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Discharge Summary

Mrs. Gayathri, a 25-year-old female, was admitted on September 9, 2019 for increased liquor with labor pain and discharged on September 19, 2019 after an uneventful recovery from a repeat LSCS and bilateral tubectomy. A female baby was delivered via LSCS and discharged after two days of observation for mild respiratory distress. Both mother and baby were stable on discharge with advice for follow up after two weeks.

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3K views

Discharge Summary

Mrs. Gayathri, a 25-year-old female, was admitted on September 9, 2019 for increased liquor with labor pain and discharged on September 19, 2019 after an uneventful recovery from a repeat LSCS and bilateral tubectomy. A female baby was delivered via LSCS and discharged after two days of observation for mild respiratory distress. Both mother and baby were stable on discharge with advice for follow up after two weeks.

Uploaded by

Allwin
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

Reg/IP No/364 NHB : JM : 936

Name : Mrs.Gayathri

Age : 25 Years Admitted on : 09.09.2019 10.00 AM

Sex : Female Discharged on : 19.09.2019 05.00 PM

Bed No : 4 Primary Consultant: Dr.K.A.Noorjahan

Address : W/o.Suresh,
No.116, Middle Street,
Arasarkulam Vadapathi,
Arasarkulam Post, Aranthangi Taluk,
Pudukkottai Dist.
Drug Allergies : Nil
Diagnosis : 25 Years Old Multi Para with Increased Liquor with Labor Pain
Since Morning, Previous LSCS

Indication : Previous LSCS, Previous LSCS with frequent labour

Pain since one week.

Consultant : Dr.Malarvizhi MBBS., DGO.,


Dr.K.A.Noorjahan MBBS.,
Dr.Sethuraman MBBS., DA.,
Dr.V.Farook Khan MBBS., DCH.,
Complaint and History

C/o. 9 Months ammennorrhea, with discomfort with abdomen distension, labour pain since
morning
Present thistory
Multi, Menstural History, 4/30, NO H/o. Bleeding per vegina.
No H/o Vomitting No H/0 Head Ache, No H/o Vision Problem
H/O previous LSCS – 3 Years Back [Primi Post dated with fetal distress]
Clinical Examination
O/E : Patient GC Fair, afebrile, Hydrvation fair,
Pulse : 90/mt, BP : 90/60 mm of Hg, RR : 24/mt
SPo2 100 % at room air
CVS : S1S2 + No
RS : NVBS +, No added sounds
Abd : Term, FH - 160/mt
PV : OS Closed
CNS : NFND
Investigation : Report enclosed
Operation : LSCS (Rpt) with PS,
Surgery Notes : After Pre operative preparation under spinal anesthesia abdomen opened
by Lower transverse incision
LSCS done in usual way and delivered a alive female baby cried soon after mouth suction
& ENT suction & Baby handed over to pediatrician, placenta with entire membrane
removed, uterus wound closed in layers after, haemostasis rescued
The usual way Bilateral Tubetomy done
Abdomen closed in layers
Post operative period : uneventful, No active bleeding uterus convoluted, patient conscious
and answering to questions, GC Fair, PR 80/mt, RR 20/mt, BP 100/70 mm of Hg.
Treatment : Nil oral, I/O Chart ½ Hourly PTR & BP, antibiotics, IVF, Analgesics &
Sedation.
On Discharge : Afebrile, Hydration fair, comfortable vitals stable, no wound soakage,
suture removed on 19.09.2019 wound healthy.
Advice on Discharge :
Antibiotics, antiinflammatory, Vitamins, iron & Appetizer, review after 2 weeks
BABY DETAILS

Female baby, delivered by repeat LSCS, Baby cried soon after birth after suctioning
ENT Baby passed meconium & urine, Kept under warmer, 100% nasal O2 given. Baby had
mild respiratory distress so given care for one day with observation.

Born on 09.09.2019 Time : 5.14 PM Weight : 2.8 Kg

Treatment Given : Shifted to ICU for observation, Stomach wash given, IVF, antibiotics,
Vit K, Warmer, O2, Inj BCG, HBV & OPV given on discharge : Baby given breast feeding
2nd day onwards, cry and activity good, color pink, hydvation fair, No Icterus

Advice : Breast feeding &Imminization

Review : After 2 Weeks


TO WHOM SO EVER IT MAY CONCERN
This is to certify that Mrs.Gayatri W/o.Mr.Suresh residing at 116, Middle Street,
Arasarkulam Vadapathy Post, Aranthangi Taluk, Pudukkottai Dist was admitted as an
Inpatient from 09.09.2019 to 19.09.2019
Patient ID No : 364 Bill date : 19.09.2019
Hospital Reg.No : 20/2007 Bill No : 760
NHB JM : 936
Room No : 3, Bed No : 4
S.No Description Amount
1 Hospital Stay Charges (10 x 800) 8000.00
2 Nursing Charges (10 x 200) 2000.00
3 Doctor Visiting Charges (10 x 400) 4000.00
4 Operation Theater Charges 6000.00
5 Surgeons Fee 7000.00
6 Pediatriation Fees 2000.00
7 Asst Surgeon Fees 3500.00
8 OT Staff Nurse Charge 1000.00
9 OT Assistant 750.00
10 Anesthetist Charger 3000.00
11 Baby Care in ICU 2000.00
12 Medicine 13383.35
Total Amount 52633.35
Advance As per R.N : 5107, dated 09.09.2019 20000.00
Balance 32633.35

Rupees Thirty two thousand six hundred and thirty three paise thirty five only
CASH BILL
Patient Name : Mrs.Gayatri
Patient ID No : 364
S.No Description Amount
1 Hospital Stay Charges (10 x 800) 8000.00
2 Nursing Charges (10 x 200) 2000.00
3 Doctor Visiting Charges (10 x 400) 4000.00
4 Operation Theater Charges 6000.00
5 Surgeons Fee 7000.00
6 Pediatriation Fees 2000.00
7 Asst Surgeon Fees 3500.00
8 OT Staff Nurse Charge 1000.00
9 OT Assistant 750.00
10 Anesthetist Charger 3000.00
11 Baby Care in ICU 2000.00
12 Medicine 13383.35
Total Amount 52633.35
Advance As per R.N : 5107, dated 09.09.2019 20000.00
Balance 32633.35

Rupees Thirty two thousand six hundred and thirty three paise thirty five only

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