Patient Name: Mr.

Shivkesh Dahiya Location: Patparganj

Age / Sex: 31 Years/Male Date: 07 Feb 2023
MaxId: EHPG.883651 Invoice No: PGCS4655643
Doctor Name: Dr.Sharad Agarwal Referred By: SELF

Allergy: NO KNOWN ALLERGY

Chief Complaints and History of Present Illness

Pain & Stiffness Left Side neck, Left Shoulder - 1 week, H/O fall 1 week back following a seizure

Past History / Family History

H-D-, Seizure disorder, Asthmatic

Physical Examination
Left Shoulder, Cx Spine - No tenderness

Clinical Notes / Old Reports

MRI Cx Spine - 1/23 - Degenerative changes, MRI Left Shoulder - 2/23 - Degenerative changes AC Joint

Provisional Diagnosis
Degenerative Cervical Spine & AC Joint Left Shoulder Disease

Investigation Advised
PT002 Hot Fomentation (HP)
PT009 ULTRASOUND THERAPY (US)
PT010 INTERFERENTIAL THERAPY (IFT)
PT011 THERAPEUTIC EXERCISES
Neck & Left Shoulder x 10 sitings

Medicine Advised

Sno Medicine Schedule Instruction Route Days

1 ZERODOL TH 4MG TAB (1X10) TWICE IN A DAY 1 TAB (AFTER MEALS) ORAL 14
(ACECLOFENAC 100 MG +
THIOCOLCHICOSIDE 4 MG)
2 PANTOCID 40MG TAB (1X15) ONCE IN A DAY 1 TAB ORAL 14
(PANTOPRAZOLE 40 MG)
3 VOLITRA 30GM GEL TWICE IN A DAY LOCALLY PERCUTANEOUS 14
(DICLOFENAC DIETHYLAMINE 1.16
% + LINSEED OIL 3 %)

Next Follow Up: 21/02/2023

Dr.Sharad Agarwal
DMC No. : 10030

For free home sample collection and medicine delivery, call 8744 888 888
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