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
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