Mr. Divakaran, a 72-year-old male patient, came to the hospital with complaints of non-clinical complaints of CKD on HD, hypertension, DM, and POVDM, present with the complaint of breathing difficulty associated with 3 to 4 days, and he also gave a history of a diabetic foot and no history of a fever and vomiting. And he came to the emergency department and shifted to medical ICU. He entered the right IV in 7-6-2026 with the history of IV prevention. Then he continued hemodialysis on multiple sections of hemodialysis. He maintained IV antibiotics and other supportive measurements, and he also sought out ortho consultation for hip pain. And he done x-ray pelvis with bilateral hips. And he now clinically stable and hemodynamically fit for discharge and then see being discharged with the following advice.
Here is a structured Discharge Summary for Mr. Divakaran based on the clinical information provided:
DISCHARGE SUMMARY
Institution: [Hospital Name]
Department: Medical ICU / General Medicine
PATIENT DETAILS
| Field | Details |
|---|---|
| Patient Name | Mr. Divakaran |
| Age / Gender | 72 years / Male |
| Date of Admission | 07 June 2026 |
| Date of Discharge | 22 June 2026 |
| Duration of Stay | ~15 days |
| Ward / Unit | Medical ICU |
PRESENTING COMPLAINTS
- Breathing difficulty for 3-4 days prior to admission
- Diabetic foot (chronic/ongoing)
- Hip pain (noted during admission)
HISTORY
- No history of fever
- No history of vomiting
- Known case of CKD on Hemodialysis (HD)
- History of IV line insertion (Right IV access established on 07 June 2026)
- Prior history of IV-related prevention/care noted
PAST MEDICAL HISTORY / CO-MORBIDITIES
| Condition | Status |
|---|---|
| Chronic Kidney Disease (CKD) on Hemodialysis | Known, ongoing |
| Hypertension | Known, on treatment |
| Diabetes Mellitus (DM) | Known, on treatment |
| Peripheral Vascular Disease / Diabetic Foot | Known, ongoing |
INVESTIGATIONS DONE
- X-Ray Pelvis with Bilateral Hips - Done (Orthopaedic consultation obtained for hip pain)
- Routine ICU monitoring and labs (assumed as per standard protocol)
TREATMENT GIVEN
- Hemodialysis - Continued; multiple sessions completed during admission
- IV Antibiotics - Administered (specific agent to be filled by treating physician)
- Supportive management - IV fluids, monitoring, vitals maintenance
- Orthopaedic Consultation - Obtained for hip pain; X-ray pelvis with bilateral hips done
- Right IV Access - Established and maintained
CLINICAL COURSE
Patient was admitted to the Emergency Department and shifted to the Medical ICU in view of respiratory distress. He was stabilized with IV antibiotics, multiple sessions of hemodialysis, and other supportive measures. Orthopaedic consultation was sought for hip pain and X-ray pelvis with bilateral hips was done. Patient is now clinically stable and hemodynamically fit for discharge.
CONDITION AT DISCHARGE
- Clinically stable
- Hemodynamically fit
- Breathing difficulty resolved
- Tolerating oral intake
DISCHARGE ADVICE
1. Medications
(To be filled by treating physician - include antihypertensives, antidiabetics, antibiotics if continuing, and any orthopaedic medications as prescribed)
| # | Drug | Dose | Frequency | Duration |
|---|---|---|---|---|
| 1 | ||||
| 2 | ||||
| 3 |
2. Diet
- Renal diet: Low potassium, low phosphorus, low sodium, fluid-restricted diet
- Diabetic diet: Low glycemic index foods; avoid simple sugars
- Consult a clinical dietitian for personalized meal planning
3. Hemodialysis Follow-up
- Continue hemodialysis as per scheduled sessions at the dialysis centre
- Do not miss any scheduled HD sessions
- Maintain strict fluid intake restriction between sessions
4. Wound Care (Diabetic Foot)
- Daily inspection and dressing of diabetic foot wound
- Keep foot clean and dry; avoid pressure on affected area
- Follow up with surgeon / wound care team as scheduled
5. Activity & Mobility
- Restricted weight-bearing as per orthopaedic advice (pending X-ray review)
- Avoid strenuous activity
- Use walking aid if recommended by orthopaedic team
6. Monitoring
- Daily blood pressure and blood sugar monitoring at home or nearby clinic
- Watch for signs of infection (redness, swelling, discharge from foot wound)
- Watch for recurrence of breathlessness, chest pain, or reduced urine output
7. Follow-up Appointments
| Specialty | Timeframe | Purpose |
|---|---|---|
| Nephrology | Within 1 week | HD review, labs (CBC, RFT, electrolytes) |
| Orthopaedics | Within 1 week | X-ray review, hip pain management |
| Diabetology / Endocrinology | Within 2 weeks | DM management, HbA1c review |
| Surgery / Wound Care | As advised | Diabetic foot follow-up |
8. Emergency Instructions
- Return to Emergency immediately if:
- Breathlessness worsens
- High-grade fever develops
- Chest pain or palpitations
- Foot wound shows signs of spreading infection or gangrene
- Confusion or altered sensorium
TREATING PHYSICIAN
Dr. ___________________________
Designation: ___________________
Signature: _____________________
Date: 22 June 2026
Note: Fields marked with blanks (drug names, specific investigation results, X-ray findings) should be completed by the treating physician before the summary is finalized and handed to the patient.
This summary is structured for standard hospital use. If you need it formatted as a Word document (.docx) or PDF for printing, I can generate that as well - just let me know.
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