KARNATAKA INSTITUTE OF MEDICAL SCIENCES HUBLI KARNATAKA

 
Govt of Karnataka

hubballikims.karnataka.gov.in

    DISCHARGE SUMMARY    
   
  UHID : 20220284279  
Mr. BASAPPA
Patient Name: MUDAKAPPA Department: GENERAL SURGERY
MADIWALAR
75 Years 0 Months 4
Age /Sex: Unit:: F UNIT
Days 0 Hours
/
Male
S/O
: MUDAKAPPA Ward:: 203 Surgery Ward
Billing Type : ANTYODAYA CARD MLC Patient: NO
IPD Admission ID Discharge Issue Temporary Death
202252231
:: Type: Certificate
Treating Doctor: Dr. KG Byakodi, Bed No: F
Mobile No:    Drug Allergy :-  
Date of 22/10/2022 01:40:45    
Admission: PM
Operation Date: 22/10/2022    
Date of 26/10/2022 09:30:00
Discharge : PM
UPPIN BETAGERI TQ
DHARWAD,
9845839653 ADR
Address :
818344031600,
DHARWAD,
KARNATAKA, INDIA
Asst.Surgeon
Surgeon :
:
22/10/22
RESECTION 22/10/22
RESECTION
OF JEJUNUM WITH OF JEJUNUM WITH
END TO END END TO END
JEJUNOJEJUNAL JEJUNOJEJUNAL
Operative
Procedure : ANASTOMOSIS UNDER ANASTOMOSIS
Findings :
GENERAL UNDER GENERAL
ANAESTHESIA ANAESTHESIA
+EPIDURAL +EPIDURAL
ANAESTHESIA. ANAESTHESIA.
Consulting
Dr. KG Byakodi
Doctor :

  Diagnosis  
PURULENT PERITONITIS SECONDARY TO HOLLOW VISCUS PERFORATION.

ICD Code: K65. 0

 Admitted CHIEF COMPLAINTS:COMPLAINT OF PAIN ABDOMEN SINCE 3 MONTHS INCREASED SINCE 4 DAYS
COMPLAINT OF VOMITING 8
For: EPISODES SINCE ONE DAY
COMPLAINT OF FEVER SINCE ONE DAY.
HISTORY OF PRESENT ILLNESS
PATIENT WAS APPARENTLY
ALL RIGHT 3 MONTHS BACK THEN HE DEVELOPED PAIN ABDOMEN WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE
IN SEVERITY, LOCATED AROUND THE UMBILICUS NO AGGRAVATING OR RELIEVING FACTORS, NO RADIATION.
PATIENT ALSO
COMPLAINTS OF VOMITING 8 EPISODES, CONTAINING FOOD PARTICLES NON-BILIOUS,NON BLOOD STREAKED.
HISTORY OF
FEVER PRESENT
NO HISTORY OF ALTERED BOWEL HABITS.
NO HISTORY OF ABDOMINAL DISTENSION.
NO HISTORY OF BURNING
MICTURITION.
NO HISTORY OF DECREASED DURING OUTPUT
HISTORY OF ANALGESIC ABUSE PRESENT.
CURRENT MEDICATION:
KNOWN CASE OF DIABETES MELLITUS, HYPERTENSION.THE PATIENT IS ON REGULAR MEDICATIONS,THE DETAILS OF WHICH
ARE NOT AVAILABLE.
PAST HISTORY: NOT A KNOWN CASE OF TUBERCULOSIS, ASTHMA, EPILEPSY.
FAMILY HISTORY- NOT
SIGNIFICANT.
PERSONAL HISTORY DIET-MIXED
SLEEP- SOUND BOWEL AND BLADDER-REGULAR APPETITE - NORMAL
HABITS-
NO
ADDICTIVE HABITS

GENERAL PHYSICAL EXAMINATION - AN ELDERLY MALE MODERATELY BUILT AND NOURISHED, CONSCIOUS, COOPERATIVE, WELL
ORIENTED TO TIME, PLACE AND PERSON. BP- 90/60mmhg
PR - 96BPM
RR - 18 CPM
SPO2 - 98% AT ROOM AIR NO PALLOR,
ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA SYSTEMIC EXAMINATION CVS - S1S2 + NO MURMUR
RS-
BILATERAL NORMAL VESICULAR BREATH SOUNDS HEARD.
NO ADDED SOUNDS
CNS- HIGHER MENTAL FUNCTIONS NORMAL
PER
Physical ABDOMEN-
INSPECTION:
ABDOMEN-FLAT
UMBILICUS CENTRAL AND INVERTED.
ALL QUADRANTS MOVE EQUALLY WITH
Findings: RESPIRATION
NO DISCOLORATION/ SINUSES DILATED VEINS
NO VISIBLE PERISTALSIS
HERNIAL ORIFICES INTACT
EXTERNAL
GENITILIA APPEARS NORMAL
PALPATION: INSPECTORY FINDINGS ARE CONFIRMED NO LOCAL RISE OF TEMPERATURE DIFFUSE
GUARDING PRESENT.
NO ORGANOMEGALY ABDOMINAL GIRTH:80CM
PERCUSSION-
OBLITERATION OF LIVER DULLNESS
PRESENT.
AUSCULTATION- BOWEL SOUND ABSENT.
DIGITAL RECTAL EXAMINATION:TONE IS NORMAL.
WALLS FELT,MUCOSA
APPEARS NORMAL NORMAL FAECAL STAIN PRESENT

Condition
During
DECEASED
Discharge
:

  Brief Summary of the Case:
PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS. NECESSARY  
INVESTIGATIONS WERE DONE AND DIAGNOSIS OF PERITONITIS SECONDARY TO
THE JEJUNAL PERFORATION WAS MADE. ON 22/10/22 ,UNDER GENERAL
ANESTHESIA EXPLORATORY LAPAROTOMY WITH RESECTION OF JEJUNUM AND
END TO END JEJUNO-JEJUNAL ANASTOMOSIS WITH PERITONEAL LAVAGE WAS
DONE.

INTRAPERATIVE FINDINGS:

A FECULANT COLLECTION OF MORE THAN 2 L WAS NOTED.

0.5*1 CM PERFORATION NOTED 60 CM DISTAL TO DJ FLEXURE IN THE JEJUNUM,

ALONG THE ANTIMISENTRIC BORDER.

A PALPABLE CIRCUMFERENTIAL GROWTH NOTED JUST PROXIMAL TO THE

PERFORATION.

PATIENT DEVELOPED HYPOTENSION INTRAOPERATIVELY FOR WHICH PATIENT

WAS STARTED ON DUAL INOTROPES.

PATIENT WAS NOT EXTUBATED AND WAS SHIFTED TO ICU IN INTUBATED STATE.

NEPHROLOGY OPINION WAS TAKEN IN VIEW OF DERANGED RENAL FUNCTION

TESTS AND ADVICE FOLLOWED.

MEDICINE OPINION WAS TAKEN IN VIEW OF THROMBOCYTOPENIA AND ADVISE

FOLLOWED.

ON 26/10/22 PATIENT BECAME UNRESPONSIVE AND DESPITE ALL THE CARDIO

 RESPIRATORY RESUSCITATIVE EFFORTS PATIENT COULD NOT BE REVIVED AND
WAS DECLARED DEAD ON 26 10 22 AT 9:30 P.M.

Category Test Name Observation

22/10/22
BLOOD GROUP - B POSITIVE
HB-11.3G/DL, TLC-4.4K/MM3, PLT - 345K/MM3
UREA-
47MG/DL,CREATININE-1.4MG/DL
SODIUM- 142MMOL/L, POTASSIUM-4.1MMOL/L
LFT- TOTAL PROTEIN-
4.5G/DL, ALBUMIN- 1.7G/DL,TOTAL BILIRUBIN - 0.2MG/DL, DIRECT BILIRUBIN-0.1MG/DL, AST-68U/L, ALT-
34U/L, ALK PHOSPHATASE- 77U/L
HIV - NON REACTIVE
HBSAG- NEGATIVE
23/10/22
HB-10.2G/DL, TLC-
3.8K/MM3, PLT - 118K/MM3
UREA:54MG/DL
CREATININE:1.3MG/DL
SODIUM:146MMOL/L
POTASSIUM:3.7MMOL/L
24/10/22
HB-10.1G/DL, TLC-9.8K/MM3, PLT - 46K/MM3
UREA:59MG/DL
Note :      0
CREATININE:2.7MG/DL
SODIUM:144MMOL/L
POTASSIUM:3.2MMOL/L
HbA1C:5.6%
24/10/22
URINE
ROUTINE SHOWS
PROTEIN +
SUGAR NIL
10 TO 15 RBCs and 8 TO 10 PUS CELLS.
25/10/22
HB-10.3G/DL,
TLC-4.9K/MM3, PLT - 26K/MM3
UREA:58MG/DL
CREATININE:1.2MG/DL
SODIUM:147MMOL/L
POTASSIUM:2.1MMOL/L
ARTERIAL BLOOD GAS ANALYSIS:
PH:7.39mmHg
PCO2:32.0mmHg
PO2:157.0mmHg
HCO3:19.0mmol/L
TCO2:29.0mmol/L
SODIUM:148.0mmol/L
POTASSIUM:2.mmol/L
Ionised Calcium:1.05mmol/L
   

Treatment Given :

TREATMENT
22/10/22
RESECTION OF JEJUNUM WITH END TO END JEJUNOJEJUNAL ANASTOMOSIS UNDER GENERAL
ANAESTHESIA +EPIDURAL ANAESTHESIA.
NPO TILL FURTHER ORDERS
IVF 5PINT, 2PINT NS, 2PINT RL, 1PINT DNS WITH MVI
Note
INJ.CEFTRIAXONE 1G IV 1-0-1
INJ.AMIKACIN 500MG IV 1-0-1
INJ.METROGYL 100ML IV 1-1-1
INJ.PAN 40MG IV 1-0-0
:
INJ.EMESET 4MG IV 1-0-1
NEBULIZATION 6TH HOURLY ASTHALIN 1-1-1
BUDECOT 1-1-1
DRAIN CARE RT ASPIRATION MOTOR
VITALS REVIEW SOS.

Advice on Discharge: DECEASED

To come For follow up in Routine OPD on & Time

In specialist Clinics on    & Time

Senior Resident             

Operation Date            22/10/2022

Signature Treating Doctor

Dr. KG Byakodi

26/10/2022 09:30:00 PM

Date & Time