Discharge Report







LAMA SUMMARY


 Name of patient : MR. RAVINDER GOYAL cr no. : ISHHI111112
 age/ sex : 50 YRS / MALE ward / bed No. : DIALYSIS / DIAL-8
 date of admission : 10-Sep-08 date of discharge : 01-Jan-01
 consultant/ surgeon : DR. RAMESH JAIN (MBBS,MD,DNB)
 
DIAGNOSIS
  ? TIA  ?   Seizure  disorder
 
 
PRESENTING COMPLAINTS - ( WITH WHAT COMPLAINTS ADMITTED FOR, IN DETAILS )
 

Patient  admitted  with  complaints  of altered  sensorium, gait  instability.

 
 
PRESENT HISTORY OF ILLNESS
  Patient  admitted  with  history of  transient  altered  sensorium  with vertigo with gait  instability in the  morning.
 
 
PAST HISTORY
 

Nothing  Significant

 
 
FAMILY HISTORY
 

Nothing  Significant

 
 
GENERAL PHYSICAL EXAMINATION
 

Patient Conscious Oriented

General Examination

GC

--

Fair

No Clubbing

Pulse

--

87/min, reg

No Cyanosis

B.P

--

130/80 mmhg

No Pallor

Temp

--

Afebrile

No Lympadenopathy

 

 

 

JVP – Normal

 
 
SYSTEMIC EXAMINATION
 

Chest

--

B/L  Clear

CVS

--

S1S2   (N)  

CNS

--

Gait  instability (+), No Neurological  deficit

P/A

--

Soft, BS(+)

 

 

 

 
 
INVESTIGATIONS / REPORTS
 

All reports attached and  handed  over  to the  patients  attendants & photocopy  is  attached  with file.

 
 
TREATMENT GIVEN
  Inj.  Pantodac, Inj. Diazepam,  Tab. Clopitab – A, Tab. Vertin,  Tab. Epilex Chrono
 
 
DISCUSSION / COURSE IN THE HOSPITAL
  Patient  improved after the  treatment   and  discharged in satisfactory  condition
 
 
ADVISE AT DISCHARGE
 

Tab. Clopitab –A  75 mg

--

OD

 

  x    5 days

Tab. Vertin 8 mg

--

BD

Tab. Epilex Chrono  300 mg

--

BD

Cap. Becosule –Z

--

10D

 
 
NEXT REVIEW
 

Review with  Dr. P.K.Malhotra  / Dr. Rajiv  Dewan  in  M- OPD Monday / Thursday after  5  days.

 

 

 

 

DR. P.K. MALHOTRA (M.D.)

DR. RAJIV  DEWAN (M.D.)

(CONSULTANT – PHYSICIAN)

(CONSULTANT – PHYSICIAN)

MCI No. 20558

MCI No. 9124