SHRESTA HOSPITAL

#23-342/1 Beside water service station, Puttur road, Kongareddy palli, chittoor-
517001 AP
DISCHARGE SUMMARY
Consultant: Dr. G. SHALINI MBBS DNB (OBG)
Dr. Dhananjayulu MBBS, MD [Anaesthesiology]
Patient Name:-K.Ramya Guardian:- MR. T.Anjaneyulu
Age:- 23yrs sex:- Female
Date admission:03.11.2023 Date discharge: 08.11.2023 Inpatient no:031120231
Address:- Bandapalli (v),(p) Pathapalyam(M), chittoor(D) AP
Diagnosis:- Primigravida With 39 weeks 5 days of gestation in latent labour for safe
confinement
Procedure: Emergency LSCS done under spinal anaesthesia on 4.11.2023
Ind: Non Progress of labour with foetal distress
Reason of admission: Primigravida with 39weeks 6 days gestation with complaints of mild
pain abdomen.Perceiving fetal movements well.No complaints of leak PV or bleed PV
History :
Menstrual history : Regular
Obstetric History : Primi LMP:29/01/2023, EDD: 5/11/23
Medical History: Nil,Surgical History: nil,Allergies: Nil
Family History : Nil
Investigations:Reports Enclosed
Examination and findings:
PR:86/min,BP:120/80 mmHg,RR:16/min,SPO2:98% Ra
Systemic examination:CVS,RS – NAD.
P/A-Uterus term size,mildly acting,head lower pole,FHS +,
P/v – cervix-1cm dilated,30% effaced,vertex high up,pelvis -borderline
Procedure:
Emergency LSCS done under Spinal anaesthesia on 4/11/23.
Indication: CPD with Non Progress of labour and fetal distress.
Findings: LUS – Stretched,A live male baby delivered by vertex
One loop of cord present around the neck released
Intraop period :Normal
Baby Details:
Date:04.11.2023
Time:2:13 Pm
Sex: Male
Weight:3.18kgs
Postoperative notes: Uneventful
recovery - good
Advice on discharge:-
Tab.Taxim O 200mg 1-0-1 for 5 days
Tab. Pantocid DSR 1-0-1 for 5 days
Tab. Lyser D 1-0-1 for 5 days
Cap. Becosules 0-1-0 for 15 days
Review after 10 days

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