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Sumanth Naidu 1

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27 views

Sumanth Naidu 1

Uploaded by

souravsarkar20k
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Belenus Champion Hospital

Belenus, Champion Hospitals Pvt Ltd, Sarjapur,Marathahalli Rd,


opp. Decathlon, Carmelaram,Ambedkar Nagar,Chikkabellandur
Bengaluru, Karnataka-560035, Phone: 080 6936 6936
Email: [email protected] , Website:belenuschampionhospitals.com

CIN:U85100KA2021PTC155367 GSTIN:29AAKCB3644A1ZV

DISCHARGE SUMMARY
Name : Mr. SUMANTH NAIDU Visit No : ER24000001000960
UHID : BCH2410860 Room/Bed No : EMERGENCY WARD/ ER-02
Age/Gender : 23Y /MALE Arrival Date/Time : 08/07/2024 00:33
Mobile No : 6303273676
Consultant : Dr. Kushal Kumar A Dis. Date/Time : 08/07/2024 01:36
Department : EMERGENCY DEPARTMENT
DIAGNOSIS : MULTIPLE SOFT TISSUE INJURIES
CHIEF COMPLAINTS: ALLEGED HISTORY OF SELF SKID AND FALL FROM BIKE AT AROUND 12 AM TODAY NEAR
SHANESHWARA TEMPLE, SARJAPUR ROAD SUSTAINING INJURIES OVER THE LEFT SIDE OF FACE, LIPS, BOTH UPPER
LIMBS AND LOWER LIMBS. ACTIVE BLEEDING PRESENT

NO H/O LOSS OF CONSCIOUSNESS, PERSISTENT HEADACHE, SEIZURES, ALTERED MENTAL STATUS, CHANGES IN VISION,
NAUSEA, VOMITING.
MLC 422

PAST HISTORY: NO KNOWN CO-MORBIDITIES

ALLERGY: NO KNOWN DRUG ALLERGIES

GENERAL PHYSICAL EXAMINATION: PATIENT IS CONSCIOUS, ORIENTED TO TIME, PLACE AND PERSON

VITAL SIGNS ON ADMISSION:


HR: 98b/min BP : 150/80mmHg RR : 18 /min SPO2: 99% TEMP : Afebrile

SYSTEMIC EXAMINATION ON ADMISSION:


CVS : S1, S2 present. No murmur
RS : Bilateral normal vesicular breath sounds
P/A : Soft, non-tender, no organomegaly
CNS : conscious and oriented, no neurological deficits
LOCAL EXAMINATION
LOCAL EXAMINATION OF FACE:
DEEP CUT LACERATED WOUND NEAR THE OUTER CANTHUS OF LEFT EYE MEASURING ABOUT 2CMS X 1CM X 1CM
GRAZED ABRASION OVER LEFT CHEEK
DEEP CUT LACERATED WOUND AT THE ANGLE OF MOUTH EXTENDING TO INNER BUCCAL MUCOSA
LEFT PERIORBITAL SWELLING PRESENT
LACERATION PRESENT ABOVE THE UPPER LIP- LEFT SIDE

LOCAL EXAMINATION OF UPPER LIMBS: ABRASION OVER RIGHT ELBOW, RIGHT RING FINGER AND LEFT
HAND
LOCAL EXAMINATION OF KNEE:
ABRASION PRESENT OVER LEFT KNEE
RANGE OF MOVEMENTS: NORMAL
DISTAL PULSES (+), DISTAL MOVEMENTS (+)

TREATMENT / MEDICATIONS DURING HOSPITAL STAY:

WOUND CLEANED AND DRESSED UNDER ASEPTIC PRECAUTIONS


INJ TT 1AMP IM STAT GIVEN

Page No: 1/2


Belenus Champion Hospital
Belenus, Champion Hospitals Pvt Ltd, Sarjapur,Marathahalli Rd,
opp. Decathlon, Carmelaram,Ambedkar Nagar,Chikkabellandur
Bengaluru, Karnataka-560035, Phone: 080 6936 6936
Email: [email protected] , Website:belenuschampionhospitals.com

CIN:U85100KA2021PTC155367 GSTIN:29AAKCB3644A1ZV
Name Mr. SUMANTH NAIDU Age / Sex 23Y / MALE Visit No ER2400000100096

COURSE IN THE HOSPITAL : PATIENT WAS BROUGHT TO THE ER WITH THE ABOVE MENTIONED COMPLAINTS,
ASSESSED. MLC NO 422 DONE. WOUND CLEANING AND DRESSING DONE UNDER ASEPTIC PRECAUTIONS. INJ TT 1AMP
IM STAT GIVEN. PATIENT ADVISED FOR NEED FOR SUTURING OF LACERATIONS AND THE NEED FOR FURTHER
INVESTIGATIONS. HOWEVER, PATIENT IS NOT WILLING FOR ANY INVESTIGATIONS AND FURTHER MANAGEMENT AND
WANTS DISCHARGE. PATIENT IS HEMODYNAMICALLY STABLE. DANGER SIGNS EXPLAINED. HENCE, PATIENT IS BEING
DISCHARGED AGAINST MEDICAL ADVICE.

CONDITION AT DISCHARGE: HEMODYNAMICALLY STABLE

ADVICE ON DISCHARGE :

1. TAB SIGNOFLAM 1-0-1 X 3 DAYS


2. TAB RABEMAC- DSR 1-0-0 X 5 DAYS (30MINS BEFORE FOOD)
3. TAB AUGMENTIN 625MG 1-0-1 X 5 DAYS (AFTER FOOD)
4. T-BACT OINTMENT THRICE DAILY FOR 5 DAYS, LOCAL APPLICATION.
5. ICE PACK APPLICATION
6. SUTURING REQUIRED FOR DEEP CUT LACERATIONS.

FOLLOWUP:
TO REVIEW IN PLASTIC SURGERY OPD WITH DR. AMRIKA TODAY, 08TH JULY 2024
TO REVIEW IN ER SOS

DOCTOR SIGNATURE:

SEEK MEDICAL HELP IF:


The initial symptoms get aggravated.
For Booking an appointment, emergencies, or any other queries, call on 08069366936.

For any Home Care Services (Physiotherapy, Nursing services, Delivery of Medicines)
please call on 8105714951.

Discharge summary explained by ……………………….

Discharge summary handed over to …………………….

In case of any Emergency Please Call - 080 6936 6936 / 080 6936 6969

------End of Discharge Summary------

Page No: 2/2

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