INSTITUTE OF MEDICAL SCIENCES & SUM HOSPITAL
(DEPARTMENT OF MEDICINE – UNIT 3)
SIKSHA‘O’ANUSANDHAN (Deemed to be University)
K-8,KalingaNagar, Bhubaneswar
IMS&SH/Form No: 8(A-B)
PATIENT DISCHARGE SUMMARY
Name of Patient: JOGESH KUMAR MOHANTY AGE/Sex – 42YRS /MALE
Date/Time of Admission: 22-Date/Time of Discharge: 25/06/25 atWARD 32BED 23
06-2025, 02:10:07 12PM
Dept/ Unit: MED UNIT-3 IP No: 7008381523 UHID NO- 202506210679
MLC :NO Tel- 7008381523
S/O:- NATABAR MOHANTY
Address:PURI, ODISHA
Admitted with complaints of – BILATERAL LOWER LIMB SWELLING SINCE 7 DAYS,SHORTNESS OF BREATH SINCE
7 DAYS,FEVER SINCE 2 DAYS
History Of present illness: The patient was apparently normal 7 days back then he started developing B/L lower
limb swelling for last 7 days that was insidious in onset starting from bilateral feet and gradually involved bilateral
lower limb.he also complained shortness of breath on exertion since last 7 days that was insidious in onset and
gradually increasing such that it is now (NYHA 3).History of fever low grade 10 days back,,non documented,,not
associated with chills,rigors,not relieved on taking medication.now subsided since last 3 days on taking (TAB MAXIM
200,TAB OFLOMAC 400).
PAST HISTORY- newly detected type 2 dm, n/k/c/o:, HTN, Thyroid ds, Bronchial Asthma
Personal history- Sleep normal, mixed Indian diet, normal bowel & bladder movements. No addiction or
habituation.
INVESTIGATIONS DONE:
17/06/25-ULTRASOUND WHOLE ABDOMEN-GRADE 1 FATTY LIVER,GRADE 3 PROSTATOMEGALY WITH
INSIGNIFICANT PVRU,THICKENED IRREGULAR UB WALL.
18/06/25-SR Na+/K+/Cl-=120/4.21/91,PSA=5.53
RFT-UREA/CREATININE=21.9/0.878,URINE C/S =NO ORGANISM GROWN AFTER 48 HOURS OF AEROBIC
INCUBATION
22/06/25-ESR-70,RFT-UREA/CREATININE-20.0/0.77
Sr Na+/K+/Cl-=126/4.91/93,LFT-BILIRUBIN(t/d)-1.08/0.78,SGOT/SGPT-82/100,ALP-154,ALBUMIN-
3.14,GLOBULIN-3.56,SERUM CORTISOL-13.5
TDT-T3/T4/TSH-2.24/1.42/6.15,HHH-NON REACTIVE,CBC-HAEMOGLOBIN-9.7,WBC-6.94,PLATELET-3.06,PCV-28.7
23/06/25-SERUM IRON-94.9,TOTAL IRON BINDING CAPACITY-306.9,SERUM FERRITIN-1600,SERUM CALCIUM-8.38
24/06/25-STOOL OCCULT BLOOD-NEGATIVE
2D ECHO-NORMAL LVEF,NO LVDD,NO MR,NO AR,TRIVAL TR/NO PAH,NO PE CLOT VEG
FINAL DIAGNOSIS : SOB UNDER EVALUATION,BPH,HYPONATREMIA,UTI,ANEMIA UNDER
EVALUATION
TREATMENT GIVEN- INJ XONE(1GM), INJ LASIX(20),INJ PAN(40),INJ ONDEM(8),TAB DOLO(650),TAB
SILODOL D(8/0.5),SYP LOOZ(30 ml),EXTRA SALT IN DIET
PAGE – 2
COURSE IN HOSPITAL:PATIENT WAS PRESENTED WITH COMPLAINTSMENTIONED OVERLEAF.ALL THE
NECESSARY INVESTIGATIONS WERE DONE.2D ECHO WAS DONE WHICH WAS WITHIN NORMAL LIMIT.USG
ABDOMEN AND PELVIS WAS DONE WHICH SHOWED GRADE 1 FATTY LIVER,GRADE 3PROSTATOMEGALY
WTH INSIGNIFICANT PVRU.THICKENED IRREGULAR UB WALL(LIKELY OBSTRUCTIVE
UROPATHY).UROLOGY CONSULTATION WAS DONE AND ADVISE FOLLOWED .PATIENT WAS MANAGED
CONSERVATIVELY .NOW PATIENT IMPROVED SYMPTOMATICALLY ABD BEING DISCHARGED WITH THE
FOLLOWING MEDICATIONS AND ADVICES.
Discharge vital-PR-92/min, BP:124/88mm of Hg, RR:16 Cycle per minute, Temp:98.2F, SpO2:98% on RA
DISCHARGE MEDICATION -
1. TAB SILODOL D(8/0.5) 1 TAB ONCE DAILY AFTER DINNER TO CONTINUE
2. TAB PAN(40) 1 TAB ONCE DAILY BEFORE BREAKFAST FOR 15 DAYS.
REVIEW ADVICE: TO REVIEW IN MEDICINE OPD ON WEDNESDAY (09/07/25) AFTER 2 WEEKS WITH CBC,SR Na+/K+,URINE
R/M REPORTS.
UNIT HEAD Prof (Dr) Chandan Das
TREATING Dr. Siba Prasad Dalai (Asso prof)
PHYSICIANS Dr. Meghnad Meher (Asst Prof)
Dr. Brijesh Swain (Asst Prof)
Dr. N. Mahesh (Asst prof)
Dr. Debesh Ranjan Dhar (Senior Resident)
RESIDENT Dr. Srinivas
Dr Bhishma
Dr. Vivek
