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Here is the full compiled medical report based on all 6 documents:
HOSPITAL DISCHARGE REPORT SUMMARY
Lifeline Hospital, Wagholi, Pune
PATIENT INFORMATION
| Field | Details |
|---|---|
| Patient Name | Mr. Gaurav Aba Shinde |
| Age / Gender | 27 Years / Male |
| IPD No. | LH-2026/07/03-09247 |
| Admission ID | I-2026/07/03-00839 |
| Ward / Bed | Deluxe / Bed No. 205 |
| Date of Admission | 03-Jul-2026 at 12:23 PM |
| Date of Discharge | 06-Jul-2026 at 10:25 AM |
| Duration of Stay | 3 days |
| Treating Physician | Dr. Amol Ajankar, MBBS, D.Ortho |
| Insurance / Payer | Niva Bupa (Regular) |
| Address | A/p- Awalwadi, Sadguru Park, Socially Opp. Sava, Wagholi, Pune |
DIAGNOSIS
- Primary Diagnosis: Lumbar Prolapsed Intervertebral Disc (PID) at L4-L5 and L5-S1 levels
- ICD-10 Code: M51.16 (Lumbar disc disorder with radiculopathy)
HISTORY & CLINICAL FINDINGS
- Chief Complaint: Sudden onset pain in the lower back since the morning of admission (03-Jul-2026)
- Past History: No Diabetes Mellitus, no Hypertension
- Vitals on Admission: Stable; Afebrile; SpO2: 98%
- Consciousness: Conscious and oriented
- Abdomen: Soft, non-tender
- Spine Examination: Tenderness at L5-S1 level
- Range of Motion (ROM): Restricted and painful
- Straight Leg Raise (SLR) Test: Not possible due to severity of pain
- Neurological Deficit: None
LABORATORY INVESTIGATIONS (03-Jul-2026)
Complete Blood Count
| Parameter | Result | Reference Range | Status |
|---|---|---|---|
| Hemoglobin | 15.3 gm/dL | 14-18 | Normal |
| RBC Count | 5.12 mil/cmm | 4.5-6.5 | Normal |
| Packed Cell Volume (PCV) | 46.1% | 40-54 | Normal |
| MCV | 90.04 cu micron | 75-98 | Normal |
| MCH | 29.88 picograms | 25-33 | Normal |
| MCHC | 33.19 g/dL | 32-36 | Normal |
| RDW-CV | 12.6% | 11.5-14.5% | Normal |
| RDW-SD | 45.4 fL | 39-46 | Normal |
| Total WBC Count | 7,800 /cumm | 4,000-10,500 | Normal |
| Neutrophils | 67% | 40-70% | Normal |
| Lymphocytes | 30% | 20-45% | Normal |
| Eosinophils | 2% | 1-6% | Normal |
| Monocytes | 1% | 0-8% | Normal |
| Basophils | 0% | 0-1% | Normal |
| Platelet Count | 226,000 /cumm | 150,000-450,000 | Normal |
| MPV | 7.7 fL | 7.5-11.5 | Normal |
| PDW | 18.2% | 9-14 | Normal |
| PCT | 0.17% | 0.19-0.39 | Slightly low |
Peripheral Smear: RBC morphology - Normocytic Normochromic; WBC morphology - Within Normal Limits; Platelets - Adequate.
Blood Chemistry
| Parameter | Result | Status |
|---|---|---|
| Serum Creatinine | 0.9 mg/dL | Normal |
| Sodium (Na) | 137 mEq/L | Normal |
| Potassium (K) | 4.2 mEq/L | Normal |
| Chloride (Cl) | 102 mEq/L | Normal |
| Urea | 25 mg/dL | Normal |
INVESTIGATIONS - IMAGING
ECG
- Normal (03-Jul-2026)
X-Ray Reports (All within Normal Limits)
| Study | Finding |
|---|---|
| X-Ray Spine Dorso-Lumbar (AP & Lateral) | Within normal limits - vertebrae, curvature, disc spaces, soft tissues, and alignment all normal |
| X-Ray Spine Lumbar (AP & Lateral) | Within normal limits |
| X-Ray Spine Cervical (AP & Lateral) | Within normal limits |
| X-Ray Chest (AP) | Within normal limits |
MRI Lumbar Spine + Whole Spine Screening
(Reported by Dr. Mahesh Kasat, MD, Consultant Radiologist - Ruby Medical Services, Wagholi)
Lumbar Canal Sagittal Diameters:
| Level | L1-L2 | L2-L3 | L3-L4 | L4-L5 | L5-S1 |
|---|---|---|---|---|---|
| Diameter (mm) | 15 | 14 | 13 | 10 | 10 |
- Iliopsoas and perivertebral soft tissues: Unremarkable
- Sacroiliac joints: Normal
MRI Impression:
- Annular tear with posterior disc protrusions at L4-L5 and L5-S1 levels causing compression of the thecal sac, encroaching on bilateral neural foramina, and abutting the bilateral nerve roots.
- Cervico-dorsal spine screening: Disc bulges at C5-C6 and C6-C7 levels causing indentation over the thecal sac.
IN-HOSPITAL TREATMENT
Patient was treated with:
- IV Antiemetics
- IV Antacids
- IV Analgesics
- Multivitamins
- Ice packs (local application)
Injections given during hospitalization:
- Inj. Tramadol 100mg (1-0-1)
- Inj. Pan 40mg (1-0-0)
- Inj. Pantocid 1 GM (1-0-1)
- Inj. Emset 4mg (1-0-1)
- Muthrans Patch (0-0-1)
- Inj. Optineuron with 500 ml NS (0-0-1 / 1-1-1)
- Syp Instarap-1 (1-1-1)
DISCHARGE MEDICATIONS
| Medication | Dose | Duration | Instruction |
|---|---|---|---|
| Tab Flamichek-P | 1-0-1 (twice daily) | 5 days | After meals |
| Tab Tangi-Pan | 1-0-1 (twice daily) | 5 days | Before meals |
| Cap Myoril 4mg | 1-0-1 (twice daily) | 5 days | After meals |
| Cap X Corich | 1-0-1 (twice daily) | 15 days | After meals |
| Flexabenz Gel | 1-1-1 (three times daily, local application) | 5 days | Apply locally |
Allergies: None
Discharge Condition: Normal / Vitally Stable
ADVICE ON DISCHARGE
- Activity Restrictions: Avoid bending forward, avoid prolonged sitting, avoid travelling for 7 days
- Physiotherapy: IFT (Interferential Therapy) + back strengthening exercises for 7 days
- Diet: Regular diet
- Emergency Symptoms: Report immediately if pain or vomiting develops
- Follow-up Date: 13-Jul-2026 at Ortho OPD
CONTACT INFORMATION
- Hospital: Lifeline Hospital, 648/2, Kesnand Phata, Pune-Nagar Road, Wagholi, Pune - 412207
- Phone: 020-40566400 / 8007040806 / 8956409201
- OPD Appointments: 020-40566401 / 020-40566402 / 8007040806
- Emergency Mob: 8007040805
Report compiled from 6 medical documents: Discharge Card Summary, Discharge Prescription, Pathology CBC Reports (x2), X-Ray Dorso-Lumbar Report, and MRI Spine Report (Ruby Medical Services). All documents dated 03-06 July 2026.
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