DISCHARGE SUMMARY
DEPARTMENT OF GENERAL MEDICINE
VISWABHARATI MEDICAL COLLEGE& GENERALHOSPITAL RT NAGAR,
PENCHIKALAPADU KURNOOL .
NAME OF THE PATIENT: K.ADHILAKSHMI AGE/SEX: 46Y /F
VMCH NUMBER: 512007 ADRESS : PENCHIKALAPADU
DATE OF ADMISSION : 27/7/24 DATE OF DISCHARGE:5/8/24
UNIT/CHIEF:DR. SHAIFULLA
FINAL DIAGNOSIS :Alleged h/o unknown poisioning (? Fungicide)
CHIEF COMPLAINTs: Alleged h/o consumption of unknown poison (INO×FUNGICIDE) around
40-50ml at 7am on 27/7/24 with empty stomach at her home. HISTORY OF
PRESENTING ILLNESS: H/o induced vomitings 2 times / day
COURSE IN THE HOSPITAL : patient was came with consumption of unknown poisioning in
casualty stomach wash was done and was admitted to icu supportive treatment was given
and on investigations patient found to be anaemic for which 1 pint blood transfusion was
done . patient condition was improved and discharged today.
INVESTIGATIONS:
27/7/24 28/7/24 29/724 01/8/24 5/8/24
CBP: HB(g/dl) 11.2 9.4 8.0 8.3
WBC 12900 10100 10900 12300
PLATELET 2.5 2.2 2.4 2.2
(Lakhs)
RBC 4.0 3.6 3.1 2.8
HCT 30.1 27.1 22.6 22.6
MCV 74.2 74.5 73 78.8
MCH 27.5 25.8 25.8 28.8
MCHC 37.2 34.6 35.3 36.7
LFT TB 0.5 0.5
DB 0.3 0.3
SGOT 12 33
SGPT 14 10
ALP 74 67
TP 7.2 6.1
Albumin 4.1 3.5
A/G 1.3 1.3
RFT RBS(mg/ 89 82
dl)
UREA(mg/ 28 28
dl)
Serum Na+ 140 142 136
Electrolytes
K+ 3.9 4.1 3.5
Cl- 108 109 105
CUE PH 6.0
Albumin Trace
Glucose Nil
Ketone Nil
bodies
Leucocyte Nil
s
Nitrite Nil
Specific 1.010
gravity
Urobilinog Nil
en
Rbc Nil
Bilirubin Nil
Urine Pus cells 2-3
microscopy
Epithelial 1-2
cells
Rbc Nil
Casts Nil
Crystals Nil
Others Nil
Serology Hiv Non reactive Non Non
reactive reactive
Hcv Negative Negative Negative
Hbsag Negative Negative Negative
PT 23 24 17
INR 1.7 1.8 1.2
APTT 40 Negative
Cholinesteras 5806
e
TREATMENT GIVEN :
INJ XONE 1GM IV BD 1-0-1.
INJ EMESET 8MG IV TID 1-1-1
INJ PANTOP 40MG OD 1-0-1
IVF 2 dns 1ns with MVI 1500ML /DAY
TAB EVION BD 1-0-1
INJ VIT C BD 1-0-1
TAB MUCINAC 600MG IN A GLS OF WATER TID 1-1-1
SYP MUCAINE GEL TID 1-1-1
TAB MIRTAZAPINE 7.5MG 0-0-1/2
Inj N ACETYL CYSTINE 1200MG IV TID 1-1-1
INJ ELDERVIT OD 1-0-0
ADVICE ON DISCHARGE:
REVIEW TO GM OPD IN 3 Weeks. IN EMERGENCY REPORT TO CASUALTY VISWABHARATI GENERAL
HOSPITAL, PENCHIKALAPADU.
DR INDHU (JR 3) DR. Saifulla PROFESSOR/UNIT CHIEF
DR HITESH (JR 2 )
DR RANI(JR1)
