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✅ 1. CHRONOLOGICAL CASE SUMMARY (290–300 words)
Patient Name: Mrs. Chhaya Rani Mandal
UHID: 1000028588
Age: 76 years 4 months 25 days
Sex: Female
Date of Admission: 06-08-2025
Consultant Name: Dr. Priyojit Bagchi
Bed No: 8009
Mrs. Chhaya Rani Mandal, a 76-year-old female, presented to Desun Hospital Emergency on 05-08-2025 at 23:54 hrs
with complaints of 5–6 episodes of loose stools since morning, generalized weakness, and worsening urinary
incontinence. BP at home recorded as high (160/100 mmHg at 4 PM, 95/55 mmHg at 10 PM). She also had shortness
of breath on exertion for 15 days, and dull pain and discomfort in the abdomen for 1 month.
Known comorbidities include HTN, hypothyroidism, and PPM in situ (2024) for LV dysfunction.
Initial evaluation by Dr. Pritam Langal revealed signs of AGE and electrolyte disturbance. She was shifted to ICU under
Dr. Priyojit Bagchi’s care. On assessment, she was hemodynamically stable. Echo showed concentric LVH, dilated
LA/RA, EF 60%, mild MR/TR, mild PAH, no PR, and JVC collapse.
Ultrasound dated 18-06-2025 (Ruby Hospital) showed grade I fatty liver, simple hepatic cyst, congested IVC,
pericholecystic edema, and acalculous cholecystitis.
Lab workup on 06-08-2025 showed anemia (Hb 11.1), thrombocytopenia (Plt 0.75), high ESR (80), CRP, LFT, RFT, PT-
INR, and ABG advised.
Started on IV RL @ 30ml/hr, Inj. Cefoperazone+Sulbactam, Inj. PAN, Tab. Eltroxin, Tab. Vymada, Tab. Rosavas, Tab.
PCM, eye drops Moistane, Synca LS, Bimatoprost.
Patient is improving on supportive care, on salt-restricted diet and under regular monitoring.
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✅ 2. PROVISIONAL DIAGNOSIS
1. Acute Gastroenteritis (AGE)
2. Acalculous Cholecystitis
3. Hypothyroidism
4. Hypertension
5. S/P Permanent Pacemaker In Situ
6. Mild PAH
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✅ 2A. ONGOING MEDICATION (DOSE & FREQUENCY)
Drug Name Dose Frequency
Inj. PAN40 mg IV OD
Inj. Cefoperazone+Sulbactam 3 gm IV BD
Tab. Eltroxin 50 mcg OD
Tab. Vymada 50 mg BD
Tab. Rosavas 10 mg OD
Tab. PCM 1 gm TDS
Moistane (Eye Drop) 1 drop TDS
Synca LS (Eye Drop) 1 drop BD
Bimatoprost (Eye Drop) 1 drop OD
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✅ 2B. SIGNIFICANT CHANGES IN INVESTIGATION
Hb: 11.1 g/dL
Platelets: 0.75 lakh/cumm
ESR: 80 mm/hr
BUN/Cr: Urea 45.1 mg/dl, Cr 1.4
Na: 135.8, K: 4.28
Amylase: 58.1, Lipase: 27.6
Echo: EF 60%, LVH, mild TR/MR, dilated LA/RA
USG: Pericholecystic edema, acalculous cholecystitis, IVC congestion
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✅ 3. DAILY ROUND NOTE (190–200 WORDS)
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CASE SEEN BY –––– DR MUSTAFA (RMO)
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PROVISIONAL DIAGNOSIS:-
.••
1. Acute Gastroenteritis
2. Acalculous Cholecystitis
3. Hypothyroidism
4. Systemic Hypertension
5. S/P Pacemaker Implantation
6. Mild Pulmonary Arterial Hypertension
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PATIENT CONDITION:-
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ALERT
CONCIOUS
COOPERATIVE
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7. GCS:- E-4 V-5 M-6
8. INFUSION THERAPY:- RL @ 30 ml/hr
9. VASOPRESSOR SUPPORT:- Not required
10. AIRWAY SUPPORT THERAPY:- SELF VENTILLATION
11. Feeding:- Salt-restricted oral diet
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VITALS:-
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BP:- 130 / 80 mmHg
HR:- 60 beats per min
RR:- 19 per min
SPO2:- 98% AT 2L O2 VENTILLATION FiO2 = 2L
S1S2:- PRESENT
B/L VBS:- PRESENT
STOOL:- Passed
URINE OUTPUT:- Adequate
CBS:- 124 mg/dl at 6AM
INTAKE/OUTPUT:- 2000 / 2100 ml
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ADVICE:-
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12. CONTINUE ALL CURRENT MEDICATIONS
13. Chest and limb physiotherapy
14. MONITOR VITALS REGULARLY & INFORM RMO SOS
