AKASH INSTITUTE OF MEDICAL SCIENCES & RESEARCH CENTRE
Prasannahalli Road, Devanahalli Bangalore Rural, Bangalore- 562110
Hospital No: 080-71159900/19
DEPARTMENT OF GENERAL MEDICINE
DISCHARGE SUMMARY
Treating Consultant :
[Link] KULKARNI
Professor and UNIT I CHIEF
Patient’s Name : MALA A Age and Sex : 22yrs/ female
Hospital No : 2543306
IP No : 283191
Unit : Medicine I
Date of Admission: 10/06/2024
Date of Discharge : 12/06/2024
chief complains-
C/o loose stools since 1 day
C/o vomiting since 1 day
C/o gidiness since 1day
RELEVANT HISTORY & PHYSICAL FINDINGS
as stated by the patient she was apparently alright 1 day back when she developed loose stools acute
onset progressive 2-3 episodes non blood tinged non-foul smelling ,no aggravating and relieving factors
no associated pain abdomen and fever . Vomiting 2-3 episodes consists food particles non projectile,
associated with nausea, no aggravating relieving factors
Associated gidiness since 1 day after fall no h/o tinittes or vertigo no h/o
Consumption of outside food
N/K/C/O,PTB,ASTHAMA ,HTN , TYPE 2 DM, EPILEPSY
On Examination:-
BP – 100/70mmHg
PR - 80 bpm
SPO2 -98% on room air
Systemic examination :-
RS – B/L AE +,B/L NVBS+
CVS – S1 S2 +,no murmer
CNS – Conscious oriented
P/A – Soft,non tender
RELEVANT INVESTIGATIONS:
HB-11.9 percentage, PLT-275000, SR CREAT-0.56, UREA-28.1
U ACID-3.7 , NA+ 133 , K+ 3.92 U/R- yellow, turbid , UKB +++
DENGUE -ve
COURSE IN HOSPITAL:Patient came to the OPD with the above complains and was admitted to the
GENERAL WARD of Akash hospital and diagnosis of Acute Gastroentrities made blood
investigations were done and followed patient is being discharged as she is hemodynamicaly stable
DIAGNOSIS:-
-ACUTE GASTROENTRITIES
TREATMENT GIVEN:-
TAB DOLO 650MG 1-1-1
TAB SPOROLAC 1-1-1
TAB REDOTIL STAT
INJ METROGYL 100ML 1-1-1
INJ EMESET 4MG 1-0-0
INJ CIPLOX 500 MG (ATD) 1-0-1
INJ PANTOP 40mg 1-0-0
IV FLUIDS 1NS with optineuron 1-0-0 at 75ml/hr
IV FLUIDS NS /RL @ 100ML/HR
CONDITION ON DISCHARGE :
HEMODYNAMICALLY STABLE
ADVICE ON DISCHARGE-
TAB SOMPRAZ-D 1-0-0 3DAYS
TAB SPOROLAC 1-1-1 3DAYS
TAB DOLO 650 MG 1-1-1 SOS
TAB REDOTIL 1-0-1 3DAYS
TAB ORNI-O 1-0-1. 3DAYS
Review in the medicine I OPD on monday and thursday after 1 week
VERIFIED BY AP AND SR
