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Discharge Summary

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Discharge Summary

Uploaded by

1980006
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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KIMS102411200567

Discharge Summary
Dept. of GENERAL SURGERY

General Information
Head of the Dept : Dr.AMARESH MISHRA Admitting : Dr Priyabrat Rath
Doctor/
Consultant
Treating Doctor : Dr Sarojkant Sahoo
Unit : III D.O.A : : 20-NOV-24 06:01 PM
Unit Head : Dr.SAROJKANT SAHOO D.O.D :
Name of Patient : Mr CHINMAYA SINGH IP No : ADNKIMS102411200144
Age/Sex : 21 Yrs 11 Mnth 4 Days / MALE Mobile No : 7873849223
Address : natapada BALASORE ODISHA
INDIA

Patient's History
Clinical Profile: A 21 YRS MALE CAME WITH C/O PAIN IN PERIANAL REGION WITH ACTIVE
BLEEDING. A/H/O FALL FFROM 15 FT HEIGHT AT 12 PM, AT ITR COLLEGE,
KHURDA.

HISTORY OF PRESENT ILLNESS-


PATIENT WAS APPARENTLY ALL RIGHT TILL AFTERNOON THEN THERE IS
A/H/O FALL FROM 15 FT AT 12 PM AT ITR COLLEGE, KHURDA.
SUSTAINED INJURY TO PERIANAL REGION WITH ACTIVE BLEEDING.

HISTORY OF PAST ILLNESS-


NO COMORBIDITIES. NO PREVIOUS SURGICAL HISTORY.

FAMILY HISTORY-
NOT CONTRIBUTORY

PERSONAL HISTORY-
MIXED DIET
NORMAL AND REGULAR BOWEL AND BLADDER HABITS

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KIMS102411200567

SOUND SLEEP

TREATMENT HISTORY-
NOT CONTRIBUTORY

ALLERGY HISTORY-
NOT CONTRIBUTORY

GENERAL PHYSICAL EXAMINATION-


NO PALLOR, ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY AND
EDEMA
VITALS- STABLE

SYSTEMIC EXAMINATION-
CNS- NAD
CVS- NAD
RS- NAD
P/A- NAD

LOCAL EXAMINATION-
MULTIPLE PENETRATING WOUNDS IN PERIANAL REGION AND BUTTOCK
REGION.
1) 2X 6 CM CLEFT
2) 3X1X6 CM AT LEFT BUTTOCK AT 2 O'CLOCK, 15 CM FROM ANAL
VEREGE
3) LYING 3X1 CM AT ANAL VERGE 11 O'CLOCK

RADIOLOGICAL FINDINGS
NCCT HEAD (22-11-2024): ESSENTIALLY WITHIN NORMAL LIMITS FOR
BRAIN.
CT SCAN WHOLE ABDOMEN (PLAIN & CONTRAST) (21-11-2024): FEATURES
SUGGESTIVE OF PERFORATION OF ANAL CANAL WITH DEFECT SEEN
ANTEROLATERALLY ON LEFT SIDE WITH AIR AND FLUID SEEN
EXTENDING INTO EXTRAPERITONEAL PLANE IN PELVIS WITH
POSSIBLE . ? INJURY OF LOWER 1/3RD OF RECTUM AS DESCRIBED.
FRACTURE OF SACRUM ON LEFT SIDE WITH FEW BONE FRAGMENTS SEEN
POSTERIORLY.
ULTRASOUND OF WHOLE ABDOMEN(MALE) (21-11-2024): MINIMAL TO
MILD ASCITES

PROVISIONAL DIAGNOSIS- POLYTRAUMA

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KIMS102411200567

Final Diagnosis POLYTRAUMA

SARS-COV-2:

SURGERY/(if any)/Course in A 21 YRS MALE CAME WITH C/O PAIN IN PERIANAL REGION WITH ACTIVE
the hospital: BLEEDING AND A/H/O FALL FFROM 15 FT HEIGHT AT 12 PM, AT ITR
COLLEGE, KHURDA DIAGNOSED AS POLYTRAUMA. ALL RELEVANT
INVESTIGATIONS WERE DONE.

PERINEAL INJURY REPAIR AND ILEOSTOMY WAS DONE BY DR.


SAROJKANT SAHOO AND DR. P.K.KHUNTIA AND HIS TEAM ON 21/11/24.
INTRAOP FINDINGS:
1. PERINEAL INJURY AT MULTPLE LOCATIONS (TOTAL 5) WITH RECTAL
INJURY, EXTENDING 15 CM DEEP FROM LEFT TO RIGHT INVOLVING BOTH
ANAL SPHINCTERS.
2. HEMORRHAGIC FLUID PRESENT INTRAPERITONERALLY~500ML NON
FAECULENT, NO LARGE OR SMALL BOWEL INJURY IDENTIFIED.
3. PREPERITONEAL BOGGY HEMATOMA PRESENT IN SUPRAPUBIC REGION
EXTENDING TOWARDS UMBILBICUS.

1. WITH PATIENT IN LITHOTOMY POOSITION, PERINEAL WOUNDS


INSPECTED AND ABOVE FINDINGS NOTED. THROROUGH IRRIGATION OF
ANAL CANAL DONE AND ANAL CANAL REPAIR DONE. REST INUURIES
CLEANED AND APACKED. GELSPON GIVEN PR AND DRESSING DONE.
2. IN SUPINE POSTION EXPLORATORY LAPAROTOMY DONE VIA
INFRAUMBILICAL INCISION AND ABOVE FINDINGS NOTED. THOROUOGH
PERINEAL TOILETING DONE.
4. NO. 20 ADK DRAIN GIVEN IN PELVIS. ABDOMEN CLOSED IN LAYERS IN
INTERRUPTED MANNER WITH PDS 2-0.
5. SKIN STAPLED. ASEPTIC DRESSING DONE.
1 PINT PRBC TRANSFUSED INTRAOPERATIVELY.

POST OP RECOVERY WAS UNEVENTFUL AND PATIENT WAS


CONSERVATIVELY MANAGED WITH REGULAR IV FLUIDS, ANALGESICS
AND ANTIBIOTICS. PATIENT IS NOW BEING DISCHARGED IN
HEMODYNAMICALLY STABLE CONDITION.

SURGERY NAME DATE


ILEOSTOMY (GSLS) Nov 21, 2024 12:00 AM
EXPLORATORY LAPAROTOMY Nov 21, 2024 12:00 AM

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KIMS102411200567

Type of Discharge: Normal Discharge

Advice On Discharge
Diet: NORMAL HIGH PROTEIN DIET WITH 2 EGGS PER DAY

Follow up: REVIEW AFTER 2 WEEKS IN SURGERY OPD ON WEDNESDAY

Physical activity: AS TOLERATED

Medication: TAB PAN 40 MG 1 TAB ONCE DAILY BEFORE BREAKFAST


TAB PARACETAMOL 650 MG 1 TAB THRICE DAILY
TAB ZINCOVIT 1 TAB ONCE DAILY
TAB LIMCEE 500 MG 1 TAB ONCE DAILY
NEBULISATION WITH DUOLIN THRICE DAILY AND BUDECORT TWICE
DAILY
TAB OTSKI 1 TAB ONCE DAILY
ENSURE PROTEIN POWDER 2 SCOOPS THRICE DAILY
TAB ALPRAX 0.5 MG 1 TAB ONCE DAILY BEFORE BEDTIME
KETOIPATCH FOR LOCAL APPLIACTYION ONCE DAILY
CHEST PHYSIOTHERAPY
INCETIVE SPIROMETRY
SYRUP ALKASOL 10 ML THRICE DAILY
TAB URISPAS 200 MG ONCE DAILY

Miscellaneous(If any): DAILY SOAP WATER BATH


MAINTAIN LOCAL HYGIENE

Investigations: ALL ATTACHED AND HANDED OVER TO THE PATIENT

Radiology Notes :

Radiology Service DATE


CT (HEAD/BRAIN) PLAIN 2024-11-21 19:36:08.884
CT WHOLE ABDOMEN (CONTRAST) 2024-11-21 10:34:29.442
USG ABDOMEN AND PELVIS 2024-11-21 09:29:35.785
USG KUB 2024-12-08 11:17:08.365
X RAY BED SIDE CHEST 2024-11-21 18:47:51.545

Page 4 of 5
KIMS102411200567

Radiology Notes :

Radiology Service DATE


X RAY FOOT AP AND LAT LEFT 2024-12-07 08:59:30.807

Prepared By (Name & DR VARSHA (PG1)


designation): DR SHWETA (PG1)

Dr Sarojkant Sahoo
GENERAL SURGERY
Treating Doctor

Please understand your discharge prescription from your doctor before using the medicines.
You can contact Emergency Room Physician, KIMS HOSPITALS

Page 5 of 5

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