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Discharge summary. Patient : DUMMY, MARY ( B/N 1111111 ) Dept. of Psychiatry
An Rannog Siciatracha
GP ADDRESS
Patient No:
PATIENT NAME:
Address:
ADMISSION DATE: 02/07/2008
DISCHARGE DATE: 12/08/2008
SPECIALTY: MEDICAL DISCHARGE CONSULTANT: MULKERRIN, PROF. E.
DIAGNOSIS:
(K92.0) -- Haematemesis (I10) -- Hypertension - Primary / Essential (I48) -- Atrial fibrillation and flutter (K56.6) -- Intestinal obstruction Small Bowel Obstruction Depression Intermittent reflux x years ADMISSION
PLANNED:
ADMISSION
CHIEF COMPLAINT AND DURATION:
Admitted 2/07/2008 with haematemesis in association with epigastric discomfort and waterbrash against background history of intermittent post prandial abdominal distension associated with nausea and reduced dietary intake. Initally managed on IV PPI bd with surgical advice for conservative management. SPECIALTY DEPARTMENTS CONSULTED:
ABNORMAL TEST RESULTS:
Haematology: On admission: PT high 16.3, INR 1.4, Urea 8.7, Bilirubin 28. On discharge: Hb 9.3, Platelets 463, CRP 25.1, ESR 81, Urea 2.6, creatinine 41, Total protein 48, Albumin 24. Tumour markers: CEA 1.7 (N=6-42), CA 19.9: 37.1 (N=0-27) Discharge summary. Patient : DUMMY, MARY ( B/N 1111111 ) Radiology: 1. Chest xray:02/02/2008 Lungs hyperinflated bilaterally with bronchovascular markings consistent with COPD. Calcification of trachea and bronchi. Lungs clear of active disease. 2. Plain film abdomen: 02/07/2008: Bowel gas pattern normal, curvilinear density projected on left lateral to lumbar spine which may represent ectatic aorta or aortic aneurysm. 3. CT abdomen: 02/07/2008: Infrarenal aortic aneurysm measuring 5cm in maximum diameter. Large amount of thrombus present and calcification of the wall. Aorta is ectactic. No evidence of rupture or leak. 4. Plain film abdomen: Large aneurysm, non specific bowel gas pattern. 5. Barium meal: Hold up at level of the third part of the duodenum. Difficult to be certain if the barium extended beyond this due to very distended barium filled stomach overlapping small bowel. 6. Barium follow through:17/07/2008: The barium was ingested for barium meal seven days ago and has now reached colon. This demonstrated that the duodenal obstruction is not complete, therefore the procedure was abandoned. NORMAL TESTS:
Haematology: Troponins, Liver function test (With the exception of bilirubin). OPERATION AND OTHER TREATMENTS GIVEN:
IV fluids IV vitamin K Group and hold NPO, wide bore NG tube, surgical follow-up TPN through central line PROCEDURES:
(13815-00) -- Central vein catheterisation (36800-00) -- Bladder catheterisation (92036-00) -- Insertion of nasogastric tube (90220-00) -- Catheterisation/cannulation of other vein PROGRESS:
Patient condition improved and mobilising well. MEDICATIONS ON DISCHARGE:
Lactulose 15mls PO TDS Frusemide 40mg PO OD Digoxin 250 micrograms PO OD Lansoprazole FT 30mg PO OD Ferrous fumurate 305mg PO OD Paracetamol 1g PO PRN Metaclopramide 10 mg PO TDS/PRN OTHER RECOMMENDATIONS ON DISCHARGE:
Transfer from UCH Galway straight to hospital in Castledouglas would be prefered. Have advised her family of this but they plan to fly her home on 11/08/08, where she will stay one night with her son, before going to Castle douglas hospital. Patients should surgical review in Scotland, following episode of small bowel obstruction in UCHG. Warfarin to be held due to GI Bleed in UCHG. Return SOS to A&E or GP should condition detiorate or symptoms reoccur. FOLLOW UP PLANS
REFERRED TO:
Discharge summary. Patient : DUMMY, MARY ( B/N 1111111 ) Yours sincerely,
DISCHARGE CONSULTANT:
MULKERRIN, PROF. E.
NCHD/AUTHOR:

Source: http://www.dmfsystems.ie/dmfsystems.ie/info/p7012PSY_demo.pdf