LOK NAYAK HOSPITAL
JAWAHAR LAL NEHRU MARG, NEW DELHI- 110002
SURGERY-UNIT I (WARD 4A)
Prof. Pawanindra Lal
Director Professor & HOD
Dr. Vivek Sachan Dr. Deepak Bharadwaj Dr.
Devender Kumar
DISCHARGE SUMMARY
Name: Bashar Ali
Age/Sex: 31 years/ Male
CR No: 112667
ATTACHMENTS Address: I 191-3rd Floor Narayan Nagar, Laxmi Nagar, Delhi, India
: Date of Admission: 31/05/2024
Date of Discharge: 04/06/2024
XRAY Chest Diagnosis: Recurrent Appendicitis
(11/05/24) Treatment: Laparoscopic Appendicectomy under General
ECG (11/05/24) Anesthesia on
03/06/2024
Clinical History: Patient presented to Surgery OPD for interval
appendectomy
The Patient was apparently well 3 month ago, when he presented to
Surgery emergency with complaint of Right lower abdomen , acute onset ,started from
peri-umbilical region alter confined to right lower abdomen ,moderate-severe in
intensity , relieved on medication
H/o Nausea and vomiting present -2 3 episodes during acute attack of pain
H/o Anorexia present
No h/o fever with chills/burning micturition/constipation/loose stools/abdominal
distension/non passage of feces and flatus\
No history similar attack over past 3 months.
No known comorbidities. No previous surgeries.
No significant family history. No h/o substance abuse.
11/05/ 1/6/24
24 Clinical Examination: Conscious, oriented; Afebrile.
PR: 84/min; BP: 110/70mm Of Hg; SpO2-98% on room
Hb 14.1 12.7
air; RR- 16/min, blood glucose level 120mg/dl. No
TLC 14260 11980 Pallor/icterus/lymphadenopathy/edema.
DLC 86/8 72/21 Per Abdomen Examination: Umbilicus central and
inverted. Corresponding quadrants move equally with
Platelet 5.74 3.04 respiration. Non-distended, soft, non-tender, no
s guarding/rigidity, no lump or organomegaly. No signs of
free fluid; Bowel Sound present.
Hct 42.6 37.8 CVS- S1S2 heard, no murmur heard, RS- Bilateral Air
Ur/Cr 26/0.7 27/0.8 entry present; no added sounds CNS- No focal
neurological deficit.
Na/K 142/4. 140/4
7 Investigations
USG Abdomen and pelvis (03/05/24): 65x29mm
[Link]/ 0.59 0.6 XRAY Chest (11/05/24) : bowel
Normal studyis seen in
edematous non compressible loops
[Link] ECG (11/05/24): Normal sinus rhythm
right iliac fossa with a small amount of 1cc collection at
AST/ 31/46 28/38 theTRIDOT (16/05/24):
tip of lesion. Non-reactive
Increased adjacent Fatty haziness and
ALT minimal probe tenderness noted. Reactionary
thickening of caeco colic bowel noted loop noted.
ALP 124 153 Appendicular inflammation with ? sealed off perforation.
Liver: Normal in size 9.6 cm and echo pattern no focal
TP/SA 8/4.6 8.4/4.5
lesion seen liver .intrahepatic bile duct and CBD are not
PT/INR 11.5/0.
9
dilated ,GB distended ,echofree. Both kidney: normal size ,echo, no mass lesion,
cortical thickness and CMD maintained no calculi/hydronephrosis Spleen: normal in
size ,pancreas normal size no obvious focal lesion , bladder is well distended , normal
wall thickness , no calculus , no mass. Prostate- Enlarged – garde I – size- 34x42x38
mm vol: 29cc with normal shape and echo pattern.
CECT W/A (09/05/24): Non opacified enhancing wall tubular bowel loop seen in
between the ileocecal wall and apex of the caecum measure 6x3 cm in size with
periappendiceal hyperchoic indurated fat and reactive lymphadenopathy. Increased
mesenteric thickening and haziness also appreciated. Compressing the apex seen at
the cecal base. There is mild thickening of medial wall of right lower colon also noted.
No surrounding abscess formation noted. Imp: Acute appendicular inflammation with
adjacent bowel wall thickening . No sign of perforation noted. No sign of gangrene .
Procedure: Laparoscopic Appendectomy under General Anesthesia on
03/06/2024
Operating Surgeons:
● Dr. Atul (SR)
● Dr. Ujala (PG1)
● Dr. Jaya (Intern)
● Dr. Disha (UG)
Intra Operative Findings:
● Enlarged appendix 10cm in length
● Dense adhesion present between parietal wall , appendix and small bowel.
● Cecal base healthy
● Rest of the visualized structures within normal limits
Course during hospital stay:
● Patient presented to Surgery OPD with above mentioned complaints and
admitted.
● Underwent Laparoscopic Appendectomy under General Anesthesia on
03/06/2024
● No intraoperative or immediate postoperative complications noted.
● Allowed orally on POD0, accepting well, gradually increased.
● Patient passing feces and flatus.
● Rest of hospital stay uneventful and afebrile.
Condition on discharge:
No fresh complaints, Accepting orally. Afebrile. PR - 68/min; BP - 122/80 mm of Hg.
Per Abdomen –Soft, non-tender, Bowel sound present, Staple line healthy, no
discharge.
Advise on Discharge:
Daily bath, maintain local hygiene
Tab. Augmentin 625mg TDS
Tab. Pantoprazole 40 mg OD BBF x 5 days
Tab. Diclofenac 50 mg SOS
Staple removal on OPD basis.
Collect biopsy report from MAMC Pathology Collection Centre Room no. 90.
Follow up in Surgery OPD on Tuesday in Room No. 416.
SR Signature JR
Signature