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Give me the discharge summary of pt named Prasad aged 37male Co sore throat fever cough giddiness

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Here is the compiled Discharge Summary based on all documents in the patient file:

DISCHARGE SUMMARY

Sri Lakshmi Multi-Speciality Hospital #127/1, Sri Gandhada Kaval, Sunkadakatte, Vishwaneedam Post, Magadi Main Road, Bangalore - 560091, Karnataka, India

PATIENT DETAILS

FieldDetails
NameMr. Prasad
Age / Gender37 Years / Male
IP No.H2-25/000090 (IP-LH)
Date of Admission20/07/2026
Date of Discharge21/07/2026
Admitting ConsultantDr. Vinod Kumar (Cardiologist)
Medicolegal CaseNo
AllergiesNone

CHIEF COMPLAINTS

  • Sore throat - since 1 hour
  • Fever - since 1 hour
  • Cough - since 1 hour
  • Giddiness - since 1 hour

HISTORY OF PRESENT ILLNESS

Mr. Prasad, a 37-year-old male, was apparently normal and subsequently developed the above-mentioned complaints. On presentation to the Emergency Department, he was found to have tachycardia, profuse sweating, and hypotension, for which he was admitted for further management and evaluation.
Detailed history revealed:
  • Palpitations (newly presenting)
  • Newly detected hypertension (HTN)
  • Generalized weakness
  • Giddiness - 1 year duration
  • Fever - 2 days duration
  • Positional vertigo (giddiness worsened with positional changes)
  • 1 episode of vomiting

PAST HISTORY

Not significant / Not documented.

ON EXAMINATION AT ADMISSION

  • General Condition: Tachycardia, profuse sweating
  • BP: 190/100 mmHg (significantly elevated)
  • Moving all 4 limbs (normal motor function)
  • CVS / RS: No abnormality detected

PROVISIONAL DIAGNOSIS

  1. ? Accelerated Hypertension (newly detected)
  2. Positional Vertigo under evaluation (Benign Paroxysmal Positional Vertigo - BPPV)
  3. Acute pharyngitis / Upper respiratory tract infection (sore throat, fever, cough)

INVESTIGATIONS ADVISED / DONE

  • CBC (Complete Blood Count)
  • RFT (Renal Function Test)
  • Troponin I (Trop I) - Result: Negative
  • 2D ECHO
  • ECG - Repeat ECG ordered after 4 hours
  • CXR (Chest X-Ray)
  • CT (CT imaging - type as advised)
  • Althermal score / ASCOR pain score assessment

SPECIALIST OPINIONS SOUGHT

  • Neuro Physician Opinion
  • ENT Opinion

TREATMENT GIVEN

DrugRouteFrequency
Inj. Pan (Pantoprazole)IV1-0-0
Inj. Emeset (Ondansetron)IV1-0-0
Inj. Labetalol 10 mgIVBP/HR monitoring guided
Tab. AltheralOralBD
Syp. Ascor PainOralBD
Tab. Verten LongOralBD
BP monitoring-Continuous
Repeat ECG-After 4 hours

PROGRESS & CLINICAL COURSE

Day 1 (20/07/2026 - 18:30): Admitted with tachycardia, profuse sweating, hypotension, and sore throat/fever/cough/giddiness. Treated with IV medications, BP management started.
Day 1 (20/07/2026 - 21:00, reviewed by Dr. Soumya Raghu):
  • BP: 130/80 mmHg (improved)
  • Pulse: 82 bpm
  • CVS/RS: NAD
  • Troponin I: Negative
  • Patient assessed for positional vertigo; advice for Vestib long Inj given; ENT opinion requested.
Day 1 (21/07/2026 - 5:30, reviewed by Neurology/Dr. Soumya):
  • Giddiness - c/o Positional Vertigo
  • BP: 130/80g, Pulse: 82 bpm
  • Confirmed case of BPPV (Positional Vertigo)
  • Neurology physician opinion obtained
  • ENT opinion sought
Day 2 (21/07/2026 - 09:11, reviewed by Resident Dr. Karthik):
  • Patient symptomatically better
  • BP: 130/90 mmHg
  • PR: 69 bpm
  • SpO2: 98% on Room Air
  • Diagnosis: ? Accelerated HTN + Giddiness under evaluation
  • Advice: Strict vital monitoring, medications as per chart

FINAL DIAGNOSIS

  1. Accelerated Hypertension (Newly detected)
  2. Benign Paroxysmal Positional Vertigo (BPPV)
  3. Acute Upper Respiratory Tract Infection (sore throat, fever, cough)

CONDITION AT DISCHARGE

Symptomatically better. Vitals stable.
  • BP: 130/90 mmHg
  • PR: 69 bpm
  • SpO2: 98% on Room Air

DISCHARGE MEDICATIONS

(As per chart - to be filled by treating physician)
  • Tab. Verten Long (Betahistine) - BD
  • Tab. Altheral (Antihypertensive) - BD
  • Syp. / Tab. Ascor Pain - BD
  • Antihypertensive therapy to be continued as advised

ADVICE AT DISCHARGE

  1. Strict regular BP monitoring at home
  2. Low-salt, low-fat diet
  3. Avoid sudden positional changes (for vertigo)
  4. Follow-up with Dr. Vinod Kumar (Cardiology) within 1 week
  5. ENT follow-up as advised
  6. Neurology follow-up as advised
  7. Return to Emergency if BP rises above 160/100 mmHg, or giddiness recurs severely
Prepared by: Resident Dr. Karthik Verified by: Dr. Vinod Kumar (Cardiologist) Date: 21/07/2026
Note: This discharge summary has been prepared based on the available in-patient records, history & assessment form, and progress notes. Any missing investigation results or final medication doses should be verified from the original prescription chart.

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