DISCHARGE MEDICAL REPORT

NAME : OLGA PAUL

AGE : 32 YEARS OLD
SEX : FEMALE
NATIONALITY : GERMANY
DATE OF HOSPITALIZATION : 17TH NOVEMBER 2018
DATE OF DISCHARGE : 18TH NOVEMBER 2018
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INPATIENT COURSE:
PATIENT REPORTS FEELING BETTER, NO PRESENT NAUSEA OR VOMOTING, ABDOMINAL
PAIN, DIARRHEA AND ANOTHER SYMPTOMS.
DURING HER HOSPITALIZATION WAS RECEIVING IV ANTIBIOTIC (CEFTRIAXONE 2 GR EV
EVERY 24 HOURS), PARENTERAL HYDRATION AND SYMPTOMATIC TREATMENT.

AUXILIARY EXAMS
 CBC:
LEUKOCYTES: 6.8 XUL (SEG 72%)
HEMATOCRITE: 49%
HEMOGLOBINE: 16.3 GR/DL
 SERIC GLUCOSE: 97 MG/DL
 SERIC UREA: 24.6 MG/DL
 SERIC CREATININE: 0.72 MG/DL
 CRP: 0.44 MG/DL
 SERIC ELECTROLYTES: NA: 143 MMMOL/L, K: 3.9 MMOL/L, CL: 109 MMOL/L
 WIDAL TEST: TYPHIC O: 1/80 DILS, TYPHIC H: 1/80 DILS, PARATYPHIC A: NEGATIVE,
PARATYPHIC B: 1/80 DILS
 URIANALYSIS: LEUKOCYTES 3-5 X FIELD, BLOOD CELLS: 0-1 X FIELD
 FECANALYSIS: NO PARASITES, NO INFLAMMATORY REACTION, BACTERIAL FLORA
CONSERVED

PHYSICAL EXAMINATION:
VITAL SIGNS:
BLOOD PRESSURE: 110/70 mmHg HEART RATE: 80/min BREATHING RATE:
20/min TEMPERATURE: 36.6° C SPO2: 93% WITHOUT O2

PREFERENCE PHYSICAL EXAM:

 GENERAL: PATIENT IN GOOD GENERAL CONDITION, GOOD STATE OF HYDRATION,

 HEAD: WET ORAL MUCOSAL, OROPHARYNX NO CONGESTIVE
 CARDIOVASCULAR: REGULAR RHYTHYM, NO MURMURS
 LUNGS: CLEAR TO AUSCULTATION BILATERALLY
 ABDOMEN: BOWEL SOUNDS NORMAL , SOFT, NON TENDER
 GENITOURINARY: NORMAL
 NEUROLOGIC: AWAKE, GLASGOW 15

DIAGNOSTIC IMPRESSION:
 1. ACUTE GASTROENTEROCOLITIS ON TREATMENT A09.X

DISCHARGE TREATMENT:

 PO CIPROFLOXACINE 500 MG Q/12 HOURS FOR FIVE DAYS

 PO OMEPRAZOLE 20 MG EVERY DAY BEFORE BREAKFAST FOR FIVE DAYS
 PO DIMENHIDRINATE 50 MG IN CASE OF NAUSEA
 PO HIOSCINE 10 MG IN CASE OF ABDOMINAL PAIN
 PO HYDRATION
 MEDICAL CONTROL ACCORDING PATIENT´S SYMPTOMS

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CAROLINA VARGAS RODRIGUEZ, MD
CMP 79993