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Fdssummary 16105360050950.5658381507651854

Mr. Milind was admitted to the hospital with difficulty retracting his prepuce and was diagnosed with Balanoposthitis. He underwent a stapler circumcision procedure which had an uneventful postoperative period. He was discharged in a stable condition with medications and follow up advice to avoid sex for 4 weeks and return for review in 7 days.

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Harish Tripathi 14
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360 views2 pages

Fdssummary 16105360050950.5658381507651854

Mr. Milind was admitted to the hospital with difficulty retracting his prepuce and was diagnosed with Balanoposthitis. He underwent a stapler circumcision procedure which had an uneventful postoperative period. He was discharged in a stable condition with medications and follow up advice to avoid sex for 4 weeks and return for review in 7 days.

Uploaded by

Harish Tripathi 14
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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DISCHARGE SUMMARY

PATIENT’S NAME: Mr. Milind IPID:


AGE: Years DATE OF ADMISSION: 12/01/2021
GENDER: Male DATE OF OPERATION: 12/01/2021
ROOM/BED NO: 502 DATE OF DISCHARGE: 13/01/2021
PATIENT’S ADDRESS:
PATIENT’S CONTACT NUMBER:

CONSULTANT: Dr. Aman Priya Khanna

DIAGNOSIS:
− Balanoposthitis

CHIEF COMPLAINTS:
Difficulty in retracting prepuce

HISTORY OF PRESENT ILLNESS:


Patient came with above mentioned complaints. Patient was evaluated and diagnosed with
Balanoposthitis and planned for surgery.

PAST HISTORY:
Nothing significant.

CLINICAL EXAMINATION ON ADMISSION:


Pulse - 80/min
RR - 18/min
Temp - Afebrile
BP - 120/80 mmHg

PROCEDURE DONE:
Stapler Circumcision

OPERATIVE FINDINGS:
Balanoposthitis

COURSE IN HOSPITAL: Patient was admitted in the hospital with above mentioned complaints.
After pre-anaesthetic clearance, patient underwent Stapler circumcision under RA on 12/01/2021 .
Post-operative period was uneventful. Patient has gradually improved and now is being
discharged in stable condition.

MEDICATIONS GIVEN:
Inj. Supacef 1.5 gm I/V twice a day
Inj. Dynapar 75 mg I/V thrice a day
Inj. Pan 40 mg I/V twice a day
CONDITION AT DISCHARGE: Patient is afebrile, vitals are stable, accepting oral diet. Surgical
wounds are healthy and no bleeding noted.

MEDICATION ON DISCHARGE:
DRUG COMPOSITION DOSE ROUTE FREQUENCY DURATION
TAB. CEFOPRIT CEFUROXIME 500 MG PER TWICE A DAY 5 DAYS
ORALLY
TAB. RAZO RABEPRAZOLE 20 MG PER ONCE A DAY (BEFORE 2 WEEKS
ORALLY BREAKFAST)
TAB. ULTRACET 1 TAB PER THRICE A DAY 1 WEEK
ORALLY
TAB. ENZOFLAM PARACETAMOL & 1 TAB PER THRICE A DAY 5 DAYS
IBUPROFEN ORALLY
TAB. CHYMORAL 1 TAB PER THRICE A DAY 5 DAYS
FORTE ORALLY
LOX JELLY LOCAL TWICE A DAY
APPLICATI
ON
MUPIROCIN OINT LOCAL 1 WEEK
APPLICATI
ON

FOLLOW UP ADVICE:
Avoid sex for 4 weeks
Daily dressing as advised
Review in OPD after 7 days with Dr Aman Priya Khanna with prior appointment (+91-9311233277)
In case, if any emergency, contact on - (+91-7303763211)

WHEN TO OBTAIN URGENT CARE: If patient develops fever, recurrent vomiting, severe pain,
excessive bleeding / pus discharge.

Dr. Aman Priya Khanna

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