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    Discharge Summary (2)

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    1980006

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    Discharge Summary (2)

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    1980006
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    Discharge Summary (2)

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    1980006

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    You are on page 1of 4

    KIMS102412030351

    Discharge Summary
    Dept. of GENERAL MEDICINE

    General Information
    Head of the Dept : Dr.SHUBHRANSU PATRO Admitting : Dr Rabinarayan Rout
    Doctor/
    Consultant
    Treating Doctor : Dr Rabinarayan Rout
    Unit : V D.O.A : : 03-DEC-24 01:32 PM
    Unit Head : Dr.DIPTIMAYEE TRIPATHY D.O.D : 08-DEC-24 08:36 AM
    Name of Patient : Mrs ANNAPURNA MUDULI IP No : ADNKIMS102412030095
    Age/Sex : 37 Yrs 7 Mnth 29 Days / FEMALEMobile No : 8658830148
    Address : BALASORE ODISHA INDIA

    Patient's History
    Clinical Profile: A 37 year old female presented with the complaints of low backache for 2 months.

    History of present illness- The patient was apparently alright 2 momths back to start
    with she developed low back ache .

    History of past illness- Known case of htn,T2DM,OLD ISCHEMIC stroke(15 yrs


    back),DVT.
    Family history - No significant family history.
    Personal history - Mixed Indian diet, adequate appetite, no weight loss/gain , regular
    bowel and bladder, normal sleep. No known allergies.

    General physical Examination:


    No pallor, no icterus, no cyanosis, no clubbing, no edema ,no lymphadenopathy, no
    koilonychias
    BP: 116/82 mmHg ,PR:86 bpm, RR; 16 min

    Systemic examination:
    CNS- Conscious ,oriented,cooperative
    E4V5M6

    Page 1 of 4
    KIMS102412030351

    B/l plantar flexor


    B/L pupils RTL
    No FND
    CVS-S1, S2 heard , No murmurs heard
    RS-Bilateral Vesicular breath sounds present, No added sounds
    P/A-Soft, non-tender, no organomegaly , Bowel sounds present .

    Final Diagnosis E10-E14 : Diabetes mellitus


    I10 : Essential (primary) hypertension
    I82.9 : Embolism and thrombosis of unspecified vein

    SARS-COV-2:

    SURGERY/(if any)/Course in Patient presented with all the above mentioned complaints. All the relevant
    the hospital: investigations were done. APLA profile was done which was negative. MRI LS spine
    with whole spine screening was done which showed bilateral facet joint arthropathy
    (left >right) and ligamentum flavum hypertrophy causing bilateral neural foraminal
    narrowing (left >right) and indentation of bilateral exiting nerve roots (left > right) at
    L4-L5 level. Cervical spondylosis. Doppler(arterial and venous) of bilateral lower limb
    was done which showed . 2 D ECHO was done which showed concentric LVH
    with grade 1 diastolic dysfunction. Patient improved symptomatically, accepting orally
    well and is now being discharged in a clinically and haemodynamically stable condition.
    FINAL DIAGNOSIS
    Type 2 DM
    HTN
    DVT
    Old CVA

    Type of Discharge: Normal Discharge

    Advice On Discharge
    Diet: Diabetic Low salt diet.

    Follow up: Review in medicine opd after 2 weeks Tuesday/Friday.

    Physical activity: As tolerated.

    Medication:

    Page 2 of 4
    KIMS102412030351

    TAB.CITANIL-TRIO (6.25) 1 TAB PER ORAL ONCE DAILY TO CONTINUE


    TAB.ABAXIS 5 MG 1 TAB PER ORAL ONCE DAILY TO CONTINUE
    TAB.GLYCOMET-SR 500 MG 1 TAB PER ORAL ONCE DAILY BEFORE
    BREAKFAST TO CONTINUE.
    TAB.PANTOP 40 MG 1 TAB PER ORAL ONCE DAILY BEFORE BREAKFAST
    FOR 10 DAYS.
    TAB.GABAPIN-NT (200/10) 1 TAB PER ORAL ONCE DAILY AT BED TIME.
    CAP.DV 60K 1 CAP ONCE WEEKLY FOR 8 WEEKS.
    TAB.ATORVA 20 MG 1 TAB PER ORAL ONCE DAILY AT BEDTIME TO
    CONTINUE.

    Miscellaneous(If any): TREATING DOCTORS:


    PROF DR LALATENDU MOHANTY
    PROF DR CBK MOHANTY
    DR B R P RAO
    DR R N ROUT
    DR GYANAMITRA PANIGRAHI
    DR SARTHAK MISHRA
    DR ANANYA MOHANTY
    DR RAJDEEP SARKAR

    Investigations: Attached and handed over to the patient.

    Radiology Notes :

    Radiology Service DATE


    DOPPLER ARTERIAL AND VENOUS LOWER LIMB 2024-12-05 14:22:37.581
    BILATERAL
    ECHO WITH FILM AND REPORT 2024-12-04 11:38:48.931
    MRI L S SPINE WITH WHOLE SPINE SCREENING 2024-12-04 08:57:39.496
    X RAY CHEST PA 2024-12-04 00:32:56.285

    Prepared By (Name & Dr.Oman(PGT1)


    designation): Dr.Shibsailam(INTERN)

    Dr Rabinarayan Rout
    GENERAL MEDICINE
    Treating Doctor

    Page 3 of 4
    KIMS102412030351
    Please understand your discharge prescription from your doctor before using the medicines.
    You can contact Emergency Room Physician, KIMS HOSPITALS

    Page 4 of 4

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