Case Summary

Patient Name : MRS. SATISH ARORA Admission Date : 26-Apr-23 12: 29 PM

Age : 75.6 YRS / FEMALE : -
UHID No : 170266 Husband : BAL KRISHAN AHUJA
IP No : 33789 Panel : ECHS New NABH
Department : PHYSICIAN Prim Consult. : Dr. VIVEK TAYAL

Discharge Type :
MLC No(if App.) :
Patient Mo. No. : 07895819277
Doctor Mo. No 9818405502

Final Diagnosis
Back pain ? Vertebral Compressed Fracture D11
Uncontrolled T2DM
Hypothyroidism

Presenting Complaints
Patient was admitted with the c/o Fever with chills a/w weakness in B/ L lower limbs with swelling and unable to walk with
dyspnea.
H/O- Fall in washroom 10 days back
Drug Allergy
Not known

History Of Past Illness

K/C/O - CAD S/P PTCA(12 yrs back)/LVEF-35%
- T2DM
- Hypothyroidism

Family History
Nothing significant

Examination Finding On Admission

GC- sick
BP -150/90 mmHg , P- 100/min , T -101* f
Chest -B/L Chest AE+ , CVS - NAD , CNS - NAD
P/A- Soft ,tenderness+
L/E- B/L Pedal edema +
- B/L Lower limb Power 4/5

Hospitalization Summary
Pt admitted with above said complaints , all relevant investigation were done , CRP-42, ESR-24, S.TSH-5.81,
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IP No
: 33789 Patient Name : MRS. SATISH ARORA
Admission Date : 26-Apr-23 12: 29 PM Panel : ECHS New NABH
Discharge Date : -
Prim Consult. : Dr. VIVEK TAYAL
CBC/LFT/KFT-WNR, HbA1C-7.2, NT Pro BNP-129
CXR also done .
Orthopedics opinion was taken from Dr. Rajesh Thiyam and advise ensured.
X Ray B/L Hip joint and Xray LS Spine AP/Lat view was done which s/o - ? Vertebral Compressed Fracture D11 Inj
Vitamin D3 6Lac unit i/m given on 28/04/2023.
Echocardiography showed Normal size cardiac chambers, Mild LVH, Mitral leaflets are thickened, Mild MR, Trace TR,
Posterior wall ,inferior wall are severe hypokinetic , LVEF- 40 %, Grade I LV diastolic dysfunction, Intact IAS/IVS, No
PE/Clots/Vegetations seen, IVC is normal
Regular RBS - vitals - were monitored, with strict I/O charting done
Pt treated with Inj Monocef, Inj Pantop, Inj Neurokind gold, Inj Ally, Inj Human Actrapid, Inj Lantus, Cap Ecosprin Gold, Tab
Thyroxin, Tab Dytor plus, Tab Dytor, Tab Retoz MR and other supportive care . Patient is in ICU and requires hospitalisation
for further management with neurosurgeon intervention.

Condition At the time of Discharge

Hemodynamically stable
Vitals - Stable
Accepting orally well
Advised- MRI LS Spine with whole spine screening.
Treatment given during hospital stay
Inj Monocef 1gm i/v twice
Inj Pantop 40mg i/v once
Inj Emset 4mg i/v thrice Inj
Ally 1gm i/v twice
Inj Neurokind gold 1amp i/v once
Inj Human Actrapid S/ As per sliding scale Inj
Lantus 24unit S/C At night
Tab Thyroxin 50mcg once
Cap Ecosprin Gold (75/75/20) At night Tab
Dytor plus (10/50) 1/2 tab once (8am) Tab
Retoz MR twice
Tab Careup LM twice Tab
Bonback forte twice Tab
MgD3 twice
Tab Onderomet 2.5/500 twice
Tab Neugaba NT 50mg at night
Gabafix gel L/A twice

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IP No
: 33789 Patient Name : MRS. SATISH ARORA
Admission Date : 26-Apr-23 12: 29 PM Panel : ECHS New NABH
Discharge Date : -
Prim Consult. : Dr. VIVEK TAYAL

DIAGNOSIS :

ICD ID Diagnosis Code Diagnosis Description

9172 S22.0 Fracture of thoracic vertebra

2655 E11.9 Non-insulin-dependent diabetes mellitus without

2598 E03.9 Hypothyroidism, unspecified

14762 Z95.5 Presence of coronary angioplasty implant and gr

RMO's Signature Dr. VIVEK TAYAL

PHYSICIAN
MAYOM Hospital Patient's Signature MBBS, DNB
( I have been explained regarding
discharge medicines and precautions)
Discharge Report Prepared By: Mr.ICU
*Report is invalid without sign and seal of concerned authority.
In Case of Emergency, Please Call on Emergency No 8860079523 or Hospital No 0124-4111880
End

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