lI Jai Sri Gurudev II
Adichunchanagiri Hospital & Research Centre
B.G. NAGARA – 571448. Nagamangala Taluk, Mandya District
DEPARTMENT OF ORTHOPAEDICS
DISCHARGE SUMMARY
NAME: RAGHU DATE OF ADMISSION: 18/12/2024
AGE: 37 years DATE OF SURGERY : -
SEX: Male DATE OF DISCHARGE: 22/12/2024
IP. NUMBER 23- 37049 ADDRESS: S/O SRINIVAS
CHOLENHALLI ,Nagamangla
UNIT : ORTHO -C UNIT CHIEF: Dr. HARISH
ORTHO - C ( OPD : Wednesday/Saturday)
DR. Harish K (Professor)
Dr. Bellad S H (Associate Professor)
Dr. Guruprasad shivanna ( AssistantProfessor)
Dr.Kiran (Senior Resident)
Diagnosis : CHRONIC LOWER BACK PAIN
CHIEF COMPLAINTS AND HISTORY OF PRESENTING ILLNESS:
C/O back pain since 1 week.
Patient was apparently alright 1 week back, he developed pain with is sudden in onset and
progressive in nature,mild to moderate in intensity,radiation back pain to B/L thigh, aggrevated on
work and relieved on taking rest and medication.
No H/o trauma elsewhere.
No H/O fever
PAST HISTORY
Not a K/C/O Tyep-2 Diabetes Mellitus,Hypertension,Asthma,Epilepsy and TB
CLINICAL EXAMINATION:
Vitals:
BP - 120/80 mmHg
PR - 82 bpm
RR- 16 cpm
Spo2-98 %@RA
Local Examination
Gait – Antalgic gait
Attitude - Patient examined in supine position
Head, neck and trunk all aligned in midline
Both shoulders at same level
B/L ASIS are at same level
LS SPINE
Examination. Right. Left.
1.SLRT 70*. 80*
2.Patricks Negative Negative
3.EHL. 5/5. 5/5
4.FHL. 5/5. 5/5
Motor Examination
Hip
1.Felxion-B/L Normal
2.Extension-B/L Normal
3.Adduction-B/L Normal
4.Abduction-B/L Normal
5.Internal Rotation-B/L Normal
6.External Rotation-B/L Normal
Knee
1.Flexion-B/L Normal
2.Extension-B/L Normal
Ankle
1.Plantar flexion-B/L Normal
2.Dorsi Flexion-B/L Normal
3.Inversion-B/L Normal
4.Eversion-B/L Normal
Sensory Examination
L1-B/L Normal
L2-B/L Normal
L3-B/L Normal
L4-B/L Normal
L5-B/L Normal
S1-B/L Normal
S2-B/L Normal
Systemic examination:
CVS: S1 S2 heard, no murmurs,
CNS: conscious, oriented
P/A: Soft, non-tender, Bowel sounds present
RS: B/L normal vesicular breath sounds, No added sounds
INVESTIGATIONS:
DATE:
Hb (Hemoglobin) - UREA -
TLC - CREATININE -
DC - SODIUM -
PLT - POTASSIUM -
Pcv - CHLORIDE -
ESR - LFT -
BT - HIV -
CT - HbsAG -
PT - HCV -
INR - BLOOD GROUP -
APTT - URINE ANALYSIS -
RBS -
FBS/PPBS
Xray shows- Loss of lumbar lordosis
Treatment : CONSERVATIVE MANAGEMENT
● Inj ZERODOL T IV 1-0-0 for 6 days
● Inj DYNAPAR IV 1-0-1 for 6 days
● Inj Nervijen P 0-0-1 for 6 days
● Tab Pregaba 0-1-0 for 6 days
CONDITION AT DISCHARGE:
● Pain subsided
● ROM improved
● Active toe movements present
● Sensations present
● Distal pulses felt
● No DNVD
COURSE IN HOSPITAL:
Patient was admitted under Ortho C unit with above mentioned complaints. Relevant
radiological investigations were done. He was diagnosed with CHRONIC LOWER BACK
ACHE and conservatively treated. Patient is now fit for discharge.
ADVICE ON DISCHARGE:
● Physiotherapy
Low Back exercise
● Tab.PAN 40 1-0-0 for 5 days
● Tab.Nervijen P 0-0-1 for 10 days
● Tab.PreGaba 0-1-0 for 10 days
Review in ORTHO-C OPD on 27/12/23 Wednesday for review.
FOLLOW-UP: Further follow up in Orthopaedics on Wednesday and Saturday
IF ANY OF THE FOLLOWING “WARNING SIGNS” LIKE EXCESSIVE PAIN, FEVER,
DISCHARGE, AND SWELLING OCCUR PLEASE CONTACT ON THE DETAILS GIVEN
BELOW IMMEDIATELY.
IN CASE OF EMERGENCY/URGENCY PLEASE CALL
WRITTEN BY: Dr. Gagan B R
VERIFIED BY: Dr. K Harish
SIGNATURE OF UNIT CHIEF
