Discharge Summary
Patient Name : [80 Yr /M] LSHHI275913
Address : H NO 680 Sec- 7 B, Faridabad, HARYANA
Mob. No. :
Next Of Kin : Vivek (SON)
IP. No. : IP195829 Dept./Speciality : INTERNAL MEDICINE
Adm. Date : Discharge Date :
Ward Info. : BED NO.-4109/SINGLE ROOM
CATEGORY/FOURTH FLOOR-
SAVITRI BLOCK
Discharge Condition : Stable
Treating Doctor : Dr.Sumit Aggarwal (Internal Medicine)
Patient Category : Park Mediclaim
Final Diagnosis
? DENGUE FEVER(IGM POSITIVE)
SEVERE DIFFUSE ARTHALGIA
FUC- DIABETES MELLITUS/ HYPERTENSION
Presenting Complaints
C/O high grade fever , bodyache , severe generalised weakness , difficulty in walking , cough , shortness of breath ,
increase frequency of urination.
Provisional Diagnosis
ACUTE FEBRILE ILLNESS ? CAUSE WITH DIFFUSE ARTHRALGIA
Examinations
23-11-2019 02:32 PM
Conscious, Oriented, febrile
PR - /min, BP -130/90 mmHg,
RR - 20/min,
Chest - B/L clear,
CVS - S1,S2 (N),
CNS - NAD,
P/A - Soft, BS (+)
Course in Hospital
A 80 year old male presented with c/o high grade fever , bodyache , sevre generalised weakness , difficulty in
walking , cough , shortness of breath , freaquency of urination since 3-4 days
IP. No. - IP195829 Page 2 of 4 / LSHHI275913
FUC-DM/HTN
At the time of examination, patient was conscious, oriented and febrile.
After evaluation, patient was admitted in wards under Dr.Sumit Aggarwal.
All relevant investigations done in which
CBC-Hb-11.6gm,TLC-12.37,ESR-78,Platelets count-315K
KFT:-WNL
LFT:-WNL
USG Abdomen-grade 2 fatty changes in liver , cholelithaisis , PVR-18 CC
Urine for R/M-WNL
DENGUE IGM- detected
Chest x-ray-WNL
Patient managed accordingly with i/v antibiotics(INJ
ceftriaxone ,),antiemetics,PPI,antipyretics,analgesics,probiotics,decongestants,i/v fluids and other supportive
measures.patient was started on blood sugar series and managed accordingly.
on25.11.2019 patient had c/o fever , cough nausea , difficulty in walking
repeat cbc : hb-11.1 , tlc- 11.78 , plt-322k
RA FACTOR-12
ANTI CCP-7
same lin eof treatment continued
ON 26.11.2019 patient had c/o fever , diffuse bodyache
repeat cbc : hb-11.8 , tlc-12.67 , plt-311k
serum creatinine-1.07
tab saaz added and rest same line of treatment continued.
on 27.11.2019 patient had c/o fever , bodyache
repeat cbc : hb-11.8 , tlc-13.45 , plt-215k
same lin eof treatment continued
on 28.11.2019 patient had no fresh complaints and is symptomatically better than before
Repeat investigation showed -CBC -Hb - 11.8, TLC - 13.45, PLT - 215K.
Patient responded well to the given treatment and hence being discharged with follow up advise and medications.
IP. No. - IP195829 Page 3 of 4 / LSHHI275913
Vitals at discharge:-P-88/ min
BP-120/70mmhg
SPO2-98%on room air
Temp-98*f
.
Treatment Advice On Discharge
Sr.No Description Remark
1 Cap PAN D - 1 cap twice a day 2 days
2 Tab DOLO - 650MG 1 tab As required
3 Tab FOLVITE - 5MG 1 tab Once a day 2 days
4 Tab TELMA AM - 1 tab twice a day 5 days
- (40+5)
5 Tab SAAZ - 500MG 1 tab twice a day 2 days
6 Tab MONTAIR LC - 1 tab at bed time 2 days
7 Tab JANUMET 50/500MG - 1 tab twice a day 2 days
- After breakfast and after dinner
8 Rotacap FORACORT (400) WITH rotacap twice a day 2 days
REVOLIZER - - FOLLOWED BY GARGLES
9 Nebulizer DUOLIN - 6 - 8 hourly 4 times a day 2 days
- F/B GRAGLES
10 Nebulizer BUDECORT - 12 hourly twice a day 2 days
- FOLLOWED BY GARGLES
11 Tab AMRYL - 1MG 1 tab Once a day 2 days
- 1MG BEFORE BREAKFAST
Advice
Do not stop any medication without doctor advice
Back and shoulder physiotherapy x 1 week
Consult Doctor/Hospital In Case Of
IP. No. - IP195829 Page 4 of 4 I / LSHHI275913
High grade fever / Vomiting / Pain Abdomen / Giddiness / Palpitation
DIET
Diet as advised
Avoid spicy, oily, fatty meals
No tea, coffee on empty stomach
Condition At Discharge
Symptomatically better
Accepting oral feeds well.
Follow Up
Follow up after 2 days with Dr Sumit Aggrawal in internal medicine OPD with blood sugar charting, fasting, 2
hours after breakfast, lunch, dinner with Repeat CBC.
Dr.Sumit Aggarwal Prepared By
Senior Consultant - Internal Medicine RMO SINGNATURE
SARVODAYA HOSPITAL
