JINDAL HEART INSTITUTE

&INFERTILITY CENTRE
A Vnit of whatmda Wealtheara n 1nd, mathinda

Carug touch...

DISCHARGE SUMMARY

NAME:TIRLOK CHAND AGE: 70 Years/Male REG. NO.:JH2003232

ONTACT NO. 94662-23181 IPD NO.:- 26445
ADDRESS:WARD N.9,NEAR OLD HANUMAN MANDIR, MANDI DABWALI.
ATE OFADMISSION: 13/03/2021 (07:10 AM) DATE OF DISCHARGE: 17/0:/2021

AGNOSIS DM (New Onset)

CAD/ Ac.AWMI (STEMI)
LVEF 25%/ Sev.LVD/ Ac.LVF
TVD/ (S.Cr. 1.4)
ROCEDURE CART done on 15/03/2021
MEDICATION 1 TAB.PANTOPRAZOLE 40 mg once a day (Before Break Fast).
2 TAB.AVAS 40 mg once a day
3 TAB.ECOSPRIN 75 mg once a day (x3 days). a
4 TABMONIT GTN 2.6 mg twice a day.
5 TAB.RACË 1,25 mg oncea day.
6 TAB.DYTOR PLUS 10 mg oncea day.
7 TAB.ZORYL M1 once a day.
8 TAB.FERONEM ER 300 mg twice a day.
9TAB.LEVOFLOX 500 mg once a day.
10 INJ.L.M.W,X 60 mg S/C once a day (x1 day).
11 NEBULIZATION DUOLIN+BUDECORT thrice a day.
12 STEAM INHALATION thrice a day.
13 SPIROMETERY EXERCISE thrice a day.

All above treatment for 2 days. 2thindo

HISTORY: 70 Yr old male patient known case of Non HTN /Non DM hospitalized with chief
was

chest pain dyspnea exertion. 12 leads ECG showed

omplaints of severe dyspnea since morning,
to our hospital for further management.
(AWMI). Regarding these complaints, patient brought
COURSE IN THE HOSPITAL 2D ECHO done on 13/03/2021 which revealed (Dyskinetic
LV clot). 2D
RCA/Akinetic LAD/Hypokinetic LCX/ LVEF 25%/Mild MR/Collapsing IVC/No
ECHO done on 14/03/2021 which revealed (Dyskinetic RCA/Akinetic LAD/Hypokinetic LCA
LVEF 25%/ Mild MR/Collapsing IVC/No LV clot). CART done on 15/03/2021 which revealed
TVD. Patient managed with antiplatelet ,anticoagulant, Insulin, PPI and with other supportive
was uneventrul
medicines. Patient gradually improved on treatment. His rest of the hospital stay
and he is being discharged in a stable condition with advise daily blood sugar monitring
P.T.O
 low cholesterol, low fat diet
Diet advine-By Dietician: 1 Patient being discharged on

2 Diet chart attached along

3 All the queries related to diet duely adressed
4 Next dietry advise on next OPD Visit.

LABREIPORTS:
INVISTIGATION 1oy2021 14/0y/2021 15/0/2021 16/03/2021 17/03/2021
12.1 12.3 |2.9
113
146 14.2 16,8
2H 7 20

538 542 558 509

SHI,165,240 123 mg/d 250,62,114,145 130,217 104 mg/dl

g/d mg/di mg/di
40 40
URIA 15
1.6 1.4
.REATININE
9URUBIN 085
.0.1 54

SGPT 7
HAI 12.4

MB 27
hI1ONE BODIES Negative
2.93
Na 134 139 140 137
K 4.2 3.6 3.5 4.4
Ca 4.75 4.85 4.87 4.84

HBAg Non-Reactive
HCV Non-Reactive
HIV (12) Non-Reactive

ADVISE:1 Review in opd with prior appointment.

2 All appointments to be taken from hospital reception (Ph. 2211111,
2213111).
3 Patient is advised to visit the hospital with discharge summary.
4 Review after 2 days (Saturday).
5 Advise CABG.

IN CASE OF EMERGENCY: If patient has Chest pain, Sweating, Palpitation, Faintin, Dizz
Difficulty in breathing, Please contact at- ICU NO- 87258-83332.
DR. RAJESH KUMAR JIN
DM (CARDIOLOGY),
JIDRARAE&M JANDAL
Dete 17/03/2021 cONSEHANTSRI
UNTT
BATHINDA HEALI
PVT. LTD., BATHINDA
 JINDAL HEART INSTITUTE
&INFERTILITY CENTRE
A Unit of Bhatinda Healthcare ut. Ctd, Bathinda

caring touch....

ANGIOGRAPHY REPORT
NAME:MR: TIRLOK CHAND AGE: 70Y
REG. NO.: JH2003232 SEX:MALE
CATH N0.:10188
IPD NO.: 26445 DATE:15/03/2021
CATHETER: Tig Sfr
DYE: VISIPAQUE
ROUTE: Right Radial Artery.
CLINICAL DIAGNOSIS :CAD/ Acute AWMI/ Unstable
angina.
PRESSURE:
AO mmHg 120/70 LV
RA
mmHg PA mmHg PCW mmHg
mmHg
**8 RV mmHg LA mmHg
LV ANGI0: LAO VIEW Not done, RAO VIEW- Not
done

ANGIOGRAPHIC RESULT:

LMCA Normal
LAD Calcified vessel, 90% stenosis in proximal to mid vessel.
D1 95% stenosis in ostial vessel.
LCX Calcified vessel, 50-60% stenosis in proximal vessel. 70-80%
stenosis in mid vessel.
OM1 100% occlusion in ostial vessel, filling
retrogradely.
OM2 Normal.
RCA 100% occlusion in proximal vessel, filling retrogradely.
PDA Filling retrogradely.
PLV Filling retrogradely.
DOMINANCE: Right.
CONCLUSION : Triple vessel disease.
RECOMMENDATION: Myocardial revascularization(CABG). JINDAL

KUMAR

DM (CARDIOLOGY)
RAJESH
INSTITUTE &
DR.
NENTRYGENTRE,
BATHINDA

HEART

BPAL

CONSULTÄNTARDföLoGIST

REGD.OFFICE :#21373,POWER HOUSE ROAD, BATHINDA. PH. 0164-22111 FAX:0164-221311 Mob.87258-8331,94171-59275

 JINDAL HEART INSTITUTE CORONARY ANGIOGRAM
&INFERTILITY CENTRE
(A Unit of Bhatinda Healthcare Pvt. Ltd., Bhatinda)

Power House Road, Bathinda 151001

Ph.0164-2211111, 2213111 Fax: 0164-2213111

Cath No. 200323 Anglo No. .LBE ****************** Date. ISl03/202

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RCA RV
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CX
OM-2
LAD
AM

LVANGIOGRAM
AO
N-NORMAL AO
A-HYPOKINESIA
LV
B-AKINESIA

C-DYSKINESIA

D-ANEURYSUM LV

LAO