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Gastroenterology Discharge Summary

Mr. Dasari A. Lincon, a 50-year-old male, was admitted to the hospital for management of GI bleed, alcoholic liver disease, alcohol withdrawal, and hepatic encephalopathy. Key findings included early esophageal varices, portal gastro-duodenopathy, and cirrhotic liver disease with portal hypertension on endoscopy and MRI. He was treated medically during his hospital stay and discharged in stable condition with follow up advice.

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MEDICAL REPORTING
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116 views3 pages

Gastroenterology Discharge Summary

Mr. Dasari A. Lincon, a 50-year-old male, was admitted to the hospital for management of GI bleed, alcoholic liver disease, alcohol withdrawal, and hepatic encephalopathy. Key findings included early esophageal varices, portal gastro-duodenopathy, and cirrhotic liver disease with portal hypertension on endoscopy and MRI. He was treated medically during his hospital stay and discharged in stable condition with follow up advice.

Uploaded by

MEDICAL REPORTING
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as ODT, PDF, TXT or read online on Scribd

DISCHARGE SUMMARY

DEPARTMENT OF MEDICAL GASTROENTEROLOGY

KAHHS.0000246002 /
REG/IP NO : NAME : MR. DASARI A. LINCON
HHSIP54925
AGE : 50 Years ADMITTED ON : 21/11/2023
SEX : MALE DISCHARGE ON : ---/12/2023
PRIMARY Dr. SANJEEV CHATNI
BED NO : 342-7 :
CONSULTANT MBBS,MD, DNB
ADDRESS : HUBLI

DIAGNOSIS:
- GI BLEED
- DCLD (ETHANOL INDUCED)
- ALCOHOL WITHDRAWAL
- ADL
- HEPATIC ENCEPHALOPATHY

INCHARGE CONSULTANTS:
Dr. Sanjeev Chanti (Gastroenterologist)
Dr. Shivaranjan Bali (Psychiatrist)
Dr. Ameet G Sattur (Cardiologist)

BRIEF CLINICAL HISTORY:


Mr. Dasari A. Lincon, 50 years old male history of generalized weakness, melena and knee joint pain
since 5 days. Known case of Hypertension, CLD. Presently being admitted here for further evaluation
and management. Relevant test and consultation were done.

REASON FOR ADMISSION: Medical Management

SIGNIFICANT FINDINGS:
The patient is afebrile. Pulse-68/min, R/R-20/min, BP- 120/80mmHg.

DETAILS OF INVESTIGATION RESULTS:


UPPER GI ENDOSCOPY DATED 22/11/2023:
IMPRESSION: 1) EARLY ESOPHAGEAL VARICES. 2) PORTAL GASTRO-DUODENOPATHY.

MRI – ABDOMEN DATED 21/11/2023:


IMPRESSION:
- CIRRHOTIC LIVER DISEASE WITH PORTAL HYPERTENSION.
- SPLENOMEGALY.
- MODERATE ASCITES WITH RIGHT MILD PLEURAL EFFUSION.

2D ECHO DATED 27/11/2023:


CONCLUSION:
- NORMAL LV SYSTOLIC FUNCTION.
- LVEF – 60%
- NORMAL PA PRESSURE.
- NO CLOT / EFFUSION.

LAB REPORTS ENCLOSED.

MEDICATION ADMINISTERED DURING STAY:


INJ PAN STAT
INJ PIPZO 4.5GM TID
INJ ALCOMAX OD
TAB UDILIV 300MG BD
TAB SILYBON 140MG BD
SYP DUPHALAC 30ML/TID
TAB RIFAGUT 550MG BD
TAB CIPLAR 10MG HS
SYP SUCRAFIL O 10ML TOD
TAB QUITIPINE 25MG HS
TAB LOPEZ 2MG HS
INJ SERENACE 5MG BD/TID/SOS
SYP FULL 365 10ML BD
TAB LOREL 2MG TID /BD

DISCHARGE ADVICE:

DETAILS OF ANY OTHER TREATMENT GIVEN:

PATIENT CONDITION ON DISCHARGE:

FOLLOW UP ADVICE AND INSTRUCTIONS IN DETAIL:

WHEN TO BE OBTAINED URGENT CARE:


In case of emergency fever (>99.5°F), cough throat pain, breathing difficulty, oral ulcer, bleeding from
any site, loose stools, pain in abdomen, vomiting, etc.,Contact: 0836 2239027/2239000

DUTY DOCTOR: Dr.

Dr. SANJEEV CHATNI


MBBS,MD, DNB.
Discharge Summary has been explained by:________

Discharge Summary has been Understood by:_______

Reports Handed over to:____________

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