DISCHARGE SUMMARY

Dept. of OBSTETRICS & GYNAECOLOGY

Patient’s Name : BINGI VIJAYA

Age: 23 yrs. IP No.:23122336

Husband Name : LOKANADHAM

Ward / Room No. OBG UNIT III

Address: KAVITI

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

Date of Admission : 16/12/23

Date of surgery:20/12/23

Date of Discharge : 29/12/23

Clinical Diagnosis :Primi With 39wks + 1 day with POG With Pain abdomen under evaluation.

Final diagnosis: P1L1 OF PRIMARY LSCS with CRHD with Hypothyroidism.

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

C/O abdominal pain and abdominal tightening since morning.

Perceiving FM well
No c/o leaking/bleeding p/v
CONDITION AT TIME OF ADMISSION:
Vitals : PR : 80/min, BP : 120/80 mmhg RR:18/min ; TEMP : Afebrile

B/l breast soft

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

P/V : EGH, CERVIX SOFT POSTERIOR, UNEFFACED, External OS admitting 1 finger, PPVX - high up, PELVIS
GYNECOID

Course in the hospital :

FHR monitoring

REST IN LLP

DFMC

NST

W/F CONTRACTIONS LEAKING PV /BLEEDING PV

T.ISURGE PO OD
T.SHELCAL PO OD

CCLV3 PESSARIES H/S

Parts preparation

PROCEDURE: PRIMARY EMERGENCY UNDER SPINAL ANAESTHESIA

Indication - Primi With 39 weeks 4 days with POG With Hypothyroidism with CRHD with mild Mitral
stenosis.
Intraoperative findings:-
LUS well formed
Liqour clear and adequate.
presented as Vx,Occipito posterior position, and delivered as such.
Single live term male baby delivered on 20/12/2023 @05:27pm
Placenta and it’s membrane delivered into by CVT
B/L tubes and Ovaries appear healthy.

BABY DETAILS:
Single/live/term male baby delivered on 20/12/23 at 05:27pm WITH B.wt 2.9 kg with APGAR 7,9

POST OP TREATMENT:

1. Propped up position
2. IVF 1UNIT RL/1UNIT DNS /¹UNIT NS @50ML/HR
3. INJ. PIPTAZ 4.5 GM IV BD 5days
4. INJ. PANTOP 40 MG IV OD 5days
5. INJ. METROGYL 100 ML IV TID
6. INJ. GENTAMYCIN 80MG IV BD
7. INJ. TRAMADOL 1 amp IM SOS
8. INJ. TRAPIC 1 GM IV TID
9. PAIN MANAGEMENT BY EPIDURAL TOP UP (SOS)
10. STRICT IO CHART
11. TAB.CEFAKIND CV 625 MG BD×1d
12. TAB.METROGYL 400MG TID×1d
13. TAB ECOSPIRIN 75MG OD
14. TAB.PANTOP 40MG OD×1d
15. TAB.CHYMEROL FORTE TIDx3d
16. TAB.LIMCEE OD
17. TAB.SUPRADYN OD
18. SYP. LACTULOSE 15ML H/S
19. SYP. REWAS 10ML TID
20. NEB BUDECORT BD
21. VITALS MONITORING
22. CHEST PHYSIOTHERAPY
23. AMBULATION
24. TUSQ LOZENGES
25. TAB. AZEE 500MG OD
26. TAB. BROCLEAR BD
27. TAB. MUCINAC 600MG IN 1 GLASS OF WATER
Investigations :
Hb : 12.7 mg/dL (16/12/23) Hb : 11.4 mg/dl(23/08/23)
Platelets 160 x 10^3/micro lt
TC: 12.5 x10^3/ul(29/10)

DC: P-67 L-23 M-07 E-03, B-00.

BGT: O POSITIVE

RFT
B.UREA 14 mg/DL
Creat. 0.6 mg/dl
LFT
T.BILIRUBIN 0.4 mg/dl
D.bilirubin. 0.1mg/dl

RBS : 119 MG/DL

VIRAL MARKERS : NON REACTIVE

Thyroid profile:
T3: 1.50 ng /dl
T4: 15.90 ug /dl
TSH: 4.58 uIU/ml
ECG,2D ECHO:NORMAL

ANTENATAL SCAN:
● SINGLE LIVE FETUS IN CEPHALIC PRESENTATION CORRESPONDING TO 38 WEEKS 5 day +/- 2
WEEKS GA
FETAL DOPPLER SCAN :
 Increased RI, PI, S/D VALUES OF LEFT UTERINE ARTERY
 Rest of fetal doppler findings are within normal.

Condition at the time of Discharge:

Vitals : TEMP : Afebrile PR : 96 bpm RR : 18/min BP 110/80mmHg.

● General condition – Fair

● B/l breast soft
● MALE BABY mother side
● P/A:soft, Uterus retracted well
● Wound healthy
● Stolls passed

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.LIMCEE OD FOR 15 DAYS
5. T.SUPRADYN OD 15 DAYS
6. T.SHELCAL OD 3months
7. T.OROFER XT OD 3MONTHS
8. T.CHYMORAL PLUS TID 5 DAYS
9. EXCLUSIVE BREASTFEEDING 6 MONTHS
10. OINT. T BACT L/A

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 POSTNATAL 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: