Database ID:1299099

Basic Infomation
MRD SUR/22/00115411 Name Akila abdul hak
Age 62 Gender F
OPD Number OP/220524/00746 Indoor Number IPD-117
Date of 2022-05-31 Date of 2022-06-06
Admission Discahrge
Discharge Type Discharge

Clinical Information
DIAGNOSIS Viral fever with k/c/o htn with past h/o
ihd

Investigations
Laboratory on Hb-10.30
Laboratory on TBCD reference done at 3/6/22

admission Tlc-4600
discharge Sputum AFB negative

Plc-181000
Sputum GM negative

Urine rm-
T .PCM 500 1-1-1

Sqaumous epithelial cell-1-2/hpf

T.CPM 1 HS

Esr-52
T.alophylline 1-0-1

Rbs-91
Syp nosicold 2tsp TDS

Alt-23
Follow up after report

Tb-0.3
Mantoux test negative
Db-0.1

Ib-0.2

Na-136

K-3.77

Creat-1.21

Radiology on 2d echo-45%
Radiology on
admission Mild mr mild ar
Discharge
Ivc 11mm

USG abdomen

Liver normal in size shape and

echotexture

Kidney normal in size

Spleen normal in size shape

Chest X ray WNL

ECG on WNL,sinus rhythm ECG on

Admission discharge

Treatment Given
Backrest Other Psychiatry reference done on 1/6/22

Treatment T escitalopram 10 1-0-0 for 10.days

T.clonazepam 0.5 0-0-1 10 days

Follow up OPD 13 sos

T.aspirin 75 0-1-0 with food

T atorvas 10 1 tab HS

T.metoprolol 50 1-0-0

T.escitalopram 10 0-0-1

T.clonazepam 0.5 0-0-1

T.acebrophylline 100 1-0-1

Syp duphalac 30cc HS

Syp nosicold 2tsp 1-1-1

Fundus examination done on 6/6/22

Normal retina,no signs of hypertensive

features

IV Fluids ANTIBIOTICS T.azithromycin 500 1 tab for 4 days

ANTACIDS Inj pantop 40 IV 12 hourly ANTIEMETICS Inj emeset 2cc iv sos

IV FLUIDS NSAIDS
ANTIHYPERTESIVE
T.amlodipine 5 1-0-0
ANTI -
T CTD 12.5 1-0-0 DIABETICS

Advice on Discharge
Other Advices T.aspirin 75 0-1-0 with food

T atorvas 10 1 tab HS

T.metoprolol 50 1-0-0

T.escitalopram 10 0-0-1

T.clonazepam 0.5 0-0-1

T.acebrophylline 100 1-0-1

Syp duphalac 30cc HS

Syp nosicold 2tsp 1-1-1