ROYAL GOVERNMENT OF BHUTAN

JIGME DORJI WANGCHUK NATIONAL REFERRAL HOSPITAL

Patient Discharge Form FORM Q3
Name Jamyang Tashi Age 39 Sex Male
Date of admission 09.04.2021 Time 16:00 HRS CID No. 11913001318
Date of Discharge 12.04.2021 Time 11:00 hrs Mobile No. 17311276
Ward Surgery. Cabin B Hospital Reg. No. 34211
Allergies Yes No

DIAGNOSIS ICD CODE

FINAL Symptomatic Varicose Vein (Left Leg)
OTHERS
SUMMARY OF HISTORY AND TREATMENT:
Known case of varicose vein who underwent phelobotomy in 2001, this time presented with history of left
leg pruritus and ulcer for 3 years duration. No history of leg swelling or fever.

On examination:
Afebrile, not pale or icterus with adequate hydration.
Local examination- C2 varicose vein at the medial aspect of Left Leg. Trendelenburg test negative.
Rest of the systemic examination was normal

Investigation:
WBC- 5.03, N-52.6% Hb- 16 g/dl, Plt- 317. RFT/LFT-WNL.PT/INR- WNL.TFT- TSH-5.55, T3/T4-
WNL.
USG Lower limb venous Doppler- Incompetent saphenopopliteal junction with persistent reflux into dilated
tortuous SSV. Varicose vein and perforator as described above. Competent SFJ. No evidence of DVT.

Management:
Surgery: Left Sapheno-popliteal ligation and multiple phlebotomy under SA done on 10/04/21 by Dr.
Jigme Dorji and Dr. Jigme Sherab.
Findings: Grossly dilated SSV of left leg
Post-Op: Uneventful

On Discharge:
Patient is clinically and hemodynamically stable.
☐Recovered ☐Recovering ☐Terminal Care ☐LAMA ☐Absconded ☐ Referred ☐ Death
INSTRUCTIONS ON DISCHARGE:
1. Tab Paracetamol 500 mg TDS X 3 days
2. Compression stocking X 3 months (remove at night)
3. Keep limb elevated
4. Suture removal on 19/4/21 at chamber 12

FOLLOW UP
Review SOS of patient develops pain, discharge from surgical site or fever.

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Surgical Appointment number: 77858801/17841104
 ROYAL GOVERNMENT OF BHUTAN
JIGME DORJI WANGCHUK NATIONAL REFERRAL HOSPITAL
Patient Discharge Form FORM Q3
Prepared by Dr. Jeewanath Lamichaney P.reg 206

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Surgical Appointment number: 77858801/17841104