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: Vikas
Age/Sex: 20 years/ Male
CR No: 112669
ATTACHMENTS Address: Hno. 304 Plotno. 359,360,361. Gno. 40, Vipin garden Ext.
: Uttam Nagar, Delhi, India
Date of Admission: 31/05/2024
XRAY Chest Date of Discharge: 04/06/2024
(27/02/24) Diagnosis: Recurrent Appendicitis
ECG (27/02/24) Treatment: Laparoscopic Appendicectomy under General
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.
27/2/2 1/6/24 No significant family history. No h/o substance abuse.
4
Clinical Examination: Conscious, oriented; Afebrile.
Hb 14.2 14.7
PR: 84/min; BP: 110/70mm Of Hg; SpO2-98% on room
TLC 10200 5090 air; RR- 16/min, blood glucose level 120mg/dl. No
Pallor/icterus/lymphadenopathy/edema.
DLC 71/4 64/32
Per Abdomen Examination: Umbilicus central and
Platelet 1.76 1.18 inverted. Corresponding quadrants move equally with
s respiration. Non-distended, soft, non-tender, no
guarding/rigidity, no lump or organomegaly. No signs of
Hct 42.6 44.8 free fluid; Bowel Sound present.
Ur/Cr 26/0.7 27/0.8 CVS- S1S2 heard, no murmur heard, RS- Bilateral Air
entry present; no added sounds CNS- No focal
Na/K 142/4. 140/3. neurological deficit.
7 6
Investigations
[Link]/ 0.59 1.1
USG Abdomen and pelvis (02/03/24): Tender
[Link] XRAY Chest
edematous bowel(27/02/24)
and appendix: Normal
6.7 mm study
seen with
ECG
excess (27/02/24):
bowel gas is Normal
seen in sinus
right rhythm
iliac fossa with few
AST/ 31/25 35/28
TRIDOT
enlarged (27/02/24):
discrete tender Non-reactive
nonnecrotic mesenteric lymph
ALT
nodes are seen, largest- 13x 6 mm. Liver: Normal in size
ALP 88 109 9.6 cm and echo pattern no focal lesion seen
liver .intrahepatic bile duct and CBD are not dilated ,GB
TP/SA 7.2/2.8 7.6/4.8
distended ,echofree. Both kidney: normal size ,echo, no
PT/INR 13.9/1. 13.5/1
1
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. Imp: ? Appendicitis
CECT W/A (13/03/24): Appendix is normal in calibre, measuring approx.. 5.6 mm .
No inflammatory changes seen. No evidence of appendicitis. Few tiny lymph nodes in
RIF.
Procedure: Laparoscopic Appendectomy under General Anesthesia on
03/06/2024
Operating Surgeons:
● Dr. Jony (Consultant)
● Dr. Binit ( PG3)
Intra Operative Findings:
● Flimsy adhesion of appendix visualized
● Long tubular appendix visualized
● 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
● Allowed orally on POD1, 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. 410.
SR Signature JR
Signature