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Discharge Summary

Mr. Sonaimuthu, a 71-year-old male, was admitted to the hospital with complaints of inability to swallow food and vomiting for 3 months and was diagnosed with lower esophageal hiatus hernia. He was treated conservatively and improved symptomatically before being discharged with advice for an endoscopy and follow up after 5 days. His treatment included antibiotics, anti-emetics, PPIs, and he was able to swallow solid foods without vomiting upon discharge.

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Natarajan Palani
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55K views5 pages

Discharge Summary

Mr. Sonaimuthu, a 71-year-old male, was admitted to the hospital with complaints of inability to swallow food and vomiting for 3 months and was diagnosed with lower esophageal hiatus hernia. He was treated conservatively and improved symptomatically before being discharged with advice for an endoscopy and follow up after 5 days. His treatment included antibiotics, anti-emetics, PPIs, and he was able to swallow solid foods without vomiting upon discharge.

Uploaded by

Natarajan Palani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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DISCHARGE SUMMARY

NAME OF THE PATIENT: Mr. SONAIMUTHU


AGE / SEX: 71 Yrs / Male
ADDRESS: Manamadurai
DATE OF ADMISSION : 21/01/2019
DATE OF DISCHARGE: 25/01/2019
CONSULTANT: DR. Anand MBBS, MD.
DIAGNOSIS: LOWER OESOPHAGEAL HIATUS HERNIA

CLINICAL SUMMARY
Patient came to the hospital with complaints of inability to swallow food and vomiting of undigested food
particles for past 3 months.

B,P. 80/50 mm/hg


P.R 56mints
SPO2 97%

COURSE IN HOSPITAL :

CT scan of chest and abdomen done revealed, dialation of oesophagus with thin regular wall and air fluid level within,
subcarinal oesophageal narrowing present small hiatus hernia. Patient was treated conservatively with antibiotics, antiematics
and ppi. Patient improved symptomatically with ability to swallow solid foods with no episodes of vomiting. Patient was
advised endoscopy and dilatation of oesophagus with biopsy at a later stage.

COMPLETE BLOOD CELL COUNT:

HAEMATOLOGY
SCOT-29 full Urobllinogen-Normal
Haemoglobin10.§,m/d1
Total wbc count-8900 Cells/cum SGPT-27 Iu/l Billrubin-Negative
DIABETIC PROFILE
Neu trophils-69% TOTAL PROTEIN-7.6
FBS-95
Lymphocyte-26% Serum Albumin-4.1 PPBS-159
LIPID PROFILE
Eosinophils-5% Globulin-2.6
Cholestrol- 179

RBC count- 3.9 million / cumm Alk phosphatise-79 HdI cholesterol-32

URINE ANALYSIS
Pcv - 42% Ldl cholesterol-128
Specific gravity:I.010
MCV-74 cumm Ph-5 Vldl cholesterol-33
MCH -28pg I.eukocytes-negative T.c/hdl ratio-5
MCHC – 32gm / dl Nitrite-negative
Platelet count- 2,00.000 1akhsl / cumm Protein-negative

LIVER FUNCTION TEST


Glucose-Normal
Total billiruhin0.2mg.d1
Direct billirubin- 0.1mg/dl Keytones-Negative

ADVICE: FOLLOW UP AFTER 5 DAYS


T.EM ESET: (1-0-1)

T.YEES D: (1-0-1)

T.DIGIPEN: (1-0-1)

T.ACILOC: (1-0-1)

T.MUCYST: (0-0-1)

T.NEFTRON: (1-0-1)

T. AZ1TH RA L: (0-0-1)

5YP.LUPIZ1ME PLUS: 10ml

5YP.SUCRAFIL PLUS: 5ml

When and how to obtain urgent care :

Report in case of pain, bleeding and or other emergencies.

Summary Prepared By: Dr. Anand

(This is not a legal document. This report is given to enable the patient to understand their disease nature, treatment and
follow up. Any clarification, if necessary should be discussed with the consultant)

The content of discharge summary and follow up instructions including drugs has been explained to me in my
understandable language.

Attenders Sign:

Name & Relationship:

Phone No:
Invoice

Bill No: SH00012/102/19 Bill Date: 23/07/2019

NAME OF THE PATIENT: Mr. SONAIMUTHU


AGE / SEX: 71 Yrs / Male
ADDRESS: 74/36 New Street, Vadavalli, Manamadurai
DATE OF ADMISSION : 21/01/2019 3.30PM
DATE OF DISCHARGE: 25/01/2019 4.50PM
CONSULTANT: DR. Anand MBBS, MD.
DIAGNOSIS: LOWER OESOPHAGEAL HIATUS HERNIA
DEPARTMENT: Critical care
Accommodation Type: Special
Room No : 102

Code Billing Heads Rate Quantity Amount in Rs.


1 Room Rent 1000 3 3000
2 Nursing Charges 100 10 1000
3 RMO Charges 200 3 600
IV Fluids Administration
4 40 10 400
Charges
Blood Transfusion
5 0 0 0
Administration Charges
6 Injection Charges 20 20 400
Total Room Rent
5400
Services
1 ICU Rent 3000 2 6000
2 ICU Nursing Expenses 500 2 1000
3 ICU RMO charges 500 2 1000
IV Fluids Administration
4 40 5 200
Charges
Blood Transfusion
5 250 2 500
Administration Charges
6 Injection Charges 20 20 400
Total ICU Services 9100
1 Surgeon Charges 4500 2 9000
2 Anesthetist Charges 2000 1 2000
Medical Practitioner
3 1000 2 2000
Charges
4 Consultants Charges 300 2 600
5 Specialist Charges 1500 1 1500
Total Professional Fee 15100
1 Anesthesia 200 1 200
2 Blood 1500 1 1500
3 Oxygen 450 1 450
Operation Theater
4 2500 1 2500
Charges
5 Surgical Appliances 670 1 670
6 Medicines and Drugs 3210 1 3210
7 Diagnostic Materials 0 0 0
8 General Investigations 0 0 0
Specialized
9 0 0 0
Investigations
10 Dialysis 0 0 0
11 Chemotherapy 0 0 0
12 Radiotherapy 0 0 0
13 Cost of Artificial Limbs 0 0 0
14 Cost of Implants 0 0 0
Total of Other
8530
Expenses

Grand Total 38130


Patient Paid Amount 25000
Balance 13130
OP CASH BILL

Bill. No: SSH/000123/072019 Bill Date : 21/07/2019

Patient Name : Mr. SONAIMUTHU Age / Sex: 71 Yrs / Male


Address : Manamadurai Lab Ref.No : OP/989859438
Consultant: Dr.Anand

S.No Item Name Rate Qty Amount


INVESTIGATIONS
1 PRENATAL SCREENING 2780 1 2780

Total 2780

(Rupees Two Thousand Seven Hundred And Eighty Rupees Only)

For Sangeetha Hospitals

Paid Date: 21/07/2019 Payment Mode: Cash

Billed By : Kavitha 21/07/2019 12:32:56 PM

Sangeetha Super Speciality Hospitals

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