Asian Institute of Gastroenterology BO 6 Ph: 91-40-23378888 (10 Lines), Fax: 91-40-29324255 fs Email: aigindainfo® yahoo.co.in wen snags DISCHARGE SUMMARY NAME : Mr. KAMAL KISHORE AGE / SEX: 53/M DOA : 04.02.2009 DOD : 09.02.2009 ROOM No : 219 Registration No : 0800039352 IP No: 0900000922 Diagnosis * BETATHALASEMMIA TRAIT WITH ANEMIA * SECONDARY HEMOCHROMATOSIS WITH CIRRHOSIS OF LIVER - CHILD’s ‘B’ STATUS + BLEEDER SEVERE PORTAL HYPERTENSIVE GASTROPATHY, HVPG =12 + HYPERTENSION, ISCHEMIC HEART DISEASE *HISTORY & COURSE IN THE HOSPITAL: Mr, Kamal Kishore presented with h/o intermittent malena since last 1 year, received multiple transfusions fer anemia and also diagnosed to have Betathalasemmia. Evaluated and found to have chronic liver disease due to probably secondary hemochromatosis, OGD showed _gastropathy Colonoscopy done earlier was normal and also capsule Endoscopy done out side didn’t show any evidence ectopic varices. Ultrasound didn’t show any evidence of SOL and alpha-fetoprotein was normal, HVPG done showed pressure of 12 mm, Patient was transfused 1 point of blood and there was no fall in the hemoglobin during stay in hospital although stool occult blood was positive. Relatives explained about the log term prognosis and advised to keep hemoglobin around 9 ~ 10 gms. INVESTIGATIONS DONE: * CD & USG Abdomen (05.02.09) Cirrhosis of liver with portal hypertension and minimal ascites. + UGI Endoscopy (05.02.09) Gastropathy + hn ety waren aus rans ce * Hepatic vein pressure gradient (06.02.09) Hepatic vein pressure gradient 12 mmHg, Setter Sere ri mala Botner - Aneshneslobgytensive Care DrananPaps Rss DD sarah 2 BS doer rbd Puy, Oxv Rime. RAE bienAsian Institute of Gastroenterology B® 6-661, Somajigud, Hyderabad -5¢0 082, INDIA o py ob astione Ge lnoe) Fax atao-eeeass Email: aigindiainto@ yahoo.co.in sand Sriaabont Caeave EnSepy Medical Gastroenterology ere = mEmoonas (05.02.09) Coen Roemer meee > Total WBC 7100 Cells/mm: DiRtpa Bij 0 >Rpc 28 mill mim Bin co > Haemoglobin 68 gm/dl Sera ais raer 2 | Of Seat Gene >McV 76 al = Pace oe Seater >» MCHC 31 em% pL eae >RDW 19 fl rear a F Platelets count 12 Tatehs/men Seen oom > Digjerentiat WC: ee Peoneole 6° | % = lomphoeret Om =. Eosinophils os % we Monocytes: 03, % Satta Minos oe RBC : Mild degree anisocytosis normecytic Normochromic and normocytic hypachromic cells, few Microcytic hypochromic celle with Hepatology & Nutrition Rraenegat Ss few pencil shaped cells and occasional target cells and occasional tear Peete ern drops Surgical Gastroenterology WBC : Total Count & differential count within normal limits PVR wie felets : Mild Thrombocytopenia Sarena No abnormal cells, No Haemoparasites Dr pear an Abnormal Cells : Correlate clinically ‘nfo aon ‘Haemoglobin (07.02) 7.1 gm/dl Srna ra Platelet Count 1.4 Lakhs/mm* ieee sLiver Function Test: (0502.09) Srna ‘Total Bilirubin meat SosTaw Direct Bilirubin maya = In Direct Bilirubin mg/dL ‘eae SGPT U/L ene sor oft ai ap up a ciabey 1 Protea sae DeM A Mates, on ae gm) EvguoeteSa mane Giobulin mjd Srinae Priamos 2PT With INR (05.02.09) (06.02) cna tok Pest 18.7153. Sec eee Pean Control 130 180. See SmaregS PINR Lag 18 Laboratory Medicine ome pst Pic raus rinse ‘b:Potasstum: + 39 mEq/L Ste stneesine Serum Iron & TIBD (04.02.09) Brine oe doa sre. miwe 280 ug/L B3iareBense pa Serum Creatinine (05.02): 0.8 mg/l Anesthesiology/Intensive Care oi Beso inh evn ics stad Iravscacbecesea6-361, Somajiguda, Hyderabad - 500 082, Ph: 91-40-25978888 (10 Lines), Fax: 91-40: Email aigindiainfo@yahco.co.in sro 89 ugvat. stipe 296 wg/aL 2.9 U/mL 21% Anti HCV (Spot) Negative sHBs Ag (Spot) Negative eHIV (Spo!) : Negative ‘Stool for occult blood (05.02) (06.02) (07.02): Positive Ferritin 216 ng/mL Moro: SANTEE LIM raw once vary | ie R FOOD) WITH Dre hain ee DrMaer san Heneritone, casey REVIEW AFTER 1 MONTH oremiten oe In case of Medical Emergency Contact Laboratory Medicine Dr. Sendeep (Medical Registrar) Ph.No. 9701230280 Seuosmcetencanes DR envoead Convavaa =. Novica Regatar Anesthesiologyiintensive Care DR. D. NAGESHWAR REDDY, DR. RAJESH GUPTA, aterm MDADM. FANS FRCP. De MD. Dal Seton hier antecntersopst Conmitant Gastro Sbarro eine Ria ta aoa ars