INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
INHS ASVINI HOSPITAL, COLABA
DISCHARGE SUMMARY
Patient ID: 903321 Name: Mr. Shubham Ambre
Age/Gender: 27 Years / Male Ward: F-South 14
Room No.: Officers Room Date of Admission: 01 July 2025
Date of Discharge: 27 July 2025 Consultant in Charge: Lt. Cdr. Dr. H. Mehta
(Internal Medicine)
Diagnosis at Admission: Enteric Fever (Typhoid Fever)
Chief Complaints:
High-grade fever for 6 days prior to admission
Generalized weakness
Mild abdominal discomfort
Loss of appetite
Clinical Findings on Admission:
Temperature: 103.2°F
Pulse: 96 bpm
BP: 110/70 mmHg
Respiratory Rate: 20/min
Abdomen: Mild tenderness in right lower quadrant
CNS, CVS, RS: Within normal limits
Generated By: MS17419F on 29 Feb 2025 9:41 1
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Investigations:
Hospital Course Summary
Clinical Course in Hospital
Day 1–3 (1st–3rd July):
Patient presented with high-grade fever (up to 103°F), body ache, malaise,
and loss of appetite. Initial blood work revealed leukopenia, elevated liver
enzymes, and positive Widal test (TO 1:160). Started on IV fluids and
empirical antibiotics (IV Ceftriaxone).
Day 4–7 (4th–7th July):
Persistent fever spikes noted. Antibiotic regimen continued. Blood cultures
confirmed Salmonella typhi sensitive to ceftriaxone. Paracetamol
administered for fever control. Adequate oral intake gradually encouraged.
Day 8–14 (8th–14th July):
Fever showed gradual reduction. Appetite improved. Liver function tests
trending toward normal. Patient mobilized. IV antibiotics continued with close
monitoring. Vital signs stable.
Day 15–21 (15th–21st July):
Afebrile for more than 72 hours. Shifted to oral antibiotics (Cefixime). Full
recovery of appetite and energy. Repeat labs showed normalization of blood
counts and liver enzymes.
Day 22–27 (22nd–27th July):
Continued on oral medication. Discharge planning initiated. Patient counseled
on hygiene, hydration, and follow-up care. No residual symptoms at
Observation Summary
Generated By: MS17419F on 29 Feb 2025 9:41 2
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Initial Presentation:
High-grade fever (102–103°F), chills, generalized body ache
Complaints of headache, anorexia, and fatigue
No vomiting or diarrhea initially reported
Vitals: Febrile, pulse 96/min, BP 110/70 mmHg
On Examination:
Mild coated tongue
No icterus, pallor, or rash
Abdomen: mild tenderness in right lower quadrant, no hepatosplenomegaly
CNS: Alert and oriented
Respiratory & CVS: Normal findings
Response to Treatment:
Gradual improvement observed from Day 4 onward
Fever subsided by Day 10
Appetite and general condition improved significantly
No complications during hospital stay
Initial Full Body Checkup (01 July 2025):
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INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
CBC:
WBC: 4,200 /cu mm
Hemoglobin: 12.5 g/dL
Platelets: 210,000 /cu mm
Blood Culture: Salmonella typhi positive (sensitive to Ceftriaxone)
LFT:
SGPT: 54 U/L
SGOT: 48 U/L
Bilirubin: 0.9 mg/dL
RFT: Within normal limits
Chest X-ray: Normal
Ultrasound Abdomen: Mild mesenteric lymphadenopathy, no
organomegaly
Weekly Blood Tests:
Week 1 (07 July):
WBC: 3,800 /cu mm
CRP: 34 mg/L
Temp: 101.2°F
Week 2 (14 July):
WBC: 4,600 /cu mm
CRP: 18 mg/L
Temp: 100.8°F
Generated By: MS17419F on 29 Feb 2025 9:41 4
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Week 3 (21 July):
WBC: 5,200 /cu mm
CRP: 9 mg/L
Temp: 99.6°F
Treatment Administered:
Treatment Summary for Typhoid Fever
Duration: July 1 2025 to July 25, 2025
During this period, the patient received targeted treatment for typhoid fever, a
systemic infection typically caused by Salmonella typhi. Here's a concise
overview of the care provided:
Initial Diagnosis: Confirmed via blood culture and Widal test at the start of
July. Symptoms included persistent fever, abdominal discomfort, and fatigue.
Medication Administered:
Antibiotics such as ceftriaxone or azithromycin were prescribed to eliminate
the bacterial infection.
Antipyretics like paracetamol helped reduce fever and ease discomfort.
Supportive Care:
Oral rehydration therapy and nutritional support to maintain fluid and
electrolyte balance.
Rest and isolation to prevent spread and ensure proper recovery.
Monitoring:
Regular follow-ups were scheduled to track progress and adjust treatment as
needed.
Vital signs and liver function were monitored, as complications can arise.
Generated By: MS17419F on 29 Feb 2025 9:41 5
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Medications & Antibiotics:
IV Ceftriaxone 1g twice daily x 10 days (01 – 10 July)
IV Paracetamol 1g PRN for fever >101°F
Oral Azithromycin 500 mg OD x 5 days (11 – 15 July)
Tab Pantoprazole 40 mg OD
Tab Ondansetron 4 mg SOS for nausea
ORS solution – as advised
IV Fluids:
NS 100ml/hr x 3 days
DNS 500ml BD for 4 days
RL 500ml TID during febrile episodes
Supportive Care:
Tepid sponging for high-grade fever
High-protein soft diet
Bed rest and hydration monitoring
Daily monitoring of vitals and input-output charting
Generated By: MS17419F on 29 Feb 2025 9:41 6
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Daily Temperature Record (Random Range 100–104°F):
Date Morning Temp Evening Temp
01 July 103.2°F 104.8°F
02 July 102.6°F 103.9°F
03 July 101.4°F 102.8°F
04 July 100.6°F 102.0°F
05–10 July Range 100–101°F 99.07°F
11–15 July Avg. 99.8–100.2°F 101.45°F
Afebrile (98.6–
16–27 July 99.78°F
99.4°F)
Progress During Stay:
Fever began to subside by Day 5 of IV antibiotics
Appetite and energy levels improved by second week
|Blood parameters normalized by third week
No complications observed during hospitalization
Condition on Discharge:
Afebrile
Vitals stable
Tolerating oral diet well
Ambulatory and oriented
Advised rest and continued oral hydration for 1 more week
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INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Discharge Medications:
Tab Azithromycin 500 mg OD x 3 more days
Tab Paracetamol 500 mg SOS for fever/pain
Tab Pantoprazole 40 mg OD x 7 days
ORS Sachets – PRN
Follow-up:
Review in OPD after 1 week with CBC and LFT
Report earlier in case of recurrence of fever, loose stools, or vomiting
--End of Report--
Discharging Doctor:
Lt. Cdr. Dr. H. Mehta
Internal Medicine
INHS Asvini Hospital, Colaba
Date: 29July 2025
Signature: ___________________
Generated By: MS17419F on 29 Feb 2025 9:41 8
INHS ASVINI HOSPITAL, COLABA
Cuffe Parade, Near Roman Catholic Church, Maharashtra 400005
022 22151666 | [Link]
Generated By: MS17419F on 29 Feb 2025 9:41 9
