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Royal Government of Bhutan Jigme Dorji Wangchuk National Referral Hospital Patient Discharge Form

1. An 83-year-old man with a history of hypertension and chronic kidney disease on dialysis presented with bleeding from his left arm fistula site. 2. He underwent two surgeries - a venoplasty and arterioplasty, followed by an exploration and vein grafting of the left brachial artery - to address erosion of the artery and vein from his previous graft. 3. On discharge, he was clinically stable with instructions to follow up at the surgical clinic for suture removal and to continue medications including warfarin.

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77 views2 pages

Royal Government of Bhutan Jigme Dorji Wangchuk National Referral Hospital Patient Discharge Form

1. An 83-year-old man with a history of hypertension and chronic kidney disease on dialysis presented with bleeding from his left arm fistula site. 2. He underwent two surgeries - a venoplasty and arterioplasty, followed by an exploration and vein grafting of the left brachial artery - to address erosion of the artery and vein from his previous graft. 3. On discharge, he was clinically stable with instructions to follow up at the surgical clinic for suture removal and to continue medications including warfarin.

Uploaded by

Suman Pradhan 2803
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

ROYAL GOVERNMENT OF BHUTAN

JIGME DORJI WANGCHUK NATIONAL REFERRAL HOSPITAL


Patient Discharge Form FORM Q3
Name Dorji Age 83 years Sex Male
Date of admission 07/05/2021 Time 1800 HRS CID No. 11902002483
Date of Discharge 17/05/2021 Time 11:00 HRS Mobile No. 17718065
Ward Surgery Hospital Reg. No. 195053
Allergies Yes No

DIAGNOSIS ICD CODE


FINAL
OTHERS CKD, HYPERTENSION
SUMMARY OF HISTORY AND TREATMENT:
Known case of Hypertension and CKD on MHD since 2018. S/p PTFE graft removal on 30/03/2021.
Presented with bleeding from Left AVF site for 2 days associated with pain over the left forearm and
dizziness. However, denied fever or loss of consciousness

On examination:
Afebrile, pale but not icteric.
BP- 149/79mm Hg, PR-
Left arm- tight bandage+, soaked+, peripheral pulses+, CRFT < 2secs, can move the fingers of the left hand
Rest of the systemic examination was normal

Investigation:
WBC- 16.98, N- 90.2% Hb-6.28.3 g/dl, Plt- 208
RFT:Urea-12367, Crea-6.64.4, Na-130, K-6.34.1, Cl-108 Corr. Ca- 8.64
LFT: WNL, PT/INR- 11/0.77
USG (09/05/2021): limited sonographic view of left upper limb arterial Doppler. However, visualized part
of brachial artery shows satisfactory color flow and spectral wave pattern. Grossly thickened left arm
subcutaneous tissue with diffuse extensive edema.

Management:

1) SURGERY: Left brachial venoplasty and left brachial arterioplasty done under GA by Dr.
Tashi Tenzin and assisted by Dr. Sonam Wangchuk on 08/05/2021.

FINDINGS: distal part of previous graft at brachial artery dislodged and erosion+. 4 cm of anterior wall of
brachial artery eroded.3 cm of anterior wall of brachial vein eroded.
Post Op: rebleed from the surgical site and patient had to be operated again.

2) Exploration + vein grafting of the left brachial artery done under GA by dr. Tashi Tenzin and
Dr. Sonam Wangchuk on 13/05/2021.
FINDINGS: erosion of the junction of the previous graft and distal part of brachial artery with active
bleeding.
Post Op: Drain removed on POD3

PRC BT done before the surgery and tab. Tab. Warfarin started on 16/05/2021

On Discharge: Patient is clinically and hemodynamically stable.


Page | 1 of 2 CONTROLLED FORM
Surgical Appointment number: 77858801/17841104
ROYAL GOVERNMENT OF BHUTAN
JIGME DORJI WANGCHUK NATIONAL REFERRAL HOSPITAL
Patient Discharge Form FORM Q3

☐Recovered ☐Recovering ☐Terminal Care ☐LAMA ☐Absconded ☐ Referred ☐ Death

INSTRUCTIONS ON DISCHARGE:
1. Tab. Paracetamol 1 g PO SOS- 16 tabs
2. Tab Vitamin C 2 tabs BD x 2 weeks
3. Tab. Warfarin 3 mg OD for 1 week
4. Repeat PT/INR on 19/05/2021 and review at the surgical OPD
5. Keep the left arm elevated.
6. Remove dressing at home after 3 days
7. Suture removal at Post Op Day 10 at chamber 12
8.
FOLLOW UP
1. Review SOS

Prepared by Dr. Karma Choden. P.reg.210

Page | 2 of 2 CONTROLLED FORM


Surgical Appointment number: 77858801/17841104

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