DISCHARGE SUMMARY
Department INTERNAL MEDICINE
UHID 1000659017
Patient’s Name MOHAMMAD SHAHAB UDDIN
DOB/Age: 66 Years Gender MALE
Ward/Unit: 6TH Floor, Wing A Cabin/Bed 633
Height Weight
Primary Consultant DR. PRADIP RANJAN SAHA
Date of Admission 18.2.25 Date Of Discharge 20.2.25
Type of Discharge Routine ✘
LAMA
Diagnosis
B/L PNEUMONIA
AGE
DM
HTN
IHD (S/P PTCA)
HYPOTHYROIDISM
ECZEMA
Allergy History
Not known
Chief Complaints
1. Fever for 1 day
2. Productive cough for the same duration
3. Vomiting for 2-3 episodes since morning
Past History (Medical + Surgical)
DM
HTN
IHD (S/P PTCA)
HYPOTHYROIDISM
ECZEMA
S/P PHACO
Significant Physical & Other Findings
On admission, patient was conscious, oriented, BP-100/80 mmHg, Pulse: 96 bpm, SpO 2: 97% on room air, Temp: 98°F, Heart:
S1+S2+0, Lungs: Vesicular Breath Sound with few crepitation in right lower zone. Tongue: Dry. Abdomen: Soft & non-tender.
Investigations (Significant)
All the investigations reports are supplied with patient.
On Admission
CBC Hb: 12.9, HCT: 37.9, PLT: 184, TC-WBC: 11.5
ESR 27
Inflammatory Markers CRP: Procalcitonin:
LFT S. Bilirubin: ALT: AST: ALP: S. Ammonia: 35, S. Albumin: 32
UHL/MR-191/VER-2
DISCHARGE SUMMARY
Coagulation Profile APTT: PT with INR:
RFT S. Creatinine with eGFR: S. Urea: S. Uric Acid:
S. Electrolytes Na: 130, K: 4, Cl: 95, HCO3: 18, Ca: Mg:
Cardiac Markers HsTnI:
NTProBNP:
Metabolic Fasting Lipid Profile: TC: 95, HDL: 32, LDL: 45, TG: 49
HbA1c:
FBS:
TFT TSH: fT4: fT3:
S. Vitamin D
S. Folate
S. Active Vit D3
Infection Screening Dengue NS1 Antigen:
RT PCT for COVID-19:
PCR for 6 Respiratory Pathogens:
Microbiology Urine R/E:
Urine C/S:
Stool R/E:
Blood C/S:
Sputum C/S:
TB Sputum for AFB:
Sputum for GeneXpert:
QuantiFERON TB Gold:
On Discharge
CBC Hb: 12.9, HCT: 37.9, PLT: 184, TC-WBC: 11.5
S. Electrolytes Na: 131, K: 3.9, Cl: 101, HCO3: 21
NTProBNP
Imaging
CXR P/A View:
a. Right CP Angle blunt due to small pleural effusion or thickening
b. Bilateral Pulmonary Edema
USG of Both Lower Extremity Veins with Color Doppler:
a. Mild atherosclerotic changes in both lower limb arteries
b. No evidence of DVT
USG of Whole Abdomen with PVR
a. Bilateral Renal Parenchymal Disease
b. Bilateral Pleural Effusion
HRCT of Chest:
a. Bilateral Pneumonitis with focal emphysematous changes
b. Right sided minimal pleural effusion
ECHO 2D with Color Doppler:
a. No RWMA
b. LVEF:64%
c. RV Systolic Dysfunction
d. PASP: 62 mmHg PASP: 62 mmHg
UHL/MR-191/VER-1 Page 2 of 5
DISCHARGE SUMMARY
Imaging (Cont.)
ECHO 2D with Color Doppler:
No RWMA
LVEF:64%
RV Systolic Dysfunction
PASP: 62 mmHg PASP: 62 mmHg
Hospital Course (Including Procedures Performed)
On 15.12.24 patient presented with the above mentioned complaints and after proper evaluation he was admitted to
GHDU/GICU of UHL.
Thereafter, on 16.12.24, due to hypotension and increased respiratory distress, he was shifted to GICU and there patient
needed intermittent BiPAP AND VASOPRESSOR SUPPORT.
After stabilization, on 21.12.24, patient was transferred to GHDU as part of step-down process.
After stabilization, on 22.12.24, patient was shifted to CABIN under Internal Medicine as final step-down process
ICT was inserted on 29.12.24 and removed on 4.1.25 uneventfully on both occasions.
During his hospital stay, with proper clinical evaluation and investigation findings, patient was diagnosed as above and was
treated with I/V Fluids, Inj. MEROPENEM, Inj. LEVOFLOXACIN, Inj. TEICOPLANIN, Inj. CLINDAMYCIN, Inj. CEFTAROLINE, Inj.
POLYMIXIN B, Tab. LINEZOLID and other medications.
Also, throughout his hospital stay, he was periodically reviewed by THORACIC SURGERY, RESPIRATORY MEDICINE,
CARDIOLOGY, ENDOCRINOLOGY, and PSYCHIATRY consultants. Now the patient is stable and is being discharged with the
following medications and advice.
but for completion of doses of injectable Antibiotics, patient is being discharged with I/V Cannula In-situ.
Hospital Course (Including Procedures Performed)
After proper clinical examination and relevant investigations, she was diagnosed as above and treated with IV Fluids, Inj.
MEROPENEM 1gm 8 Hourly and other conservative management. She was suggested further hospital stay to establish
diagnosis and further management. However, she refused any further hospital stay along with necessary investigations.
Potential Residual Effect(s) of Medications Administered During Hospitalisation
Nil
Condition at the Time of Discharge
Hemodynamically Stable
Since patient still requires Patient is being discharged as LAMA (Leave Against Medical Advice)
Diet
Diabetic
Normal
Renal
Non-renal
Medications on Discharge (In Capital Letters)
Name Frequency Instruction Duration
TAB. CEFIXIME 400 MG 1+0+1 AFTER MEAL UP TO:
S.F
INJ. AMOXICILLIN + CLAVULANIC ACID 1+1+1 AFTER MEAL UP TO:
(1000/200 MG) STARTED FROM: 25.1.25 8.1.25
NIGHT
UHL/MR-191/VER-1 Page 3 of 5
DISCHARGE SUMMARY
INJ. MEROPENEM 1 GM I/V 8 HOURLY AFTER MEAL UP TO:
STARTED FROM: 25.1.25
NIGHT
INJ. CEFTRIAXONE 2 GM I/V 12 HOURLY AFTER MEAL UP TO:
STARTED FROM: 8.1.25
24.1.25 NIGHT
INJ. LEVOFLOXACIN 500 MG 750 MG I/V 24 HOURLY AFTER MEAL UP TO:
STARTED FROM:
24.1.25 NIGHT
INJ. POLYMYXIN B SULFATE 5 LAC I/V 12 HOURLY S.F UP TO:
UNITS/VIAL
TAB. LINEZOLID 600 MG 1+0+1 S.F. 30.12.24 UP TO: 12.1.25
TAB. MOXIFLOXACIN 400 MG 1+0+0 S.F. 28.12.24 UP TO: 10.1.25
TAB. LEVOFLOXACIN 500 MG 1+0+0 S.F. UP TO:
TAB. METRONIDAZOLE 400 MG 8 HOURLY AFTER MEAL STARTED FROM:
31.12.24
UP TO:
7.1.25
CAP. FLUCONAZOLE 50 MG 0+1+0 S.F UP TO:
Medications on Discharge (In Capital Letters) – Cont.
Name Frequency Instruction Duration
TAB. CEFIXIME 400 MG 1+0+1 AFTER MEAL UP TO:
S.F
Advice On Discharge
Take medications as prescribed.
Regularly monitor Blood Pressure and Blood Sugar regularly at home and keep records.
Do CBC, CRP, S. Electrolytes, CXR P/A View after days
Follow-Up Instructions
Follow up with DR. MD. IQBAL HOSSAIN with prior appointment and all reports after 5 days at OPD 1A of UHL.
Instructions About Obtaining Urgent Care
In case of any medical emergency, please come to the emergency department of UHL.
Signature Name EMP. ID Date Time
Senior House Officer Dr. 1.2.25 1:00 pm
Specialist / Associate
Dr. 1.2.25 1:00 pm
Consultant
Consultant / Senior
1.2.25 1:00 pm
Consultant
UHL/MR-191/VER-1 Page 4 of 5
DISCHARGE SUMMARY
Dr. Syeda Fahmida Hossain 12800
Dr. Pradip Ranjan Saha 12072
Dr. Md. Iqbal Hossain 12321
Dr. Afsana Begum 11245
Prof. Dr. Taimor Nawaz 01575
Dr. Md Jahangir Talukder 13426
Dr. Rinki Kundu 14256
Dr. Asif Ahmed 19872
Dr. Sharmeen Akhter 19062
Dr. Lubna Ahmed 17905
Dr. Nusrat Jahan 17431
Dr. Zeenat Sultana 14526
Dr. Rita Mayedah 18147
UHL/MR-191/VER-1 Page 5 of 5