DISCHARGE SUMMARY

Dept. of OBSTETRICS & GYNAECOLOGY

Patient’s Name : LINGIBHERI NEELAVENI

Age: 26yrs IP No.:2312341

Husband Name : GANESH

Ward / Room No. OBG UNIT III

Address: Sotta Vani Peta, Amadalavalasa mandal

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

Date of Admission : 23/12/2023

Date of Delivery : 24/12/2023

Date of Discharge : 27/12/2023

Clinical Diagnosis : G2P1L1 39WKS + 5 DAYS GA with Prev NVD came for safe confinement.

Final diagnosis: P2L2 of NVD with RMLE

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

Came for safe confinement.

● No C/O abdominal tightening and pain.
● Perceiving FM well.
● No bleeding PV and leaking PV

CONDITION AT TIME OF ADMISSION:

Vitals : PR : 82/min, BP : 120/80 mmhg RR aa:18/min ; TEMP : Afebrile

B/l breast soft

P/A : UTERUS ~ term , ACTING,CEPHALIC, FHS+,SPTS

P/V : EGH, CERVIX - SOFT, POSTERIOR , UN EFFACED, OS ADMITTING ONE FINGER, PPVX - 3 status

,Pelvis - G, A

Course in the hospital :

1. FHR monitoring

2. REST IN LLP

3. NST

4. W/F CONTRACTIONS LEAKING PV /BLEEDING PV

5. T. OROFER-XT PO OD

6. T.SHELCAL PO OD

7. W/F SPONTANEOUS PROGRESSION OF LABOUR

8. PARTS PREPARATION

9. ENEMA

PROCEDURE: G2P1L1 WITH 39 WKS + 5 DAYS WITH PREV NVD

Indication - G2P1L1 WITH 39 WKS + 5 DAYS WITH PREV NVD in Active labour

NVD findings:-
Spontaneous delivery.
Liqour clear and adequate.
Episiotomy given in right mediolateral position
Single live term Baby presented delivered
Placenta - Entire intact 250 gm

BABY DETAILS:
Single/live/term male baby delivered on 24/12/2023 at 07:29 pm WITH B.wt 3.265 kg with APGAR 7, 8

POST OP TREATMENT:

1. Regular diet with plenty of oral fluids

2. T. AMOXICILLIN 500 MG PO BD 5days
3. T. PANTOP 40 MG PO OD 5days
4. T. METROGYL 400 MG PO TID
5. TAB.CHYMEROL PLUS TID
6. TAB.LIMCEE OD
7. TAB.SUPRADYN OD
8. T.SHELCAL OD
9. Monitor Vitals, w/f active bleeding, inform SOS
10. Active breastfeeding
11. Syp. LACTULOSE 15ML TID
12. Lactate granules in 1 glass of milk BD
Investigations :

Hb : 11.2 gm/dL (23/12/23). Repeat Hb - 11.2mg/dL (26/12/23)

Platelets : 137×10^3/uL (23/12/23)
TC: 14.3 × 10^3/uL (23/12/23)

DC: P-72 ,L-20 ,M-07 , E-01, B-00.

BGT: AB POSITIVE

RFT :
B.UREA - 17 mg/dl
Creatinine - 0.6 mg/dl
LFT :
T.BILIRUBIN 0.4mg/dl
D.bilirubin. 0.1mg/dl
RBS - 79 mg/dl
2nd HR Sample (Post Glucose Load) - 88mg/dl
Thyroid Profile :
T3 - 1.42 ng/dl
T4 - 11.41 ug/dl
TSH - 2.79 uIU/dl

VIRAL MARKERS : NON REACTIVE

ANTENATAL SCAN:
● SINGLE LIVE FETUS IN CEPHALIC PRESENTATION CORRESPONDING TO 38WEEKS 6 days
+/- 2 WEEKS GA.

Condition at the time of Discharge:

Vitals : TEMP : Afebrile PR : 86bpm RR : 18/min BP 110/70mmHg.

● General condition – Fair

● B/l breast soft
● MALE BABY in NICU
● P/A:soft, Uterus retracted well
● Episiotomy Wound healthy
● Lochia healthy

Discharge advice:

Regular diet with plenty of oral fluids

a. T. AMOXICILLIN 500 MG PO BD 5 days

b. T. PANTOP 40 MG PO OD 5days
c. T.CHYMEROL PLUS TID 3 days
d. T.LIMCEE OD 5 days
e. T.SUPRADYN OD 5days
f. T.SHELCAL OD 5days

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 emergeny

Signature of the Doctor :

Signature of the Chief: