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Kathmandu Medical College & Teaching Hospital Unit: III
PROF DR PRABIN BIKRAM THAPA
Sinamangal, Kathmandu, Nepal
4476152, 4469064 ASSOC PROF DR ROSHAN GHIMIRE
Discharge Summary
Department of Surgery
Patient Name: YUVRAJ KARKI IP No: 178065
Age/Sex: 43/Male Bed No: 428
Address: , Kathmandu, Bagmati Pradesh. Date of Admission: 2022-11-20
Phone: 9860565730 Date of Discharge: 2022-11-28
Disease Category: Others.
Diagnosis: RTA WITH BTA WITH GRADE III SPLENIC INJURY WITH BTC WITH LEFT MULTIPLE RIB FRACTURE WITH LEFT
HEMOPNEUMOTHORAX.
Management: Conservative with Chest tube Insertion
History at presentation:
Alleged history of RTA (fall from the bike) with sustained injury over head, chest and abdomen.
DOI: 2079/08/03
TOI: 4:30 PM
POI: BARDIBAS ROAD
MOI: FALL FROM BIKE
NO H/O LOC, ENT BLEED, VOMITING
Clinical examination at presentation:
O/E - G/C – FAIR
VITALS:
PR: 102BPM
BP: 140/100 mm of Hg
RR: 20 bpm
Temp:98 F
SPo2 : 99% in NP
Systemic Examination Primary survey;
Airway: patient talked spontaneously, C-spine tenderness -
Breathing: SpO2: 80% in RA on arrival, 98-99% inn NP, RR-22 bpm
Circulation: HR: 110-124 bpm, BP: 140/90 mm of Hg
Exposure: cut injury over medial aspect of left eyebrow, suture done, bruise + orbital region, abrasion over right side of abdomen
Secondary survey:
Head & face:
Chest: Tender over left posterior chest wall, palpable crepts +, decreased air entry over left axillary region, fine crepts+
PA: Distension+, abrasion of about 7*5 cm2 over right side of umbilicus, soft, non tender, rebound tenderness +, BS+
CVS: NAD
Extremities: power 5/5 in all four limbs
Investigations
2022-11-20 2022-11-21 2022-11-22 2022-11-26 2022-11-27
BLOOD GROUP HB HB HB TC
B +VE 11.7 11.6 12.9 8300
HB TC TC TC DC
13.8 6900 7300 6300 N70L22
TC DC DC DC Platelets
9100 N80L15 N75L18 N69L23 196000
DC Platelets Platelets Platelets
N78L17 170000 154000 180000
Platelets NA/K NA/K NA/K
115000 140/4.4 138/4 138/3.9
PT/INR UREA/CR UREA/CR UREA/CR
13/1.3 42/0.7 25/1 21/0.8
NA/K TB/DB
138/4 1.1/0.4
RBS SGPT/SGOT/ALP
116 87/50/64
UREA/CR
41/1
TB/DB
1.2/0.4
SGPT/SGOT/ALP
116/70/291
SEROLOGY
NR
USG ABD AND PELVIS (2022-11-19)
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11/6/23, 4:06 PM dashboard - dashboard
Focal Splenic Contusion
CECT ABD AND PELVIS (2022-11-19)
4.5*3*2.5CM Irregular shaped hypodense area in upper splenic parenchyma involving both lateral and medial surface consistent with hematoma. Multiple linear
hypodensity noted along the lateral surface of upper spleen, longest measuring 1.5cm. about 3mm deep collection noted in medial surface of spleen in <10% area
consistent with subcapsular hematoma
Splenic Injury Grade III without active bleeding
Small left Pneumothorax
Diffuse Fatty Liver
Left Lower Posterior Lung Contusion
Displaced Fracture of Left Posterior 5,6,7,8 rib fracture
Treatment at hospital:
The patient was admitted, investigated and managed conservatively with Chest tube insertion in the left pleural cavity, IV antibiotics, analgesics, IV fluids and oxygen
therapy in SICU for 2 days. Patient was stable and later shifted to highcare then to ward. Chest tube was removed on his 8th DOA and post chest tube x ray showed
normal expansion of lungs. His vitals are currently stable and he is being discharged with following advices.
Condition at Discharge:
O/E - - G/C – FAIR
VITALS:
PR:70 bpm
BP:130/80 mm of Hg
RR: 20 bpm
Temp: 98 F
SPo2 : 99% in RA
Systemic Examination Chest: B/L equal air entry
PA: soft, non tender
CVS: NAD
CNS: Grossly intact
Treatment at Discharge
TAB CLAVUM 625MG PO TDS FOR 5 DAYS
TAB LEVOFLOX 750MG PO OD FOR 5 DAYS
TAB PCM1GM PO TDS FOR 5 DAYS
TAB DUPITA 50MG PO TDS FOR 5 DAYS
TAB ACENAC-SR 200MG PO OD FOR 5 DAYS
TAB LASILACTONE 1/2 TAB PO BD FOR 10 DAYS
TAB ALLEGRA 180MG PO FOR 5 DAYS
SYP LACTONOV 30ML PO HS FOR 10 DAYS
TAB ROLFAST 20MG PO BD FOR 10 DAYS
SYP TUSQ-X 15 ML PO TDS FOR 5 DAYS.
Advice:
Normal diet
Avoid strenuous exercise, heavy weight lifting.
Take medications as prescribed.
Continue Incentive Spirometry.
In case of abdominal pain, fever, chest pain, SOB vomiting, yellowish discoloration of eyes or urine, follow up in emergency SOS.
F/U in SOPD after 1 week on TUESDAY/FRIDAY/sos
Checked By:
Dr. Sandesh Timila
Prepared By: Signed By:
Dr Aliska Niroula (Intern) Dr Spandan Adhikari (Resident, MCH GI)
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