INSTITUTE OF MEDICAL SCIENCES & SUM HOSPITAL
(DEPARTMENT OF MEDICINE – UNIT 3)
SIKSHA‘O’ANUSANDHAN (Deemed to be University)
K-8,KalingaNagar, Bhubaneswar
IMS&SH/Form No: 8(A-B)
PATIENT DISCHARGE SUMMARY
Name of Patient: Mr PURUSHOTTAM KHANDUAL AGE/Sex –68Y/MALE
Date/Time of Admission: 21-Date/Time of Discharge: 24/06/25 at 12WARD 20 BED 05
06-2025, 9:28 pm PM
Dept/ Unit: MED UNIT-3 IP No: 7327906701 UHID NO- 202407220548
MLC: NO Tel- 7327906701
S/O:- BATTAKRUSHNA KHANDUAL
Address:JAGATSINGHPUR, ODISHA
Admitted with complaints of - loose stool,vomiting,fever since 1 day
History Of present illness: The patient was apparently normal 1 day back then he developed loose stool,30 episodes
watery in consistency ,red in colour,mucoid,associated with vomiting 3 episodes with food particles non blood
stained,non mucoid,associated with fever,documented 100.2 degree f,persistent relieved on medication,associated
with generalised weakness ,head reeling.
N/k/c/o HTN,TB, THYROID DISORDER.
K/C/O-t2dm since 5 years
Personal history- Sleep normal, mixed Indian diet, normal bowel & bladder movements. No addiction or
habituation.
INVESTIGATIONS DONE:
22/06/25-HHH-NON REACTIVE
Sr Na+/K+/Cl-=138/4.27/101
LFT-BILIRUBIN(t/d)-0.72/0.27,SGOT/SGPT-38/44,ALBUMIN-3.83,GLOBULIN-2.70
HBA1C-7.4,RFT-UREA/CREATININE-17.1/1.10
CBC-HAEMOGLOBIN-14.9,WBC-14.51,PLATELET-111,PCV-45.4
AUTOMATIC URINE ANALYSIS-PUS CELLS-0-1
FINAL DIAGNOSIS :TYPE2DM,ACUTE GASTROENTERITIS
TREATMENT GIVEN-INJ XONE,INJ METROGYL,CAP DOXT XL,INJ ONDEM(8),IV FLUID,INJ H ACTRAPID,CAP
BIFILAC HP,CAP REDOTIL(100),INJ PAN (40),HGT TDS
PAGE – 2
COURSE IN HOSPITAL:. Patient presented with complaints mentioned overleaf . All relevant investigation
were done. USG W/A was done which was S/O B/L isoechoic kidneys with prominent pyramids
Ileocolonoscopy was done and biopsy was taken, result is awaited. Patient was normotensive during the
course of hospitalization. Patient was managed with IV Fluids and other supportive measures. Patient
improved symptomatically over the course of hospitalisation and is being discharged with the following
advise
Discharge vital-PR-92/min, BP:132/88mm of Hg, RR:16 Cycle per minute, Temp:98.2F, SpO2:98% on RA
DISCHARGE MEDICATION -
1. INJ H. ACTRAPID S/C
6 U BEFORE BREAKFAST
6 U BEFORE LUNCH
6 U BEFORE DINNER
2. SACHET K-BIND 1 SACHET WITH HALF GLASS OF WATER THRICE DAILY TO CONTINUE
3. NEB ASTHALIN 1 RESPULE TWICE DAILY TO CONTINUE
4. CAP BIFILAC-HP 1 CAP ONCE DAILY BEFORE FOOD FOR 10 DAYS
5. TAB PAN (40) 1 TAB ONCE DAILY BEFORE BREAKFAST FOR 10 DAYS
6. TOTAL FLUID INTAKE < 1.2 L/DAY
REVIEW ADVICE: TO REVIEW IN MEDICINE OPD ON WEDNESDAY AFTER 7 DAYS WITH CBC, RFT, BIOPSY REPORTS.
SYMPTOMNS AND HOME MANAGEMENT OF HYPOGLYCEMIA HAS BEEN EXPLAINED TO THE PATIENT AND HIS ATTENDANTS
IN THEIR OWN LOCAL LANGUAGE.
REGULAR HOME BASED GLUCOSE MONITORING HAS BEEN ADVISED AND EXPLAINED TO THE PATIENT.
IN CASE OF EMERGENCY CONTACT SUM EMERGENCY 9776544477
UNIT HEAD Prof (Dr) Chandan Das
TREATING Dr. Siba Prasad Dalai (Asso prof)
PHYSICIANS Dr. Meghnad Meher (Asst Prof)
Dr. Brijesh Swain (Asst Prof)
Dr. N. Mahesh (Asst prof)
Dr. Diptiman Behera (Asst prof)
Dr. Debesh Ranjan Dhar (Senior Resident)
RESIDENT Dr. Srinivas
Dr Bhishma
Dr. Rajat
