LATA MANGESHKAR HOSPITAL,DIGDOH HILLS,HINGNA, NAGPUR

DISHARGE SUMMARY
DISCHARGE ON REQUEST
Patient Name : Sulochana Talmale Age/Sex :45/male
Category :General UHID :IP.No : 1908281152
Address : At pardi kurd po nimkheda at mauda
D.O.A :29/08/2019 D.O.D :22/11/18
Department :Surgery Unit III
Consultant :Dr. Nitin Wasnik (unit incharge)
DR.Chetan (Lecturer)
DR.Pankaj (S.R)

DIAGNOSIS : CHOLELITHIASIS
MANAGED CONSERVATIVELY
PATIENT HAS FACILICITY FOR CHOLECYSTECTOMY. PATIENT IS UNDER E.S.I.C FASCILITY AND WANTS TO
BE OPERATED AT BHARDI L.M.H E.S.I.C HOSPITAL.

Chief Complaints with duration :

Pain in Right upper abdominal since 2 years
Pain is present at right upper abdomen radiating to back
H/o of Dyspepsia +
H/o of Burning Micturition +
No H/o Fever
No H/o nausea, vomiting
No h/o of jaundice
No h/o of any bowel or bladder complaints
No h/o loss of appetite
No h/o weight loss
No h/o hematemesis
No h/o malena
H/o similsr components in past.
Patient is not k/c/o dm/ htn/ asthma/TB

On Examination :
G/E Afebrile
Pulse-76/min
BP 110/80mm Hg
No pallor, icterus, cyanosis, clubbing, oedema, lymphadenopathy
S/E CVS- S1S2 Normal
RS – AEBE
CNS- Conscious, oriented
PA- Soft ,non tender
No Guarding, no Rigidity
BS + in all quadrants

Investigation Carried out During Hospitalization Period :

USG ABDOMEN+ PELVIS 29/0819: S/O CHOLELITHIASIS
Gall bladder distened with completely filled with sludgeand few 2.8 mm calculi and largest being
7 mm noted in neck of gall bladder .Gall bladder wall thickness appears normal. CBD appear
normal
IHBR appear normal .

Date: 19/11/18
Hemoglobin TLC Platelet S.creat S.urea S. Na S. K HIV/HBsAG

12.30 gm/dl 10600cumm 3.38lacs/cu 0.84mg/dl 18 mg/dl 137mEq/l 4.01mEq negative

mm /l
Total Direct Indirect SGOT SGPT Alkaline Total Albumin
Bilirubin Bilirubin Bilirubin Phosphatase Proteins
0.39 mg/dl 0.11 mg/dl 0.28 mg/dl 15units/l 22units/l 109 units/l 6.4 gm/dl 3.7 gm/dl

RBS – 100 mg/dl

UPPER GI ENDOSCOPY- 30/08/2019 - NORMAL GI ENDOSCOPY
Treatment Given During Hospitalization period :
TAB GANATON TOTAL ORAL BD
TAB BUSCOPAN ORAL BD
SYP CITAL 2 TSP IN HALF GLASS WATER TDS

Condition On Discharge:
Vitals stable P- 76 /min , BP- 120/80 mmhg
Patient Comfortable, Passing stools , Patient is on full oral diet. No fresh complaints

Advise on Discharge :
AS PER PATIENTS DECISION PATIENT WANTS TO BE OPERATED AT BHARDI E.SI.C HOSPITAL L.M.H
TAB GANATON TOTAL 1-0-1 X 3 DAYS
TAB BUCOPAN 1-0-1 X 3 DAYS
SYP CITAL 1-1-1 X DAYS

When to obtain urgent care:

Follow up in OPD 5 SOS in casualty in case of emergency or fresh complaints.

Resident Doctor Name & Sign Consultant doctor Name & Sign