BSR CANCER HOSPITAL, BHILAI (C.G.

)
(A unit of BSR superspeciality hospitals ltd.)

Patient name:

R.A. Tiwari

Age

70 years

Sex

Male

IPD No.

325646485

Date of Admission:

02/09/2011

Date of Discharge to Home: 17/09/2011

Admitting Diagnosis:
Basal cell carcinoma (On Chemo) Advised for Radiotherapy
Accelerated Hypertension
Ischemic Heart disease
Double vessel Disease
Obesity
Consulting Doctor: Dr. Aloka Vibha (Onco)
Dr. Dilip Ratnani (DM)

BRIEF HISTORY OF PRESENT ILLNESS:

A 70 years old male known hypertensive diagnosed case of Basal cell carcinoma from ECHS
Raipur admitted in Cancer department for wide excision surgery.
After admission all necessary investigation done as patient is known case of Hypertension patient advised
for consultation with cardiologist Dr. Dilip Ratanani (DM) to declare him fit for surgery.
TMT test done and found Positive for inducible ischemia.
ECHO done revealed Hyperkinetic apex.
Coronary Angiography done by right redial route revealed double vessel disease LAD 90%
RAMUS 80% blockage.

BSR Cancer Hospital, Bhilai (c.g.)

BSR CANCER HOSPITAL, BHILAI (C.G.)

(A unit of BSR superspeciality hospitals ltd.)

PHYSICAL EXAMINATION ON ADMISSION:

BP-160/90MMHG
Pulse 96 per min.
Elderly- Male
Respiratory System B/L Crepts,
Conducted Sound CVS - S1 S2+
Abdomen:
Extremities:
Skin: No rashes.
Neuro:

++

Normoactive bowel sounds. Soft. Non-tender, non-distended.

Pulses present.
Capillary refill brisk.
No focal deficits.

CNS- Conscious oriented

HOSPITAL COURSE: Patient required continuous nebulization treatments in the ER and

had an oxygen requirement of 6L. Once patient transferred to floor, she tolerated 5mg Q2 hr
treatments x 2. Her oxygen requirement decreased to 2 L via nasal cannula. She was weaned to
room air within the first 24 hours and her treatments were spaced to 2.5mg q2 hr. She was found
to have allergic rhinitis on exam and was prescribed singulair, which she tolerated.

INVESTIGATION:
CBC- HB-12gm, TLC -8000
X-ray ChestECHO- Hyperkinetic apex.
TMT- Positive.
Surgical Pathology Report - Basal cell Carcinoma.
CAG- Double Vessel Disease. - LAD 90%, RAMUS- 80%.

BSR Cancer Hospital, Bhilai (c.g.)

BSR CANCER HOSPITAL, BHILAI (C.G.)

(A unit of BSR superspeciality hospitals ltd.)

PHYSICAL EXAMINATION AT DISCHARGE:

T: 99.3F BP 140/90 HR 96 RR 24 Weight 30 kg
General: Awake, alert, no apparent distress
HEENT: Norm cephalic, atraumatic. Hyper pigmentation beneath eyes. Mucus membranes
moist.

MEDICATIONS:
Clopitb- A

75 1 OD 30 days.

Atorvastin

20 mg HS

Pantop

40

Nicorendil

5 mg BD

Alprex

0.25

Duphalac

75 ml HS

1 OD

HS

Diet: Low fat

Follow Up: Cardiologist Dr. Dilip Ratnani after 15 Days
Follow Up: Cancer Clinic in every 15 days for follow up.
Advised for Ct. Radiotherapy
Advise:

Patient advised for urgent Angioplasty as soon as possible.

BSR Cancer Hospital, Bhilai (c.g.)