DISCHARGE SUMMARY

Dept. of OBST & GYNAECOLOGY

Patient’s Name: Mrs. BALIVADA ASTHALATHA

Age: 38 yrs IP No.: 24010362

Ward / Room No. Gynec UNIT III

Husband name: RAVI KUMAR

Address : PALLIPETA , CHEEPURAPALLI

CONSULTANT : Dr.R.Aravind MD DGO

Date of Admission : 03/01/24

Date of PROCEDURE :08/01/24@ 2:00pm

Date of Discharge : 13/01/24

Clinical Diagnosis : AUB-A with RENAL CALCULI with DRUG ERUPTIONS.

FINAL DIAGNOSIS: POD 5 of TOTAL ABDOMINAL HYSTERECTOMY with B/L SALPINGECTOMY with LEFT
OOPHERECTOMY

Procedure done : D&C on 5/1/24 f/b TOTAL ABDOMINAL HYSTERECTOMY with B/L SALPINGECTOMY
on 8/1/24

INDICATION: AUB-A

Brief Clinical History (Complaints, Physical examination)

1. C/o lower abdominal pain since 1 year

2. C/o white discharge since 1 year (on & off)

Patient was apparently normal 1 month back and then developed lower abdominal pain since 1
month which is persistent even after 2 days of menstruation

No h/o menstrual irregularities

No h/o inter menstrual bleeding, No h/o Post coital bleeding, No h/o dysperunia

Past History:

H/O renal calculi since 4 years and for which she is on medication.

No similar complaints in the past

No h/o DM, HTN, THYROID, ASTHMA,CARDIAC PROBLEM, EPILEPSY

Patient is allergic to T. DICLOFENAC, T. NAPROXEN, T. CIPROFLOXACIN, T. OFLOXACIN, T. MEBENDAXOLE,
T. AMPICILLIN, T. TETRACYCLINES, T. PHENOBARBITONE, T. NITROFURANTOIN and LAXATIVES

Patient can use T. LINEZOLID, T. CEFPODOXIME, T. CEFIXIME, T. CEFADROXIL, T. FEROPENEM, T.

CEFALAXIME, T. METROGYL, T. PARACETAMOL, T. TRAMADOL.

Family history: Nil significant

Gynec History:

P1L1 (NVD)

LCB –15 years, Marital life : 16 yrs

Tubectomy not done

LMP - 01/12/23

Condition at the time of admission :

BP : 120/90 mmhg ; PR : 82 bpm ; RR: 18 min ; Temp : Afebrile

P/A: Soft , non tender , no palpable mass

P/S: cervix congested , vagina healthy .

BIMANUAL PELVIC EXAM: uterus bulky , AV ,mobile

,B/L FF,NFT

PR - Rectal mucosa free

Course of treatment in hospital:

INTRAVENOUS FLUIDS -2(.)NS 2(.)RL, 2(.)DNS

T. MVT PO OD

T. MEFTAL SPAS BD

Details of procedure: DILATATION AND CURRETTAGE. ON 5/1/24 UNDER LOCAL ANAESTHESIA

INDICATION: AUB-A

FINDINGS

Uterocervical length 6 cm

Uterus- normal size

adequate endometrial scrapping obtained and sent for HPE

POST procedure MEDICATION:

1. T MEFTAL SPAS BD
2. T. CEFIXIME 200mg BD
3. T. PANTOP 40mg BD
4. T. MVT OD
Details of procedure (8/1/24) :TOTAL ABDOMINAL HYSTERECTOMY with B/L
SALPINGECTOMY WITH LEFT OOPHERECTOMY on 8/1/24 UNDER SPINAL
ANAESTHESIA

FINDING -
Uterus bulky with restricted mobility
Posterior peritoneum is densely adhered & bowel adhesion present in pouch of Douglas
Left ovary - unhealthy and cystic and removed
B/L tubes - removed
Right ovary - Healthy - retained

POST OP ORDERS -
INTRAVENOUS FLUIDS -2(.)NS 2(.)RL, 2(.)DNS
INJ. MONOCEF 1GM/IV BD
INJ. METROGYL100ML/IV/TID
INJ. PANTOP 40MG/IV/OD
INJ. TRAMADOL 1AMP IV BD
INJ. FORTWIN 1CC+ PHENERGEN 1CCIM TID
INJ. TRAPIC 1GM/IV TID
INJ. VIT C 1AMP/1(.) RL
INJ. MVT 1AMP/1(.) NS
T. CEFAKIND CV BD
T. CHYMORAL FORTE TID
T. LIMCEE- OD
T. SUPRADYN-OD

INVESTIGATIONS
Hb- 10.8 gm/dL(3/1/23) POST OP -9.3(9/1/24
TC : 12.73* 10^3/ Cu mm

DC : P-87 L- 09 M-03 E-01 B- 00

Platelets : 263*10^3/micro litre

RFT:

B.UREA - 22 mg/dL

CREATININE - 0.6 mg/dL

RBS : 126 mg/dl

LFT:

T.BIL - 0.8 mg/dl

D.BIL - 0.2 md/dl

VIRAL MARKERS – NON REACTIVE

UPT- Negative

PAP SMEAR - INFLAMMATORY SMEAR

Thyroid Profile :
T3 - 1.22 ng/ml

T4 - 15.84ug/dl

TSH - 2.61 uIU/ml

USG abdomen and pelvis: Uterus: Size: 9.0x5.3x4.4cm. Bulky in size and globular shape in echotexture
with poorly maintained endometrial differentiation- likely adenomyosis change.

Cervix: Appears bulky measuring 2.9x2.7cm and heterogeneous in echotexture.

Both Ovaries:Rt: 2.9x2.7 cm. Lt: suboptimal.

Both ovaries are normal in size and echotexture.

IMPRESSION :
BULKY UTERUS WITH EARLY ADENOMYOSIS CHANGES
Cervicitis changes
Mild splenomegy
Right renal calculus
Left simple renal cortical cyst

POST OP SCAN TAH (09-01-24)- POST OPERATIVE CASE OF TAH BILATERAL SALPINGECTOMY.

NO OTHER SONOLOGICAL ABNORMALITY DETECTED.

Condition at the time of discharge :

VITALS : STABLE

Gc fair

PR- 82 bpm

BP- 130 / 90 mm Hg

RR- 18/min

Lungs / heart - NAD

P/A – Soft,NT, WOUND HEALTHY

Discharge advice :

1. T.CEFAKIND CV625 MG BD× 5DAYS

2. T. METROGYL 4OO MG BD × 5 DAYS
3. T.PANTOP 40MG OD FOR 5DAYS
4. T. MVT OD×15DAYS
5. T.LIMCEE OD FOR 15 DAYS
6. T.SUPRADYN OD FOR 15 DAYS

Advice:-

plenty of fluids and Fibre rich diet.

Rest and avoidance of heavy work and heavy weight lifting

Follow up : Review after 7 days to Gynaec OPD on wed or sat with HPE report.Review in case of
bleeding, abnormal discharge, abdominal distension or any other emergency.

Signature of the Doctor

Signature of the Chief