DISCHARGE SUMMARY - How to Fill (with Example)

🔷 PATIENT PROFILE (Top Box)

🔷 PROVISIONAL DIAGNOSIS

Example: Right ureteric calculus (kidney stone in right ureter) with hydronephrosis

🔷 FINAL DIAGNOSIS

Example: Right lower ureteric calculus (8mm) with Grade II hydronephrosis

🔷 CHIEF COMPLAINTS

Example:

• Severe right-sided flank pain since 3 days
• Burning during urination
• Blood in urine (hematuria) since 1 day
• Nausea and vomiting

🔷 PAST HISTORY / FAMILY HISTORY / PERSONAL HISTORY

Example:

• Past History: H/o kidney stone 2 years ago, managed conservatively
• Family History: Father had urinary calculi
• Personal History: Non-smoker, no alcohol, desk job, low water intake

🔷 ALLERGY

Example: No known drug allergies (NKDA) (Or: Allergic to Penicillin - rash)

🔷 EXAMINATION

Example:

• General: Conscious, oriented, mild pallor, no jaundice
• Vitals: BP 124/82 mmHg, Pulse 88/min, Temp 98.6°F, SpO2 98%
• Abdomen: Tenderness in right flank, right kidney ballottement positive
• Per Rectal / Per Vaginal: Not done

🔷 SURGERY (if any)

Example: Ureteroscopy (URS) with Pneumatic Lithotripsy - Right side Date of Surgery: 06/06/2026

🔷 PRE-OP FINDING (if any)

Example: USG abdomen showed 8mm calculus at right vesico-ureteric junction (VUJ) with proximal hydroureteronephrosis. Urine culture sterile.

🔷 PROCEDURE

Example: Under spinal anesthesia, rigid ureteroscopy done. Stone fragmented with pneumatic lithotripter. Fragments cleared. DJ stent (6Fr x 26cm) placed. Procedure uneventful.

🔷 COURSE DURING HOSPITAL STAY

Example: Patient admitted, pre-op workup done. Kept NPO from midnight. Operated on 06/06/2026 under spinal anesthesia. Post-op recovery uneventful. Catheter removed on POD-1. Tolerating orally. No fever, no bleeding.

🔷 SIGNIFICANT DIAGNOSTIC FINDINGS

Example:

• USG Abdomen: Right lower ureteric calculus 8mm, Grade II hydronephrosis
• X-ray KUB: Opaque shadow at right VUJ
• Urine R/M: RBCs 20-25/hpf, no growth on culture
• CBC: Hb 13.2 g/dL, TLC 9800, Platelets 2.1 lac
• Creatinine: 1.1 mg/dL, Blood Urea 28 mg/dL

🔷 TREATMENT GIVEN DURING HOSPITALIZATION

Example:

• IV fluids: Normal Saline 1L x 2
• Inj. Tramadol 50mg IV SOS for pain
• Inj. Ceftriaxone 1g IV BD x 2 days
• Tab. Tamsulosin 0.4mg OD
• URS + Pneumatic Lithotripsy done on 06/06/2026

🔷 PATIENT'S CONDITION AT TIME OF DISCHARGE

Example: Stable. Afebrile. Pain-free. Tolerating oral diet. Urine clear. Wound (cystoscopy port) healthy.

🔷 TREATMENT ADVICE ON DISCHARGE

Example:

• Tab. Tamsulosin 0.4mg OD x 4 weeks
• Tab. Ciprofloxacin 500mg BD x 5 days
• Tab. Diclofenac 50mg SOS for pain
• Increase water intake to 3-4 liters/day
• DJ stent removal planned after 4 weeks

🔷 NUTRITIONAL ADVICE

Example:

• Drink at least 3 liters of water daily
• Avoid spinach, tomatoes, nuts (oxalate-rich foods)
• Reduce salt and animal protein intake
• Include citrus fruits (lemon water) in diet

🔷 FOLLOW-UP PLAN

Example: Review after 1 week at OPD. DJ stent removal after 4 weeks. X-ray KUB at follow-up.

🔷 WHEN AND HOW TO OBTAIN EMERGENCY CARE

Example:

1. Severe pain not relieved by tablets
2. High fever (>101°F) or chills
3. No urine output for more than 8 hours
4. Heavy bleeding in urine

🔷 SIGNATURES

Quick Tips for Filling This Form

• NPO (written on your form) = Nil Per Oral = nothing to eat/drink before surgery
• GA / SA / LA = General Anesthesia / Spinal Anesthesia / Local Anesthesia
• CA likely refers to Clamping/Catheter or a lab value (context-dependent)
• Always attach lab reports when it says "All reports are attached"
• The doctor must sign - this is a medico-legal document