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

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  • 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