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TasnimBte Hamdan, S/Nurse
25/12/2013 12:44
Printed by:
Printed on:
Chest normal
HS normal
Significant physical and other findings:
WT 65.5KG
temp 38.5
P 98/min reg
BP 137/87
Reason for admission:
Fever day 3
Headache, bodyache
Nausea and vomited
Diarrhoea day 2, stopped
no significant travel recently
Date of Discharge:
25/12/2013
Date of Admission:
21/12/2013
EN-00898240, PCMC, Inpatient, 21/12/2013-
Dr Fauzi B. MdAnshar, Int Med& RespiratoryMedPhysicianon 25 December 2013
Discharge Summary
25December 2013 12:21
Auth (Verified)
Dischargesummary
Dr Fauzi B. MdAnshar, Int Med& RespiratoryMedPhysicianon 25December 2013
Result type:
Result date:
Result status:
Result title:
Performed by:
12:21
Verified by:
12:25
Encounter info:
MUHAMMAD KHUDRI BIN HALIM BASHAH, - 1157148 Discharge Summary
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Tasnim Bte Hamdan, S/Nurse
25/12/2013 12:44
Printed by:
Printed on:
Follow up instruction:
Patient opted to have bloodtest at panel clinic
Discharge medications, all of the medications to be taken home:
Gaviscon 10ml bd
Calamine lotion topas needed
Paracetamol 1g tds/prn
Final Diagnosis:
Denguefever
The patient's condition at the time of discharge:
Well
Significant medications and other treatments:
Improved with iv fluids and symptomatic treatment
Diagnostic and therapeutic procedures performed:
Dengue serology negative, NS1antigen +ve
FBC: Hb 12.7 , Hct 37 , wee 4.2 , Plat 127 (from 176in Klinik Kesihatan20/12/2013 )
Platelets ondischarge 105
RP K 3.4 rest normal
LFT: bili 23.2ALT 66
On discharge bilirubin 21, ALT 114
Significant diagnoses and co-morbidities:
Thallassaemia minor
Abdo soft non tender, no hepatomegaly
MUHAMMAD KHUDRI BIN HALIM BASHAH, - 1157148 Discharge Summary
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TasnimBte Hamdan, S/Nurse
25/12/2013 12:44
Printed by:
Printed on:
CompletedAction List:
* Per f or m by Dr Fauzi B. Md Anshar , I nt Med & Respi r at or y Med
Physi ci an on 25 December 2013 12: 21
* Si gn by Dr Fauzi B. Md Anshar , I nt Med & Respi r at or y Med Physi ci an
on 25 December 2013 12: 25 Request ed by Dr Fauzi B. Md Anshar , I nt
Med & Respi r at or y Med Physi ci an on 25 December 2013 12: 25
* Modi f y by Dr Fauzi B. Md Anshar , I nt Med & Respi r at or y Med
Physi ci an on 25 December 2013 12: 25
* VERI FY by Dr Fauzi B. Md Anshar , I nt Med & Respi r at or y Med
Physi ci an on 25 December 2013 12: 25
39, J alanKiaPeng, 50450KualaLumpur, Malaysia
Tel: +603 21600000
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If in urgent needof medical attention, pleasego to PCMCEmergencyDepartment +603 21600999
Special instructions:
MUHAMMAD KHUDRI BIN HALIM BASHAH, - 1157148 Discharge Summary
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