DISCHARGE SUMMARY

Patient Name MPI Gender Blood Spouse

Group Name Age
Anusha 0 1000000100088914 3065 Female Sandesh A
Positive 29Y

Admission Date Discharge Date Admission Tíme Discharge Time

02-10-2023 04-10-2023 06:42pm 03:00PM
Admission Purpose Date of surgery Admitting Physician Hospital DaywNights
Deliver 02/102023 Dr. Vecna K 3/2
Department Ward Room Bed
OBGGynic/Pediatric/Others Sccond Floor Luxury Room 206
DIAGNOSIS: Primigravida at 39+1weeks of Gestation with Hypothyroidism Cephalic Presentation
with Corrected Anaemia for Safe
HISTORY OF PRESENTING ILLNESS:
Confinement
History of 9 months of amenorrhea came for safe
Appreciating fetal movements well confinement
No complaints of pain abdomen,
Patient had regular ANC'S on iron,leaking
PV or bleeding PV
calcium and proteins, Inj. TT 2 doses taken
History of corrected anaemia, parental iron one dose 2 weeks ago,
PREVIOUS MENSTRUAL HISTORY: Cycles regular Inj. FCM 500mg
OBSTETRIC HISTORY:
Primigravida
LMP: 01/01/2023, EDD:
PAST HISTORY: Known08/10/2023,
POG - 39+1 weeks
case of Hypothyroidism on Tab. Thyronorm 50mcg
FAMILY HISTORY: Grand mother - Diabetic (since 2nd trimester)
ON EXAMINATION:
GC - Fair, conscious, oriented
Afebrile
Pulse: 116/min
BP: 120/70 mmHg
Weight - 89 kg
Breasts: Soft, Nipples Normal
CVS/RS: NAD
PA: Uterus ~term size, relaxed, FHS -
166 bpm
INVESTIGATIONS:
Blood Group - "0" Positive
Serology - Negative
02/10/ 2023: HB - 11.6 gms%, Platelet - 2.67 lakhs
OB SCAN SHOWS ON
- 12cms, EFW - 2.6 kg, 12/09/2023: SLIUF at 35+3 weeks gestation, cephalic
TREATMENT GIVEN:
PIacenta anterior upper segment, presentation, AFI
doppler-normal, BPP-8/8.
IVFluids
Inj. Xone 1gm IV BD
Inj. Paracetamol lgm IV TID
Inj. Pan 40mg IV OD
Inj. Emeset 4mg IV stat/SOS
Inj. LMWH 40mg S/Cstat
Inj. Tramazac 5Omg IM SOS
Tab. PPH 600mcg
Tab. Justin 100mgsuppository
suppository
Tab. Taxim - 0 200mg
1-0-1 (After food)
Tab. Pan 40mg 1-0-0 (Half an hour before food)
Tab. Dolo 650mg 1-0-1 (After
Tab. Emanzen -D 1-0-1 food)
(After food)
 COURSE IN HOSPITAL: Mrs. Anusha O, 29 years, Primigravida at 39+1
Cephalic Presentation with weeks of Gestation with
Emergency LSCS under SACorrected
on
Anaernia for Safe Confinenment. Patient
02/10/2023. underwent
DETAILS OF SURGERY:
Emergency LSCS under SAon 02/10/2023
Indication: Non reassuring NST
Surgeon: Dr., Veena K
Anaesthetist: Dr Arpitha
Pfannenstiel incision - Abdomen opened ir layers.
Intraoperative Findings:
delivered completely and healthy,Liquor clear and adequate,
-
placenta and membranes
normal, no utarine anomalies, plecenta -- fundal anterior, Bilateral tubes and ovaries
Delivered a single live Female
baby of
on
02/10/2023 at 10:08PM. Baby birih. weight 3.62kgextracted by vertex
Baby handed over to cried immediately after birth.
Pediatrician,
Uterus closed by continuous Placenta & membranes
extracted out in toto.
Hemostasis achieved, mops and interlocking suture.
approximated with subcutaneous instrument
sutures.
count verified. Abdomen closed in
layers. Skin
Urine clear at the end of
surgery.
Patient withstood the procedure
Post operative period well.
following advice. uneventful. Patient hemodynamically stable, hence
ADVICE ON DISCHARGE: discharged with
Normal diet/ plenty of fluids
Tab. Taxim - 0200mg 1-0-1 for 4
Tab. Pan 40mg days (After food)
Tab. Emanzen-D1-0-0 for 4 days (Half an hour before food)
Tab. Dolo 650mg 1-0-1 for 4 days (After food)
1-1-1 for 4 days (After food)
Syp.Duphalac O-0-3tsp (if there is
Next Review: Review after 1
constipation)
week with Dr. eena K with
prior appointment / SOS.
Disciaimer: Tine discharge summary has
charge of patient. Any been prepared as per
information
GRE disclaimer:
confirmrdtheyare correct.discrepancies/Inconsistencies
I have checked all the to be addressed given by consultant in
to the consultant.
demographic details of the conceraeh patient andIhave
Name
Registrar disclaimer: Ihave checked --Signature
all the medical details of
confirmed they are correct. the concernet patient and I
have
Name-
all--Signature-
Patient's
name, dateDisclaimer:
I have
of admission, DOB received the relevant details of the
of
agree that the details are correct the baby and Date of discharge among discharge summary including
including the t:sts conducted. the other things and I
Name--..An hog-o
Any --Signature----
queries/emergency,Please
please call-in house
Obstetrician: 9513909712
2433030/7996711177.
bleeding PV/ Fever/ Discharge from the Hospital inmmediately if there are Hospital No.0821
visit the
complaints of
other emergencies. operated site/ Foul smelling vaginal Excessive
discharge and for any
Dr. Veena K
Obstetrics
KMC- 61305and Gynaecology
Kangaroo care Women and Children Hospital