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    Purnima Mishra Discharge Card

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    Purnima Mishra

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    Purnima Mishra Discharge Card

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    Purnima Mishra
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    24 views2 pages

    Purnima Mishra Discharge Card

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    Purnima Mishra

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    © All Rights Reserved
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    YASH0DA

    Super Speciality Hospitals


    DISCHARGE SUMMARY: YASHODA SUPERSPECLALITY HOSPITALS
    NAME OF PATIENT: MRS. PURNIMA MISHRA
    AGE/SEX: 54 YRS 1 DAYS/EMALE
    REG. NO. :601361 IP NO. :23/22129
    DOA : 02/10/2023 DOD : 07/10/2023
    BED NO. : 4045C
    ADDRESS : 330/204, SECTOR-4, VAISHALI GHAZIABAD UTTAR PRADESH
    DOCTOR INCHARGE: DR. SUMANTO CHATTERJEE
    FINAL DIAGNOSIS :
    TRAUMATIC CERVICAL CORD INJURY WITH SEVERE SPONDYLOSIS CHANGES

    REASON FOR ADMISSION:


    54 years old female patient a history of RTA on Thursday height (28/09/2023) was
    admitted
    with complaints of injury on forehead with stitches done for outside swelling bilateral upper
    limbs.
    ON EXAMINATION:
    Temp - 98.6°F
    PR - 86 /min
    BP - 140/80mmHg
    SPO2 - 99 % on room air
    RR - 20 /min
    RBS -99 mg/dl
    Chest - B/L AE (+)
    CVS - Sis2 (N)
    P/A- Soft, BS (+)
    CNS - Conscious/ Oriented

    COURSE OF STAY IN HOSPITAL: Patient was admitted with above mentioned complaints. All
    relevant investigations were done showed Iron -52.4, Vitamin B12- 2000,Vitamin D- 69
    TIBC-373.4, Transferrin - 14.03, X-Ray Cervical Spine was done report attached & managed
    accordingly. Neurosurgery reference was done by Dr. Amit Singh/ Dr. Divya Jyoti Sharma &
    advised for cord decompression but patient attendant refused for any surgical intervention now
    &managed on medical treatment only. Now patient is being discharged in stable condition.
    IMPORTANT SPECIAL &IMAGING INVESTIGATIONS: All reports attached.
    DETAILS OF CONSERVATIVE/ TREATMENT GIVEN with OPERATIVE FINDINGS:
    Patient was admnitted with above mentioned complaints. Patient thoroughly investigated and
    managed with V fluid, and other supportive measures.

    REG. NO. : 601361 IP NO. : 23/22129


    MRS. PURNIMA MISHRA
    1

    Adaress : H-1, 24, 26, 27,Kaushambi, Near Dabur Chowk, Ghaziabad-201010 Ph.:0120-4181900, 4189500, 08506069461
    For Enquiry: admin.yhk@yashodahospital.org " For Feedback : admin.yhk@yashodahospital org
    Website: www.yashodahospital.org
    NASHODA
    Super Speciality Hospitals
    cONDITION ON DISCHARGE WITH IDENTIFICATION OF SPECIAL NEEDS AND FOLLOW
    UP ADVICE:
    Patient is comfortable on discharge
    Afebrile , Vitals - Stable
    No fresh complaints

    DISCHARGE MEDICATION:
    MEDICATION MORNING AFTER EVENING NIGHT NO. SPECLAL
    NOON OF INSTRUCTIONS
    DAYS
    Cap. Duzella 30mg
    Tab. Topaz 25mg 5
    Tab. Pruvict 2mg 5
    Svp. Looz 20ml 5 For
    Constipation.
    Tab. Aquashine 24 Once a week
    Tab. Maxgalin ER 5 7pn
    150mg
    Tab. Lupirtin P 5

    Patient wa_ advised for neurosurgical cord decompression surgery.


    Raste 5 days
    FOLLOW UP INSTRUCTIONS (INCLUDING PREVENTIVE ASPECTS):
    Review in OPD with DR. SUMANTO CHATTERJEE after 5 days with CBC/LFT/KFT.
    Review in OPD with DR. AMIT SINGH / DR. DIVYA JYOTI CHARMA after 5 days with
    Reports.
    INSTRUCTIONS ON WHEN AND HOW TO RECEIVE URGENT CARE:
    Please contact CMO, Yashoda Superspeciality Hospitals, Emergency Services (0120 - 4181900,
    +91-8750056824) in case you develop Fever more than 101°F, Breathing difficulty, Vomiting,
    Altered sensorium, Discharge from Operated Site, Onset of new Pain or worsening of existing
    Pain, Chest Pain, Palpitation or Ghabrahat, Dizziness or Any other Medical Complaint
    Requiring Immediate Medical Attention

    DR. SUMANTO CHATTERJEE


    Signature of Primary Physician/Surgeon SR/ JR / Clinical Associate / RMO
    Department
    Date/ Time

    Acknowledgement by Patient or Attendant


    Date/ Time

    NOTE: THIS IS AN IMPORTANT DOCUMENT. PLEASE KEEP THIS FOR FURTHER


    REFERENCE AND BRING IT ALONG WITH YOUON YOUR NEXT VISIT.
    MT -Amit

    REG. NO. : 601361 IP NO. : 23/22129


    MRS. PURNIMA MISHRA
    2

    Address: H-1, 24.26., 27, Kaushambi, Near Dabur Chowk, Ghaziabad-201010 Ph.: 0120-4181900, 4189500, 08506069461
    For Enquiry : admin. yhk@yashodahospital.org " For Feedback :admin.yhk@yashodahospital.org
    Website: www.yashodahospital.org

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