ROYAL GOVERNMENT OF BHUTAN

JIGME DORJI WANGCHUK NATIONAL REFERRAL HOSPITAL

Patient Discharge Form FORM Q3
Name Ugyen Wangmo Age 75 Sex Female
Date of admission 15.04.2021 Time 15:30 HRS CID No. 10211001239
Date of Discharge 16.04.2021 Time 11:00 HRS Mobile No. 77707737
Ward Surgery. Cabin B Hospital Reg. No. 228761
Allergies Yes No

DIAGNOSIS ICD CODE

FINAL Hepatic cyst under evaluation
OTHERS Hypertension on medication
SUMMARY OF HISTORY AND TREATMENT:
Presented with insidious onset right upper quadrant pain for 1 week duration, which was aching in nature
and aggravated by manual work and relieved by rest. It was not associated with fever, urinary symptoms
and yellowish discolouration of eyes.

On examination:
Afebrile, not pale or icteric with adequate hydration
Abdomen- Soft. No organomegaly
Rest of the systemic examination was normal

Investigation:
WBC- 12.55, N- 69% Hb- 13.7g/dl, Plt- 324 RFT-K-3.0, rest-WNL. LFT-AST/ALT- 33/25. ALP-107.
TB/DB-0.6/0.22, Amlyase- 41. ````
USG (15/4/21)- A well-defined thinned wall cystic lesion measuring – 13.5 X 14 cm seen in right lobe of
liver.

Management:
Conservatively.

On Discharge: Patient is clinically and hemodynamically stable

☐Recovered ☐Recovering ☐Terminal Care ☐LAMA ☐Absconded ☐ Referred ☐ Death
INSTRUCTIONS ON DISCHARGE:
1. Tab Losartan 50 mg OD X 1 month
2. Tab Hydrochlorothiazide 25 mg OD X 1 month
3. Tab Ibuprofen 400 mg TDS X 1 week
4. Tab Ranitidine 150 mg BD X 1 week

FOLLOW UP
1. CT scan on 28/4/21
2. Review at surgical OPD with CT report
3. Review SOS if abdominal pain, yellowish discolouration of eyes or fever

Prepared by Dr. Jeewanath Lamichaney P.reg 206

Page | 1 of 2 CONTROLLED FORM

Surgical Appointment number: 77858801/17841104