Medanta

Patient ID : BP00117698 Patient Name : Mrs. Baby Jha

Gender : Female Age : 53Y

Encounter ID : 10339571 Encounter Type : Inpatient

Admission Date : 05/09/2023 23:57 Location : 1st Floor Pre Cath (ICU)

Speciality : Cardiology Attending Practitioner : Dr Vijay Kumar

Discharge Summary
Date of discharge ¿ 11.09.2023

DIAGNOSIS:
Type 2 Diabetes Mellitus
Hypertension
CAD/AWMI (delayed presentation)
LVEF ¿ 35-40%
P/CAG (07.09.2023) ¿ SVD
P/PTCA + S to LAD (08.09.2023) - 3.5x15mm Onyx
ADHF ¿ Improved

ADVICE ON DISCHARGE:
1. TAB. ECOSPRIN 75mg 1 TAB DAILY AT NIGHT
2. TAB. BRILINTA 90mg 1 TAB TWICE DAILY AT MORNING & NIGHT
3. TAB. ATORVA 80mg 1 TAB DAILY AT NIGHT
4. TAB. IVABRAD 5mg 1 TAB TWICE DAILY AT MORNING & NIGHT
5. TAB. EPTUS 25mg 1 TAB DAILY AT MORNING
6. TAB. EZEDOC 10mg 1 TAB DAILY AT NIGHT
7. TAB. UDAPA 10mg 1 TAB DAILY AT MORNING
8. TAB. DYTOR 10mg 1 TAB DAILY AT MORNING
9. SYP. POTKLOR 15ml IN 30ml WATER THRICE DAILY FOR 3 DAYS
10. TAB. PAN 40mg 1 TAB DAILY AT BEFORE BREAKFAST

Review in Cardiology OPD on 16.09.2023 (11:30am) with CBC, KFT, Blood sugar fasting & PP reports with prior
appointment.
OPD are closed on Sundays/Holidays

ADMITTING COMPLAINTS:
Chest pain radiating to back associated with sweating & vomiting 3 days back
Shortness of breath since 3 days
AOE (II) since 1 month

COURSE IN HOSPITAL:
Patient 53 years old female admitted through emergency department with above mentioned complaints. All relevant
investigations were done. ECG s/o anterior wall STEMI, NSR. Patient was managed with Inj. Heparin, IV diuretic,
antiplatelet and other supportive measures. After stabilization and explaining the risk and benefit an informed consent
taken, CAG was done on 07.09.2023 which revealed SVD and advised for PTCA + S to LAD which was done on
08.09.2023. Post procedure was uneventful. Now patient is being discharge in hemodynamically stable condition with
advice.

ON EXAMINATION:
GC- Conscious SPO2-98% on room air.
Temp- Afebrile CVS-S1S2 (+)
BP- 130/70mmHg P/A- Soft, NT
Pulse- 84/min RS-B/L AE (+)

2D Echo (09.09.2023)

Authorized by Ujjwal Bhardwaj on 11 Sep 2023 10:38 This is a computer generated report. Signature is not required.

Regd. Of f ice: Global Health Patliputra Private Limited. T el: +91 11 4 4 11 4 4 11 Fax: +91 11 24 33 14 33
24 X7 help-line: +91 82922 22333 Emergency: 1068 Email: inf o@medanta.org www.medanta.org CIN: U74 999DL2015PT C283932
 Medanta

Patient ID : BP00117698 Patient Name : Mrs. Baby Jha

Gender : Female Age : 53Y

Encounter ID : 10339571 Encounter Type : Inpatient

Admission Date : 05/09/2023 23:57 Location : 1st Floor Pre Cath (ICU)

Speciality : Cardiology Attending Practitioner : Dr Vijay Kumar

1. Hypokinetic mid anterior septum and apex : LVEF-35-40%

2. Mild concentric LVH
3. No MR/MS
4. No AR/AS
5. Trace TR (PASP-25mmHg)
6. Mitral inflow pattern - Grade I diastolic dysfunction, raised LVEDP.
7. IAS/IVS intact
8. Normal aortic arch, No CoA.
9. Normal RV systolic function
10. IVC normal in size, > 50 % collapse with inspiration.
11. No intracardiac clot/vegetation/pericardial effusion seen

CAG ¿ 07.09.2023
LM: Normal
LAD: Proximal 100% cutoff
LCX: Non-Dominant, Normal
RCA: Dominant, Normal

Impression: SVD
Recommendation: PTCA to LAD

ALL DRUGS TO CONTINUE TILL NEXT VISIT.

Diet- as advised.

SPECIAL INSTRUCATION:-
All drugs may have some side effects discuss with your doctor before going home and unusual finding immediately.
Do not stop or alter any drug without Doctor¿s advice.
In Emergency (Chest Pain, Breathlessness, Palpitation, Syncope, etc) Report immediately to nearest Doctor/Hospital
or reach emergency at Jai Prabha Medanta at the earliest possible.
For further enquiries & appointment kindly contact @ 7870849974.
For details on CPR technique please log on to https://youtu.be/oi4_znOXaeQ

Dr. Pramod Kumar Dr. Ajay Kumar Sinha

MD (Medicine), DM (Cardiology) MD (Medicine) PGI Chandigarh,
Director & HOD Cardiology FRCP (EDIN), FACC, PhD (Med)
FESC, FCSI, FICC, FAPSCC, FACC
Sr. Consultant Cardiology

Dr. Vijay Kumar Dr. Pawan Kumar Singh

MD (Medicine), DNB (Cardiology), MACC MD (Medicine), DM (Cardiology)
Sr. Consultant Cardiology Consultant Cardiology

Dr. Shamshad Alam Dr. Shraddha Ranjan

MD (Medicine), DM (Cardiology) MD (Medicine), DNB (Cardiology)
Consultant Cardiology Consultant Cardiology

Dr. Shreyash Trived Dr. Sushil Kumar

MD (Medicine), DM (Cardiology) MD (Medicine), DM (Cardiology)

Authorized by Ujjwal Bhardwaj on 11 Sep 2023 10:38 This is a computer generated report. Signature is not required.

Regd. Of f ice: Global Health Patliputra Private Limited. T el: +91 11 4 4 11 4 4 11 Fax: +91 11 24 33 14 33
24 X7 help-line: +91 82922 22333 Emergency: 1068 Email: inf o@medanta.org www.medanta.org CIN: U74 999DL2015PT C283932
 Medanta

Patient ID : BP00117698 Patient Name : Mrs. Baby Jha

Gender : Female Age : 53Y

Encounter ID : 10339571 Encounter Type : Inpatient

Admission Date : 05/09/2023 23:57 Location : 1st Floor Pre Cath (ICU)

Speciality : Cardiology Attending Practitioner : Dr Vijay Kumar

Associate Consultant Cardiology Associate Consultant Cardiology

Authorized by Ujjwal Bhardwaj on 11 Sep 2023 10:38 This is a computer generated report. Signature is not required.

Regd. Of f ice: Global Health Patliputra Private Limited. T el: +91 11 4 4 11 4 4 11 Fax: +91 11 24 33 14 33
24 X7 help-line: +91 82922 22333 Emergency: 1068 Email: inf o@medanta.org www.medanta.org CIN: U74 999DL2015PT C283932