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Acute Gastritis with Dehydration Discharge

Shanti Baspore was admitted on January 25, 2025, with acute abdominal pain and was diagnosed with acute gastritis and mild dehydration upon discharge on January 26, 2025. Key investigations revealed mild leukocytosis and decreased potassium levels, with no significant findings on ultrasound. The patient was treated with IV fluids and medications, showing significant improvement, and was advised to continue proton pump inhibitors and follow a bland diet post-discharge.

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179 views2 pages

Acute Gastritis with Dehydration Discharge

Shanti Baspore was admitted on January 25, 2025, with acute abdominal pain and was diagnosed with acute gastritis and mild dehydration upon discharge on January 26, 2025. Key investigations revealed mild leukocytosis and decreased potassium levels, with no significant findings on ultrasound. The patient was treated with IV fluids and medications, showing significant improvement, and was advised to continue proton pump inhibitors and follow a bland diet post-discharge.

Uploaded by

ambarishgorai.24
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

DISCHARGE SUMMARY

Name of Patient: Shanti Baspore


Tel No. N/A Mobile No. 8420646176
IPD No. 210451679 Admission No. 210451678
Treating Consultant/s Name, contact numbers Dr. Sunil Verma, Gastroenterology
and Department/Specialty Contact No.: 9876543210
Date of Admission 25.01.2025 Time of Admission 12.37 AM
Date of Discharge 26.01.2025 Time of Discharge 05.15 PM
MLC No. / FIR No. N/A
Provisional Diagnosis at the time of Admission Acute abdominal pain, suspected gastritis
Final Diagnosis at the time of Discharge Acute gastritis with mild dehydration
ICD-10 code(s) or any other codes, as recommended K29.70 - Gastritis, unspecified, without bleeding
by the Authority, for Final diagnosis
Presenting Complaints with Duration and Reason Severe abdominal pain lasting 2 days, accompanied by
for Admission nausea and loss of appetite.
Summary of Presenting Illness The patient reported intermittent sharp pain in the
upper abdomen for 48 hours prior to admission.
Symptoms worsened on the day of admission, leading
to nausea and inability to eat.
Key findings, on physical examination at the time of Tenderness in the epigastric region, mild
admission dehydration noted, no signs of peritonitis.
History of alcoholism, tobacco or substance abuse, N/A
if any
Significant Past Medical and Surgical History, if any History of hypertension (managed with
medication), no previous abdominal surgeries.
Family History if significant/relevant to diagnosis or No relevant family history.
treatment
Summary of key investigations during  Blood tests: CBC showed mild leukocytosis.
Hospitalization  Electrolyte panel: Mildly decreased potassium
levels.
 Ultrasound abdomen: No significant findings,
mild gastric wall thickening noted.
 ECG: Normal.
Course in the Hospital including complications, if The patient was stabilized with IV fluids and
any medications, including proton pump inhibitors and
antiemetic’s. Pain reduced significantly within 12 hours.
No complications observed during hospitalization.
Advice on Discharge  Continue oral proton pump inhibitors for 14 days.
 Follow a bland diet, avoid spicy and acidic foods.
 Stay hydrated and avoid skipping meals.
 Follow-up consultation after one week.
Name of treating Signature of treating
Consultant/ Authorized Dr. Sunil Verma Consultant/ Authorized
Team Doctor Team Doctor
Name of Patient / Shanti Baspore (Patient) Signature of Patient /
Attendant Suresh Baspore (Attendant) Attendant

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