DR SISHIR SHRESTHA NMC NO 20919

1. KATHMANDU MEDICAL COLLEGE& TEACHING HOSPITAL
Sinamangal, Kathmandu, Nepal
: 4476152, 4469064*
DISCHARGE
DEPARTMENT OF INTERNAL MEDICINE
Name of the patient:
Age/Sex: YEARS/MALE
IP no: 17
Address:
Date of Admission: 2079/07/
Date of Discharge: 2079/07/
Case Summary
According to the patient, the patient was in the usual state of health 5 days back when patient developed fever associated with
chills and rigor, headache and myalgia ,Tmax=102F relieved by PCM without diurnal variation.
There was also history of a episode of nose bleed, spontaneous onset and spontaneous relieved , as fresh red on colour, non
foul smelling .
The epigastric pain which was acute onset and non radiating in nature.
Then she developed vomiting of 2 episode, non projectile and non blood and bile stained.
She also complained of looses stool for 3-4 episode , noon blood and non mucus stained.
History of SOB present , acute on onset, gradually progressive in nature, initially present while walking for a short distance
from home, later after he developed SOB even on rest, but not associated with Orthopnea and PND, uses 1 pillow for sleeping.
Also history of cough for 7 days, acute, dry in nature, more during evening , no postural variation, not associated with running
nose .
She also has history of altered consciousness level since the day of fever onset, with increased sleeping , difficulty arousing
and not recognizing relatives
No h/o altered sensorium, abnormal body movement, LOC
No h/o chest pain, SOB, cough, palpitations, pedal edema
No h/o vomiting, abdomen pain, loose stool, yellowish discoloration of eyes and body
No h/o of bleeding sites, no gum bleeding.
No h/o joint pain, rashes
No h/o burning micturition , decreased urine output, facial puffiness
Past history:
K/C/O DM under medication since 9 years
K/C/O HTN under medication since 9 years
No history of COPD, thyroid disorder
Personal history:
Non-alcoholic, non-smoker.
Normal sleep/appetite /bladder habits.
Consumes mixed diet
EXAMINATION AT THE TIME OF ADMISSION:
On examination:
S/E:
Chest: B/L NVBS with left infrascapular crepts
CVS: S1S2M0
P/A: soft, non-tender
CNS: grossly intact
G/C – ill-looking, well oriented to TPP
PILCCOD- Dehydration present, mild B/L pitting edema
present
VITALS:
Temp: 98.2 F
Pulse: 110bpm
RR- 24/min
BP- 110/70 mm of Hg
SPO2-98% in NP
DIAGNOSIS:
DENGUE FEVER (RESOLVED)
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. INVESTIGATIONS
HB/PCV
TC
DC(N-L)
PLATELETS
CRP/ESR
RBS
UREA/CR
NA/K
TB/DB
SGOT/SGPT
ALP
PT/INR
PROTIEN/ALBUMIN
AMYLASE/LIPASE
CALCIUM/PHOSPHORUS
S. URIC ACID
MCV/MCH/MCHC
TOTAL CHOLESTEROL
HDL/LDL
TGs
CPKMB/TROP I
LDH
URINE ACETONE
HBIAC
URINE RME; PUS-
EPI-
RBS-
URINE C/S
DENGUE TEST
SEROLOGY
USG AP
 Fatty liver changes
 B/L minimal pleural effusion
Treatment in the Hospital:
Patient presented to ER and was admitted in and was managed with.
The patient’s condition is subjectively improving and is being discharged with the following advice.
CONDITION AT DISCHARGE:
VITALS:
Pulse: 92 bpm
RR: 20min
Temp: 98F
BP: 110/70mm of Hg
SpO2: 93% in RA
Treatment at discharge
1. TAB PANTOCID 40 MG PO OD FOR 7 DAYS
G/C: Fair
PILCCOD –Nil
S/E:
P/A: Soft, non-tender, Bowel sounds present
RS: NVBS
CVS: S1S2M0
CNS: Grossly intact

3. ADVICE:
 F/U IN MEDICINE OPD WITH FBS, PPBS REPORT IN 1 WEEK/SOS
____________________
SIGNATURE OF RESIDENT
DR SISHIR SHRESTHA
NMC NO 20919