DISCHARGE SUMMARY

Dept. of OBSTETRICS & GYNAECOLOGY

Patient’s Name : YEDURU SWAPNA

Age: 32 yrs IP No.:24010425

Husband Name : SANTOSH KUMAR

Ward / Room No. OBG UNIT III

Address: TEKKALI

Unit: III : Dr. R. ARAVIND M.D. OBG

Date of Admission : 04/01/24

Date of surgery:08/01/24

Date of Discharge : 13/01/24

Clinical Diagnosis :PRIMI With 35 wks+ 5 days GA With Breech with UTI with Anemia with IUGR with decreased
perception of fetal movement and with Hypothyroidism.

Final diagnosis: POD 5 of PRIMARY ELECTIVE LSCS.

Brief Clinical History (Complaints, Physical examination & vital data) :

C/O Abdominal pain and abdominal tightening on and off since morning (3/1/24)
C/O decreased perception of fetal movements since morning (3/1/24)
No C/O bleeding PV or leaking PV

CONDITION AT TIME OF ADMISSION:

Vitals : PR : 88/min; BP : 90/70 mmHg; RR:18/min ; Temp : Afebrile

B/L breast soft

P/A : UTERUS ~ 32 weeks, Relaxed , BREECH, FHS+

P/V : Cervix- EGH Soft, Posterior Uneffaced, OS - closed, PPVx- high up

Course in the hospital :

1. FHR monitoring
2. REST IN LLP
3. DFMC
4. NST
5. W/F CONTRACTIONS LEAKING PV /BLEEDING PV
6. Steroid coverage done
7. IVF 1 point RL and 1 point NS @75ml/hr
8. Monitor Vitals
9. Plenty of oral fluids
10. Inform SOS
 11. Inj. MONOCEF Igm IV BD
12. Inj. PANTOP 40 MG IV OD
13. Tab. DEPIN 10MG BD
14. CCLV3 PESSARIES x 3 days
15. Inj. FCM INFUSION

PROCEDURE: PRIMARY ELECTIVE LSCS

INDICATION- PRIMI with 39weeks 2 days pog with hypothyroidism with foetal distress

Intraoperative findings:-
1. LUS well formed
2. Liqour clear and adequate.
3. Single live term female baby presented as LSA extracted as such ( Breech Presentation ) on
08/01/ 2024 @ 9:48am.
4. Placenta and membranes are delivered intoto
5. B/L tubes and Ovaries appear healthy.

BABY DETAILS:
Single/live/term female baby delivered on 08/01/24 at 09:48 am with B.wt 2.350 kg with APGAR 7,9

POST OP TREATMENT:

1.IVF 2 UNIT RL/ 2 UNIT DNS / 2 UNIT NS @75ML/HR

2. INJ. MONOCEF 1 GM IV BD 5days
3.INJ. PANTOP 40 MG IV OD 5days
4.INJ. METROGYL 100 ML IV TID
5. INJ VIT C IN 1 NS
6.INJ. TRAMADOL 1 amp IM BD
7.INJ. TRAPIC 1 GM IV TID
8.INJ. FORTWIN 1 CC+INJ. PHENERGEN 1CC IM H/S
9.INJ.MVT IN 1UNIT RL
11.TAB.METROGYL 400MG TID×1d
12.TAB.PANTOP 40MG OD×1d
13.TAB.CHYMEROL FORTE TIDx3d
14.TAB.LIMCEE OD
15.TAB.SUPRADYN OD
Investigations :
Hb : 9.6 Gm/dL (04/01/24) RtHb : 9.7 Gm/dl(28/12/23)
Preoperatively 1 dose of FCM infusion given and Postoperatively 2 doses of Iron Sucrose infusion given.
Platelets: 272 x 10^3/micro lt
TC: 18.10 x10^3/ul(04/01/24)
DC: P-92, L-06, M-01, E-01, B-00.
BGT: O POSITIVE

RFT-
B.UREA: 11 mg/dl
Sr.Creatinine: 0.5 mg/dl
LFT-
T.BILIRUBIN: 0.3 mg/dl
D.BILIRUBIN: 0.1mg/dl
RBS : 114 mg/dl

VIRAL MARKERS : NON REACTIVE

Thyroid profile:
T3: 1.33 ng /dl
T4: 15.69 ug /dl
TSH: 2.53 uIU/ml
Lipid profile:
Serum Cholesterol: 204 mg/dl
Serum Triglycerides: 105 md/dl
HDL Cholesterol: 63mg/dl
VLDL Cholesterol: 21mg/dl
LDL Cholesterol: 120 mg/dl

ANTENATAL SCAN:
● SINGLE LIVE FETUS IN BREECH PRESENTATION CORRESPONDING TO 35 WEEKS 5 day +/- 2 WEEKS
GA
● Bio Physical profile - 8/8
● Doppler values are within normal limits
● FHR : 152 BPM, AFI : 9-10 cms,
● EFBW : 2.4 kg

Condition at the time of Discharge:

Vitals : Temp : Afebrile, PR : 72bpm, RR : 18/min, BP 110/80 mmHg.

● General condition – Fair

● CVS/RS : NAD, Lungs - Clear
● B/l breast soft
● P/A:soft, Uterus retracted well
● Dressings done
● Wound healthy
● Female baby on mother side

Discharge advice:

Regular diet with plenty of oral fluids

1. ALLOW REGULAR DIET WITH PLENTY OF ORAL FLUIDS

2. T. CEFAKIND CV 625MG BD 5DAYS
3. T.PANTOP 40MG OD FOR 5 DAYS
4. T METROGYL 400mg TIDx 3days
5. T.LIMCEE OD FOR 15 DAYS
6. T.SUPRADYN OD 15 DAYS
7. T.SHELCAL OD 3months
8. T.OROFER XT OD 3MONTHS
9. T.CHYMORAL PLUS TID 5 DAYS
10. Ointment T- BACT for L/A
11. NEOSPIRIN POWER for L/A
12. EXCLUSIVE BREASTFEEDING 6 MONTHS

Mother :

Nourishing Diet and plenty of fluids to mother

Rest and avoidance of work

Hygiene : General and perineal methods are explained. Temporary methods of sterilization explained

REVIEW

Follow up : Review after 14 days to OBSTETRICS OPD on WEDNESDAY & SATURDAY. Review in case
of headache, blurring of vision, bleeding PV, abdominal distension, fever or any other emergency.

Signature of the Doctor :

Signature of the Chief: