KATHMANDU MEDICAL COLLEGE & TEACHING HOSPITAL

Sinamangal, Kathmandu, Nepal

: 4476152, 4469064*
DISCHARGE ON REQUEST
Department of medicine

Name of the patient: SAKSHI RANABHAT

Age/Sex: 21YEARS/FEMALE MEDICINE UNIT I
Address: Kuleshwor PROF DR ARPANA NEOPANE
IP no: 133101 DR SUBASH PANT
Phone No: +977 9810130776 DR TULSI RAM BHATTRAI
Bed no: C 24
Date of Admission: 2022/15/01 DR SUJAN CHANDRA POUDEL
Date of Discharge: 2022/17/01

DIAGNOSIS:
ACUTE GASTROENTERITIS
Case Summary:
The patient was in usual state of health 4 days back when she started passing clay coloured stool, semi-solid in consistency, but it was non-foul
smelling and easily flushed.
She also complains of vomiting coffee ground coloured vomitus for 1 day.
There is no history of retching, cough.
No history of use of pain killers
No history of alcohol intake
No history of abdominal distension, fever, chest pain, palpitation, orthopnea, PND, dyspnea, LOC, SOB, headache, burning micturition, gum
bleeding and rash.
PAST HISTORY:
Past history of epigastric pain. Endoscopy done and biopsy taken but reports are not available.
No history of HTN, DM, COPD, thyroid disorders in the past.
EXAMNINATION AT THE TIME OF ADMISSION:

On examination:
G/C – fair
S/E:
PILCCOD- pallor (+nt) Chest: NVBS, B/L equal air entry
VITALS: CVS: S1S2M0
T: 98.2F P/A : soft, non-tender, BS+
Pulse: 90bpm CNS: intact
RR- 32/min
BP- 120/70mm of Hg
SpO2- 94% in RA
Treatment in the Hospital: Patient was admitted, investigated, evaluated and managed for 2 days with medication INJ PANTOCID,INJ
DNS,INJ XONE,INJ ONDEM .Then patient was shifted to cabin and managed with INJ XONE,INJ ONDEM,INJ PANTOCID,SYP
SUCRALFATE,TAB GRANDEM.
Condition at Discharge:

G/C – Fair
S/E: PILCCOD –nil
P/A: soft, non-tender, no palpable Organomegaly and bowel VITALS:
sound present. Pulse:84 bpm
RS : B/L equal air entry, NVBS, no added sound RR: 20/min
CVS: S1S2M0 Temp: 98F
CNS: grossly intact BP: 120/80 mmHg
SpO2: 98% in RA
TREATMENT AT DISCHARGE:
1. TAB PANTOCID 40MG PO BD FOR 2 WEEKS
2. SYP SUCRALFATE 15MG PO QID FOR 5DAYS
3. TAB GRANDEM 1MG PO OD FOR 3DAYS
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SIGNATURE OF MEDICAL OFFICER
DR. SUJU BHATTARA
Phone No. 9851235333