All India Institute of Medical Sciences Rishikesh

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DISCHARGE SUMMARY

UHID : 20190029064 Mrd No :: 34770

Patient Mrs. PARWATI
Department:Orthopaedics
Name: DEVI
65 Years 0 Months
Age /Sex: 17 Days 0 Hours / Unit:: 3
Female
W/O : late dhanu ram Ward:: Orthopaedics
Billing Type
BPL MLC Patient:NO
Billing Type:
IPD
Discharge
Admission ID 20196558 Normal Discharge
Type:
::
Treating
Dr. Shobha S Arora Bed No: 36
Doctor:
Mobile No: *******465
Drug Allergy :-
Date of 19/02/2019
Admission: 06:28:19 PM
Date of 07/03/2019
Discharge : 01:25:00 AM

Diagnosis
SYNOVIAL SARCOMA LEFT NECK OF FEMUR
:

ICD Code:

Admitted PATIENT PRESENTED WITH COMPLAINTS OF PAIN OVER LEFT HIP AND SWELLING SINCE 3 MONTHS FOLLOWING HISTORY OF
For: FALL FROM STANDING HEIGHT ON 10/12/2018

SCAR OVER LATERAL ASPECT OF PROXIMAL THIGH. MILD DIFFUSE SWELLING PRESENT OVER LEFT LOWER LIMB AND LATERAL
Physical
ASPECT OF LEFT PROXIMAL THIGH. NO LOCAL RAISE OF TEMPERATURE. TENDERNESS PRESENT OVER SUTURE LINE. ROM
Findings:
COULD NOT BE ASSESSED DUE TO PAIN. DISTAL VESSELS PALPABLE. NO SENSORY DEFICIT.

Condition
PATIENT AFEBRILE
During
VITALS STABLE
Discharge
DNVS INTACT
:

65 YEAR OLD PATIENT PRESENTED WITH COMPLAINTS OF PAIN OVER LEFT HIP AND
SWELLING SINCE 3 MONTHS FOLLOWING HISTORY OF FALL FROM STANDING
Brief Summary of the Case: HEIGHT ON 10/12/2018. DIAGNOSED AS SYNOVIAL SARCOMA LEFT NECK OF
FEMUR. PLAN: TO TO VIEW WITH IHC AND CT REPORTS FOR FURTHER PLANNED
MANAGEMENT

Details Of Investigation and Procedures:

Category Test Name Observation

Note : Hb: 7 gm/dl

TLC: 6960 cells/cumm
DLC: N77.3%; L9.5%; E0.4%; B0.3%; M12.5%
Platelet Count: 550000/mm3
B. Urea: 19.84 mg/dl
S. Creatinine: 0.51 mg/dl
 Na: 128 mmol/L
K: 3.2 mmol/L
TOTAL BIL: 0.38 mmol/L
DIRECT BIL: 0.09 mg/dl
CRPH- 172
HIV, HCV, HBsAg: Negative
HPE: OUTSIDE BLOCK FOR REVIEW (H-3416/18): FEATURES ARE THOSE OF MALIGNANT MESENCHYMAL
TUMOR WITH LARGE AREAS OF NECROSIS.

XRAY OF PELVIS WITH BILATERAL HIPS: S/O LYTIC LESION PRESENT OVER PROXIMAL FEMUR WITH NO
CORTEX VISIBLE IN THE PROXIMAL FEMUR AT SUB TROCHANTERIC AREA WITH DHS IMPLANT IN SITU

CECT THORAX AND ABDOMEN: IN A KNOWN CASE OF SYNOVIAL SARCOME LEFT HIP JOINT, PRESENT
SCAN REVEALS NO EVIDENCE OF ANY METASTASIS IN ABDOMEN AND PELVIS. NUMEROUS TINY
CENTRILOBULAR NODULES IN BILATERAL LUNGS GIVING TREE IN BUD APPEARANCE AT PLACES
– LIKELY ACTIVE INFECTIVE ETIOLOGY (?
TUBERCULOSIS). FIBROTIC CHANGES IN BILATERAL LUNGS AS DESCRIBED WITH CALFICIED
MEDIASTINAL LYMPHADENOPATHY – SEQUELAE TO
OLD INFECTIVE ETIOLOGY.

Treatment Given :

Note : PLAN: TO TO VIEW WITH IHC AND CT REPORTS FOR FURTHER PLANNED MANAGEMENT

TAB DICLOFENAC PLUS PARACETAMOL 1 BD X 5 DAYS AND SOS

TAB VITAMIN C 500MG 1 OD TO CONT
TAB CALCIUM CITRATE 500MG 1 OD TO CONT
Advice on Discharge: TAB VTAMIN D3 (60K) ONCE WEEKLY TO CONT
TAB PANTOP 40MG 1 OD X 5 DAYS
SYR HAEMUP 5ML BD
TO REVIEW IN ORTHOPAEDIC OPD AFTER 2 WEEKS WITH REPORTS

To come For follow up in Routine OPD on 20/03/2019 & Time 08:00:00 AM

In specialist Clinics on & Time

Signature Treating Doctor

Dr. Shobha S Arora

07/03/2019 01:25:00 AM
Date & Time