablized and currenty no treatment was stared. However, the patents LFT was monitored ‘eguary The patent was gradually started on physiotherapy frst at he bed side and ten in the department “The patent was then stepped down to the non ventiator ICU where the clinical, the patent improved n the focal defct His power mproved. He remained nemodynamicaly stable and hac no tresh Romodynamic as well a¢ neurological events. His WC as well as Patlets remained on the lower side "The patent was shifted fo he foors. On the Moors, he remand conscious, ‘ented. He did have evidence of right ded woakness, However, the weakness was improving Fe was taking oral well Hence tracheostomy was decarlated and the patients speech following Temoval of tracheostomy pation recovered wel, Now al discharge patient has bilateral horzortal base patsy wih the ight sed hemiparesis, power on upper mb 26 an lower imb 4/5, DISCHARGE ADVICE ‘Tab Nearda 10mg 1~ 1-1 Teo Urman04g HS ‘homey Ot ‘Somenst! ae Bip bopnate 30m 808 te to el ligm Boma detach irene pr oN Stans ese, once awk. Patients advised to folow up with Dr N E Shah, Or PP Ashok and Or Hegde, ‘Tofollow up with Or Pip Abraham for eament of Hepat C at a ater date @ DR. P.P. ASHOK. CONSULTANT-NEUROLOGIST —_-REIMRD/VRP 19/1208