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Cache DischargeSummary

Uploaded by

satveers211
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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You are on page 1/ 4

DISCHARGE SUMMARY

Patient MRN : 15010000487019 Admission No : INP-1501-2401000622


Patient Name : Mr. Rajendra Rundla Admission Date : 20/01/2024 11:40 AM
Gender/Age/DoB : Male , 30 Years , 15/07/93 Discharge Date : 22/01/2024 05:40 PM
Patient Phone No : 9983262200 Discharge Type : Normal Discharge
Referred By : -
Admitting Consultant : Dr. Surendra Singh(NEUROSURGERY)

FINAL DIAGNOSIS
PIVD AT L5/S1 (L>R)

ADMISSION REASON
Surgical Management

CHIEF COMPLAINTS & HISTORY OF PRESENT ILLNESS


Patient presented with complaint of low backache radiating to left lower limb. Now patient has been admitted
here for further evaluation and surgical management.

PAST MEDICAL HISTORY


Not Significant

PROCEDURE HISTORY
Not Significant

VITALS

Pulse Rate: 72/min


BP: 175/102mmHg
Height: 179 cms
Weight: 80 kg
Respiratory Rate: 20/min

ALLERGY
No food and drug allergy evident during the course of hospital stay

GENERAL EXAMINATION
Pallor: Nil
Cyanosis: Nil

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Mr. Rajendra Rundla (15010000487019)

GENERAL EXAMINATION
Clubbing: Nil
Icterus: Nil
Lymphadenopathy :Nil
Oedema: Nil

SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM-S1,S2 - Normal
RESPIRATORY SYSTEM- B/L Adequate air entry+
GASTROINTESTINAL SYSTEM- P/A - Soft, Non - tender, B/S present
CENTRAL NERVOUS SYSTEM- Conscious and well oriented

COURSE IN HOSPITAL
Pre op: Patient was admitted in Private ward with above mentioned complaints and was investigated accordingly.
PAC was done and patient was prepared for surgery.

PROCEDURE DONE: LUMBAR LAMINECTOMY (L5), LUMBAR DISCECTOMY (L5/S1) DONE UNDER GA ON 20.01.2024
BY DR. SURENDRA SINGH

Post op: Patient managed with Inj Monocef, Inj Amikacin, Inj Metrogyl, Inj Pantop, Inj Dynapar and other
supportive treatments. Patient is stable at the time of discharge.

CONDITION AT THE TIME OF DISCHARGE


Stable
Patient is stable at the time of discharge.

ADVICE AT DISCHARGE
Do not stop medications without consulting your doctor.
Discharge instructions about when and how to obtain urgent care: Visit to hospital on please call 0141-7122233.
Warning Signs – Fever, Chest pain, Palpitations, Shortness of breath, any bleeding, etc.

DIETARY ADVICE
Diet as per advice by Dietitian

THERAPY ADVICE
Discharge medicines
Tab CETIL CV 500 1xBD
Tab Gabapin NT 400 1xHS
Tab Benfostar CD3 1XHS
Tab Signoflam 1-0-1
Tab Pantocid 40 1xod
Tab Sporolac ds 1-0-1

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Mr. Rajendra Rundla (15010000487019)

THERAPY ADVICE
For 10 days

FOLLOW UP DETAILS

Physical Consultation for Dr. Surendra Singh (NEUROSURGERY) after 7 Days

EMERGENCY MANAGEMENT
Contact Details: In case of any queries or emergencies please contact, Phone No: 01417122233

CARE TEAM DETAILS

Dr. Surendra Singh


CONSULTANT
-
-

SIGNOFF DETAILS

Dr. Surendra Singh


CONSULTANT
NEUROSURGERY

This summary has been explained to me in a language that I understand, and a printed copy of the same has been
issued to me.

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Mr. Rajendra Rundla (15010000487019)

SIGNATURE DATE
NAME
RELATION

Prepared By:Dr. Abhinav Saraswat | Prepared On: 22.01.2024 13:33


Generated By: Bishna Choudhary | Generated On: 22.01.2024 17:42

Page 4 of 4

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