sample documents

1. Z
KATHMANDU MEDICAL COLLEGE& TEACHING HOSPITAL
Sinamangal, Kathmandu, Nepal
: 4476152, 4469064*
DISCHARGE
DEPARTMENT OF INTERNAL MEDICINE
Name of the patient: LILA NEUPANE
Age/Sex: 37YRS/FEMALE
IP no: 164576
Address: KATHAMNDU
Bed no: 117
Date of Admission: 2079/06/25
Date of Discharge: 2079/06/27
Case Summary
Patient was in her usual state of health 6 days back when she developed fever which was acute in onset, Tmax recorded was
103F associated with chills and rigor , generalized weakness , headache , relieved on taking oral medications. Patient is afebrile
since last 3 days.
She also complained of vomiting for 3 days , acute in onset , multiple episodes , containing food particles , non-bile and blood
stained associated with nausea , not relieved on taking oral medicines .
No history of bleeding of gum and nose, black tarry stool.
No history of abnormal body movement, LOC, frothing from mouth, up-rolling of eyes.
No history of loose stool , abdominal pain , burning micturition.
Past history:
No history of DM, HTN, thyroid disorder .
Personal history:
Non-smoker and non-alcoholic .
EXAMINATION AT THE TIME OF ADMISSION:
On examination:
S/E:
Chest: NVBS, no added sounds
CVS: S1S2M0
P/A: Soft, non-tender , non distended.
CNS: GROSSLY INTACT
INVESTIGATIONS 2079/06/23 2079/06/25 2079/06/27
HB/PCV 11.3/36.9 12.3/39.3 11.6/33
TC 2000 3800 4200
DC(N-L) 60-35 47-47 37-55
PLATELETS 155000 125000 360000
SGPT/SGOT 380/560
DENGUE NS1
ANTIGEN
POSITIVE
G/C – ill looking
PILCCOD- NIL
VITALS:
Temp: 102.4 F
Pulse: 78 pm
RR- 20/min
BP- 100/70mm of Hg
SPO2-98% in RA
DIAGNOSIS: DENGUE FEVER WITH WARNING SIGNS
DEPARTMENT OF INTERNAL MEDICINE
PROF DR. MATHURA KC
ASST. PROF. DR. SUBASH PANT
DR. ALOK DHUNGEL
DR. ANANTA ARYAL
DR. SUNIL ACHARYA
DR. ABISHKAR ACHARYA

2. Z
Treatment in the Hospital:
Patient presented to ER and was admitted to general medicine WARD and where she was evaluated and managed with, IV FLUIDS, INJ
ACILOC, INJ ONDEM , TAB MEDOMOL, and other supportive management. She is being discharged after her vitals are stable.
CONDITION AT DISCHARGE:
VITALS:
Pulse: 80bpm
RR: 20min
Temp: 98.7F
BP: 110/70mm of Hg
SpO2: 96% in RA
TREATMENT AT DISCHARGE
1. TAB
2. TAB
ADVICE:
DRINK PLENTY OF FLUIDS .
FOLLOW UP IN MEDICINE OPD IN 2 DAYS/SOS WITH CBC, PCV REPORTS
____________________
SIGNATURE OF RESIDENT
DR. LAXMAN KHATI
NMC NO : 26732
G/C: Fair
PILCCOD –Nil
S/E:
P/A: Soft, non-tender, bowel sound present.
RS: NVBS, B/L equal air entry
CVS: S1S2M0
CNS: Grossly intact