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    Discharge Summary: Diagnosis

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    husainnayyer
    Mr. Saiyad Saklain, a 35-year old male, was admitted to the hospital with fever, chills, and rash. He was diagnosed with dengue fever and thrombocytopenia. During his hospital stay, he received intravenous antibiotics and medications and was monitored. His condition improved and he was discharged with oral medications and advised to follow up after 5 days.

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    Discharge Summary: Diagnosis

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    husainnayyer
    141 views4 pages
    Mr. Saiyad Saklain, a 35-year old male, was admitted to the hospital with fever, chills, and rash. He was diagnosed with dengue fever and thrombocytopenia. During his hospital stay, he received intravenous antibiotics and medications and was monitored. His condition improved and he was discharged with oral medications and advised to follow up after 5 days.

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    Mr. Saiyad Saklain, a 35-year old male, was admitted to the hospital with fever, chills, and rash. He was diagnosed with dengue fever and thrombocytopenia. During his hospital stay, he received intravenous antibiotics and medications and was monitored. His condition improved and he was discharged with oral medications and advised to follow up after 5 days.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    141 views4 pages

    Discharge Summary: Diagnosis

    Uploaded by

    husainnayyer
    Mr. Saiyad Saklain, a 35-year old male, was admitted to the hospital with fever, chills, and rash. He was diagnosed with dengue fever and thrombocytopenia. During his hospital stay, he received intravenous antibiotics and medications and was monitored. His condition improved and he was discharged with oral medications and advised to follow up after 5 days.

    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    of 4

    Patient NAME : Mr.

    SAIYAD SAKLAIN UHID : CH/23/039609


    Age/Sex : 35.9 YRS Sex : Male IPDNo : 102433
    : 27-Sep-2023 5:58
    Mobile No. : 8169045745 Admission Date
    PM
    Address : HAIDAR NAGAR, CHUNHA KARONDIYA, DHAKHVA, SULTANPUR,,INDIA Discharge Date : 03-Oct-2023 3:15 PM
    : SPR4/Third
    Doctor : Dr. Anurag Srivastava Ward
    Floor/303/4

    DISCHARGE SUMMARY

    Diagnosis :
    AFI/ DENGUE POSITIVE [ OUTSIDE ] WITH THROMBOCYTOPENIA / TRANSAMNITIS / GI BLEED

    Reason for Admission :


    FEVER WITH CHILLS AND RIGOR X 6 DAYS
    RASHES ON B/L UPPER LIMB AND ON TOUNGE X 1 DAY

    History Of Present Illness :


    PATIENT WAS APPARENTLY WELL BEFORE 22/09/2023 WHEN HE DEVELOPED B/L LOWER LIMP PAIN F/B
    FEVER WITH CHILLS AND RIGOR > TAB DOLO 650 MG WAS TAKEN > ON 23/09/2023 ON INVESTIGATION ON
    OPD BASIS PC - 160000 MEDICATION WERE TAKEN FROM LOCAL HOSPITAL > FEVER NOT SUBSIDED > ON
    25/09/2023 - PC 80000 GOT ADMITTED IN FAIZABAD HOSPITAL IN WARD > ON 26/09/2023 - PC 36000 . ON
    27/09/2023 HE DEVELOPED RASHES ON B/L LOWER LIMB AND ON TOUNGUE > REFERRED TO HIGHER
    CENTRE > BROUGHT TO CHL-ER .

    History of Past Illness :


    NO H/O HTN / T2DM / OR ANY OTHER SIGNIFICANT ILLNESS

    Examination :
    VITALS AT TIME OF ADMISSION:-
    B.P- 115/ 80 MMHG CNS- GCS-E4V5M6
    H/R- 102 / MIN CVS- S1&S2 HEARD
    R/R- 20 / MIN R/S- B/L AE+
    TEMP- 99.6 F P/A- SOFT & NT
    SPO2- 97%
    RBS- 112 MG/DL

    CURRENT VITALS:-

    11/10/2023 11:04 Prepared By : DR.DEOBRAT MISHRA Page 1 of 4


    Patient NAME : Mr. SAIYAD SAKLAIN UHID : CH/23/039609
    Age/Sex : 35.9 YRS Sex : Male IPDNo : 102433
    : 27-Sep-2023 5:58
    Mobile No. : 8169045745 Admission Date
    PM
    Address : HAIDAR NAGAR, CHUNHA KARONDIYA, DHAKHVA, SULTANPUR,,INDIA Discharge Date : 03-Oct-2023 3:15 PM
    : SPR4/Third
    Doctor : Dr. Anurag Srivastava Ward
    Floor/303/4

    B.P- MMHG CNS- GCS-EVM


    P/R- / MIN CVS-S1&S2 HEARD
    R/R- / MIN R/S- B/L AE+
    TEMP- F P/A- SOFT & NT
    SPO2- %
    RBS- MG/DL

    I/O =
    BALANCE =
    URINE OUTPUT = ML/HR

    ONGOING INFUSIONS:-
    INJ PAN 80 MG @ 4 ML/HR STOPPED ON 30/09/2023 AT 9 AM

    Significant Findings/Course of stay :


    PATIENT GOT ADMITTED WITH ABOVE MENTIONED CHIEF COMPLAINTS FOR WHICH HE WAS
    EVALUATED, RELEVANT INVESTIGATIONS WERE SENT AND THE PATIENT WAS MANAGED
    CONSERVATIVELY WITH IV ANTIBIOTICS AND OTHER ORAL MEDICATIONS. DURING THE COURSE OF
    STAY IN HOSPITAL PATIENT WAS ALSO SEEN BY GASTROENTEROLOGIST AND THEIR ADVISE WAS
    FOLLOWED. NOW THE PATIENT IS BEING DISCHARGED ON ORAL MEDICATIONS AS ADVISED.

    Investigations :
    ATTACHED

    Treatment Given :
    INJ DOXY 100 MG IV BD .............D5
    INJ PAN 40 MG IV BD
    INJ EMSET 4 MG IV SOS
    INJ TRANEXA 500 MG SOS
    INJ PCM 1GM IV SOS
    INJ OPTINEURON 1 AMP IV OD
    INJ MUCOMIX 1 GM IV TDS

    11/10/2023 11:04 Prepared By : DR.DEOBRAT MISHRA Page 2 of 4


    Patient NAME : Mr. SAIYAD SAKLAIN UHID : CH/23/039609
    Age/Sex : 35.9 YRS Sex : Male IPDNo : 102433
    : 27-Sep-2023 5:58
    Mobile No. : 8169045745 Admission Date
    PM
    Address : HAIDAR NAGAR, CHUNHA KARONDIYA, DHAKHVA, SULTANPUR,,INDIA Discharge Date : 03-Oct-2023 3:15 PM
    : SPR4/Third
    Doctor : Dr. Anurag Srivastava Ward
    Floor/303/4

    TAB ULTRACET SOS


    TAB HEPTRAL 400 MG PO OD
    TAB CARIPIL 1 TAB PO OD
    TAB UDILIV 300 MG PO BD
    TAB FOLVITE MB PO OD

    SYP DUPHALAC 30 ML PO HS
    SYP SUCRANITH PLUS 10 ML PO TDS
    SYP HEPTAGON 1TSF BD

    Treatment Advice on Discharge :


    CAP PANTOCID DSR ONCE A DAY BEFORE BREAKFAST
    TAB DOXY 1 L FORTE TWICE A DAY
    TAB FOLVITE MB ONCE A DAY
    TAB CARIPILL TWICE A DAY
    TAB DOLO 650 MG AS REQUIRED
    TAB EMSET 4 MG AS REQUIRED
    TAB UDILIV 300 MG TWICE A DAY
    SYP DUPHALAC 25 ML AS REQUIRED

    Advice On Discharge :
    REVIEW IN MEDICINE OPD AFTER 5 DAYS WITH CBC LFT KFT
    MAINTAIN ADEQUATE HYDRATION

    Follow-up Instructions :
    IN CASE OF ANY EMERGENCY LIKE FEVER, LOOSE MOTION, RECURRENT VOMITING, VERTIGO, CHEST
    PAIN, BREATHLESSNESS, DROWSINESS PLEASE VISIT CHANDAN HOSPITAL OR CONTACT AT 0522-
    6666666. FOR ONLINE APPOINTMENT CALL AT +91 7311170955 ( 8AM TO 7PM )

    Qualification & Registration No :


    DR. ANURAG SRIVASTAVA
    MBBS , MD GENERAL MEDICINE

    11/10/2023 11:04 Prepared By : DR.DEOBRAT MISHRA Page 3 of 4


    Patient NAME : Mr. SAIYAD SAKLAIN UHID : CH/23/039609
    Age/Sex : 35.9 YRS Sex : Male IPDNo : 102433
    : 27-Sep-2023 5:58
    Mobile No. : 8169045745 Admission Date
    PM
    Address : HAIDAR NAGAR, CHUNHA KARONDIYA, DHAKHVA, SULTANPUR,,INDIA Discharge Date : 03-Oct-2023 3:15 PM
    : SPR4/Third
    Doctor : Dr. Anurag Srivastava Ward
    Floor/303/4

    DFID, CCMH, CCMTD

    *** End Of Report ***

    11/10/2023 11:04 Prepared By : DR.DEOBRAT MISHRA Page 4 of 4

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