DEPARTMENT OF MEDICINE

Medicine Unit- I
ALL INDIA INSTITUTE OF MEDICAL SCIENCES NEW DELHI-110029
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DISCHARGE SUMMARY
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NAME: RAM CHANDRA SHRIVASTAV UHID:105285356
AGE: 82 YEARS/M BED NO: PW3/307
D.O.A:27/06/2023 D.O.D: 05/07/2023

DIAGNOSIS:
 Iron Deficiency Anemia (Hb-9.7)
 Type 2 Diabetes mellitus (HbA1c-7.14)
 Old Ischemic CVA(2020)- No residual neurologic deficit
 H/O SDH (2021) No residual neurological deficit
 Hypertension (Controlled)
 SOBT positive (17/6/2023) No source of bleed identified

History and physical findings at presentation:

82 years male, known case of hypertension and Type 2 diabetes mellitus presented to AIIMS
emergency on 15/06/2023 with scute onset chest pain following which he was evaluated and admitted
with diagnosis of ACS-NSTEMI in cardiology department where he was managed accordingly 15 days
back. During that time, he had severe anemia with hemoglobin 6.5 and on evaluation, Stool for occult
blood was positive. He had multiple episodes of passage of black coloured stool 1 month back. He was
then transferred to medicine department for further evaluation and management.

On Examination:

Afebrile
GCS-E4V5M6
PR- 110 bpm
BP- 130/80 mm Hg
RR- 20/min
SpO2-98% in room air
No pallor, icterus, cyanosis, clubbing, edema, No ln palpable.
Urine output: Adequate
CRT:< 2 seconds

Systemic Examination:

CVS: S1 S2+, no murmur heard.

RS: B/L air entry equal, NVBS, no added sound were heard.
PA: Soft,non-distended, no organomegaly
CNS: B/L pupils equally reactive to light , Power Right elbow, shoulder knee ankle-5/5, Left shoulder
4/5, Left elbow 4/5 Knee 4/5 Ankle 4/5
Treatment given and hospital course:
Patient was admitted with above mentioned complains. Gastroenterology advice was taken and Upper
GI endoscopy, Lower GI endoscopy was done which showed normal findings. Capsule endoscopy was
also performed which showed normal findings. CECT abdomen with Enterography + Angiography
was doe which showed no evidence of any stricture or bleed. He received one pint of PRBC on
27/06/23. Patient is now hemodynamically stable and is being discharged with following advice:

Advice on discharge:
 Follow up in medicine OPD in 2 week under Medicine I in Monday/Thursday with report of
CBC, LFT, RFT.
 Follow up in Gastroenterology OPD
 Follow up in Cardiology and Neurology OPD
 Diabetic diet, Low salt diet and Regular exercise
 Collect formal report of CECT Angio- abdomen with enterography from CT8 in 1 week.
 Visit AIIMS emergency in case of hematemesis, dizziness, SOB, or other emergencies.

SN Medicine DOSE Frequency Duration

1. Tab Met XL 25mg OD To continue
2. Tab Glimepiride 1mg OD To continue
3. Tab Metformin SR 1gm BD To continue
4. Tab Sitagliptin 50mg BD To continue
5. Tab Telma 40mg OD To continue
6. Tab Ecospirin 75mg HS To continue
7. Tab Storvas 40mg HS To continue
8. Tab Silodol- D 1tab HS To continue
9. Tab Pantop 40mg BBF To continue
10. Tab Autrin 1tab Alternate day 2 months

INVESTIGATIONS:

Date 15/06/2023 27/06/2023 04/07/2023

Hb(SLS-photometry) 6.5 g/dL 8.0 g/dL 9.7 g/dL
HCT
24.1 % 27.4 % 34.9 %
(DirectMeasure)
RBC COUNT
3.12 10*6/uL 3.73 10*6/uL 4.46 10*6/uL
(Impedance)
T.L.C
(Fluo.flowcytometry 9.58 10*3/uL 8.89 10*3/uL 9.20 10*3/uL
)
PLATELET COUNT
341 10*3/uL 405 10*3/uL 410 10*3/uL
(Impedance)
MCV (Calculated) 77.2 fL 73.5 fL 78.3 fL
MCH (Calculated) 20.8 pg 21.4 pg 21.7 pg
MCHC (Calculated) 27.0 g/dL 29.2 g/dL 27.8 g/dL
RDW CV
19.6 % 19.7 % 21.4 %
(Calculated)
 NEUTRO
(Fluo.flowcytometry 64.3 % 68.4 % 67.7 %
)
LYMPHO
(Fluo.flowcytometry 23.1 % 20.5 % 21.3 %
)
MONO
(Fluo.flowcytometry 9.7 % 8.1 % 7.9 %
)
EOSINO
(Fluo.flowcytometry 2.5 % 2.4 % 2.7 %
)
BASO
(Fluo.flowcytometry 0.4 % 0.6 % 0.4 %
)

Date 15/06/2023 19/06/2023 04-07-23

Urea 16 mg/dL 14 mg/dL 20 mg/dL
Creatinine 0.8 mg/dL 1 mg/dL 0.8 mg/dL
Uric Acid 4.4 mg/dL 4.6 mg/dL 4.9 mg/dL
Calcium 8.0 mg/dL 9 mg/dL 8.6 mg/dL
Phosphorus 3.2 mg/dL 3.3 mg/dL 4.1 mg/dL
Sodium 137 mmo/L 139 mmo/L 136 mmo/L
Potassium 4.1 mmo/L 4.8 mmo/L 4.4 mmo/L
Chloride 107 mmo/L 103 mmo/L 104 mmo/L
Bilirubin (T) 0.61 mg/dL 0.33 mg/dL 0.4 mg/dL
Bilirublin (D) 0.52 mg/dL 0.12 mg/dL 0.20 mg/dL
Bilirubin (I) 0.09 mg/dL 0.21 mg/dL 0.2 mg/dL
ALT 24 U/L 24 U/L 27 U/L
AST 36 U/L 30 U/L 38 U/L
ALP 71 U/L 82 U/L 86 U/L
Total protein 7.2 gm/dl 7.7 gm/dl 7.6 gm/dl
Albumin 3.7 gm/dl 3.9 gm/dl 4.0 gm/dl
Globulin 3.5 g/dL 3.8 g/dL 3.6 g/dL

HbA1c (16/06/23) 7.14 %

STOOL OCCULT POSITIVE

BLOOD (17/06/2023)

PT /INR( 3/07/23) 12.6 sec/1.075

Tests 04/07/23
Iron 32mcg/dl
Transferrin 302mg/dl
Ferritin 58.7 ng/ml
TIBC 381mcg/dl
Vitamin B12 847pg/ml
Serum Folate >20 ng/ml
Vitamin D3 49ng/ml
Transferrin Saturation 8.3%
TSH 0.58 micro IU/ml
T3 119 ng/dl
T4 10.7ng/dl

UGI endoscopy ( 06/17/2023) Normal Study

Colonoscopy (06/28/2023) Normal Study
Capsule Endoscopy (03/07/2023) Normal Study
CECT abdomen enterography with Angio Provisional: No evidence of stricture or
source of bleeding. No enlarged lymph nodes

JUNIOR RESIDENT SENIOR RESIDENT