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Discharge Summary 1

The document details a patient's hospital discharge summary after undergoing laparoscopic appendectomy for acute appendicitis. The patient, a 25-year old male, presented with pain in the right lower quadrant for 6 days. He underwent an uncomplicated laparoscopic appendectomy and was discharged on the fourth day of admission in a stable condition with medications and follow-up instructions.

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mouli poliparthi
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444 views1 page

Discharge Summary 1

The document details a patient's hospital discharge summary after undergoing laparoscopic appendectomy for acute appendicitis. The patient, a 25-year old male, presented with pain in the right lower quadrant for 6 days. He underwent an uncomplicated laparoscopic appendectomy and was discharged on the fourth day of admission in a stable condition with medications and follow-up instructions.

Uploaded by

mouli poliparthi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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A unit of Andhra Hospitals (Visakhapatnam) Pvt. Ltd.

,
CIN : U85110AP2022PTC123354

D.NO.14-37-45, Collector Office Junction, Maharani Peta,


VISAKAPATNAM - 530002 PH : 0891-2797676, 9151625261, 8885579733

OUT PATIENT
DISCHARGE CARD
SUMMARY
Patient name : Mr. S SRAVAN KUMAR Patient ID : MR2401653
Patient Name : ___________________________________________________________________ Age : _________________________________________
Visit ID: ________________________
Gender : IPMR240000239 Patient category : Cash
UHID : ______________________________ O.P.No : ___________________________________________________
Department
Age/Gender: _____________________________________
: 25 Y / Male Unit : ____________________________________ Roomstation
Bed/Nursing No : __________________________
: Ward2-1-GENERAL
Date : ________________________ Assessment start time : ____________________________
Admission date: 04-04-2024 Discharge date : 08-04-2024
Consultants :
Nutritional screening
Height : Weight : BMI : H/O Allergy : YES/NO Details :
1. Have you lost weightAPPENDICITIES
: ACUTE recently without trying ?

YES/NO/UNSURE
: 25-YEAR OLD MALE CAME WITH THE CHIEF COMPLAINT OF PAIN IN THE RIGHT ILIAC FOSSA SINCE 6DAYS.
If yes how
PATIENT WASmuch weight you
APPARENTLY lost : TWO
RIGHT __________
DAYS BACK WHEN HE DEVELOPED PAIN IN THE REGION WHICH MIGRATED TO THE
2. Have
RIGHT you FOSSA.
ILIAC been cutting poorly
SIMILAR because of decreases
COMPLAINTS appetite
IN THE PAST ?
3 MONTHS AGO AND WAS TREATED CONSERVATIVELY.
YES/NO Total
: CBC: scoreGMS%,
HB:16.8 : ___________
WBC: 16900 cumm, BT :2'15",CT: 4'32", HCV : NR,HIV :NR, HBsAg : NR. RFT, ECG, BGT :O+VE,

CHEST RAY PA VIEW,RBS


Chief complaints : ALL REPORTS ENCLOSED TO THE PATIENT Co-morbid conditions :
: LAPAROSCOPIC APPENDECTOMY WAS DONE ON 05/04/24 UNDER GERNERAL ANAESTHESIA.
Diabetes Hypertension
INTRA OP FINDING : INFLAMED, AND HEAVY, IS APPENDIX MEASURING 9 MM IN DIAMETER. WITH MILD ADHESIONS.
Cardiac illness Tuberculosis
PATIENT WAS POSTOPERATIVELY MANAGED WITH IV ANTIBIOTICS, AND IV ANALGESICS
Bronchial Asthama Thyroid
INJ.PIPTAZ 4.5 gm iv TID Epilepsy
INJ.METROGYL 500mg IV TID others :
INJ. PANTOP 40mg IV OD
History of present illness :
INJ.DYNAPAR 75 mg IV BD

POST OPERATIVE EVENTS FOR UNEVENTFUL,SPECIMEN AND FOR BIOPSY.

: PATIENT IS HEMODYNAMICALLY STABLE AT THE TIME OF DISCHARGE


BP:130/70mmhg

PR:68bpm

RR:20bpm
Past History
TEMP:AFEBRILE :
SPO2:97%@RA

: PATIENT TO TAKE SOFT DIET

1)TAB.OFLOZ OZ PO BD FOR 5 DAYS. 1-0-1

2)TAB.ZERODOL SP PO BD FOR 5 DAYS1-0-1


General examinations
3)TAB.RAZO : 5Temp
20 mg PO OD FOR : Pulse : BP : RR : SPO2(if indicated) :

DAILY REGULAR DRESSING


Systemic
REVIEW Examination
TO GENERAL : OPD ON SATURDAY 08-04-2024 WITH BIOPSY REPORT
SURGERY
Discharge summary received by Registrar/Consultant

Signature: Signature

Name: DR.RAHUL

For DR.SANTOSH RAJA


Relation:

Contact number

Typed date: 08-Apr-2024 Typed by: Printed by: KARLE SUGUNA

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