Ajab Singh

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ALL INDIA INSTITUTE OF MEDICAL SCIENCES BHOPAL

अ खल भारतीय आयुिव ान सं थान , साकेत नगर, भोपाल


Saket Nagar , Bhopal-462020

DISCHARGE SUMMARY

UHID : 20190259451
Patient
Mr. AJAB SINGH Department:General Medicine
Name:
55 Years 0 Months 9
Age /Sex: Unit:: General Medicine
Days 0 Hours / Male
S/O : RAM CHANDRA Ward:: Medical Ward-1
Billing Type : APL MLC Patient:NO
IPD
Discharge Issue Temporary
Admission ID 201919797
Type: Death Certificate
::
Treating
Dr. Vaibhav Ingle, Bed No: 7
Doctor:
Mobile No: *******081
Drug Allergy :-
Date of 23/12/2019
Admission: 03:28:10 PM
Date of 01/01/2020
Discharge : 04:15:00 AM
RAIPUR, SUJALPUR,
Address : MADHYA PRADESH,
INDIA

METABOLIC ENCEPHALOPATHY WITH SEPSIS WITH SEPTIC SHOCK WITH RHEUMATOID ARTHRITIS WITH
Diagnosis :
DISEASE FLARE WITH DIABETES MELLITUS

ICD Code:

Admitted For: k/c/o RA with pain all limbs and B/L pedal edema

Physical Findings: General Exam :- Systematic Exam :- Local Exam :-

Condition During
DEATH
Discharge :

55 YR M patient, k/c/o RA presented in OPD with complaint of pain all limbs and
b/l pedal edema with recently diagnosed T2DM. Patient was treated with
analgesics, DMARDs and Insulin. On 28/12/19, patient had an episode of
hypoglycemia, hyponatremia with altered sensorium. Patient was given 3% NaCl
and RT inserted. On 30/12/19, patient became drowsy and was intubated and
Brief Summary of the Case:
started on mech ventilation. On 31st Dec, patient had falling BP, aat !! PM. Inj
Nor Ad was initiated and uptitrated to maintain BP. ON 1/1/2020 at 3:00 AM,
patients pulse and BP were not recordable. CPR was initiated as pper acls
guidelines. Despiteall efforts, patient could not be revived and was declared dead
at 4:15 AM

Treatment Given :

Advice on Discharge: NA

To come For follow up in Routine OPD on & Time

In specialist Clinics on & Time


Signature Treating Doctor

Dr. Vaibhav Ingle

01/01/2020 04:15:00 AM
Date & Time

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