ER DISCHARGE SUMMARY (Unapproved)

ER ID / PatientID : 90454 / 8171334 Address : Ratopul

Name : Mr.DILIP KUMAR VERMA Discharge Ward : EMERGENCY
Age/Gender : 64 Y / Male Admission Date : 2023-04-01 AD 22:49:10 (2079-12-18 BS)
Panel Name : General-Non Cat Discharged Date : 2023-04-02 AD 00:05 (2079-12-19 BS)
Consultant Incharge : Dr.Shambhu Shah Discharged Type : -
Case Type : Emergency Medicine

Final Diagnosis : S/P LAPAROSCOPIC CHOLECYSTECTOMY DONE ON 02/APRIL/2023

K80-CHOLELITHIASIS
K/C/O PROSTATOMEGALY GRADE I

NOTES
27Y Primi was admitted to the hospital for Dexona administration. Dr Dina Consultation was done for GDM.
Patient received 6mg Dexona 12 hrs apart(total 24 mg). During her stay in the hospital she was kept on sugar
charting, her vitals and FHS were monitored regularly. She is now being discharged with stable vitals
LAB INVESTIGATION
2023-04-01 22:50:58
DLC-0 , TLC - 14680cell/cumm, HB (HAEMOGLOBIN) - 13.5gm%, HCT / PCV - 40.8%, RBC - 4.73millions/cumm, MCV -
86.4fl, MCH - 28.5pg, MCHC - 33.0%, PLATELETS COUNT - 270000cells/cumm, S. UREA - 21mg/dl, S.CREATININE -
0.74mg/dl, S.SODIUM - 132mEq/L, S.POTASSIUM - 3.6mEq/L, S. TOTAL PROTEINS - 7.40g/dL, S. GLOBULIN -
2.55g/dL, ALBUMIN - 4.85g/dL, S. SGOT - 23U/L, S. SGPT - 25U/L, S.ALKALINE PHOSPHATASE - 82U/L, S.BILIRUBIN
DIRECT - 0.16mg/dl, S.BILIRUBIN (TOTAL) - 0.31mg/dl, SUGAR RANDOM - 113.60mg/dl

ADVICES
DIABETIC DIET
W/F DECREASED FETAL MOVEMENT,PV BLEEDING, ABD PAIN

FOLLOW UP
F/U IN DR AMRITA OPD IN 1 WEEK( 12TH APRIL,2023 WEDNESDAY) WITH REPORTS/SOS
F/U IN DR DINA OPD AFTER 3 DAYS (9TH APRIL,2023 SUNDAY)WITH FASTING AND PP REPORTS.
Patient Condition : Recovered/Cured
Patient Condition : Recovered/Cured

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