CASE SUMMARY

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Ref. No/MS/DUH /2014-06-           Dated: _______, 2014


To,     

Dr. Haya-ul-Batool

Claims Examiner

Claims Department

EFU Life Assurance, LTD.

CASE SUMMARY

This is with reference to your letter dated 21-5-2014 regarding treatment of Mr. Mir Jan, s/o Ali Nawaz, resident of Larkana at Dow University Hospital, 

As per our records a 28 yr. old male named Mir Jan was admitted through emergency on 12-1-2014 with known history of hepatitis- C chronic liver disease with complaints of

  • Generalized weakness and vomiting for four days 

  • Passing black stool for one month.


General:   He was moderately anemic and jaundiced.

An initial impression of decompensated liver status and gastro-intestinal tract bleed was made and patient admitted for care.

 Hospital Course.

The patient was admitted to male medicine ward and investigations were ordered along with supportive treatment initiated.  On receipt of laboratory reports his haemoglobin was 4.7 g/dl, so the patient was shifted to Intensive Care Unit, where 3 packed red cells were arranged and transfused. With I/V terlipressin and other support medicines the patient’s condition started to improve.

Eosophago-gastro-duodenoscopy and Colonoscopy were done. Colonoscopy revealed mid gut bleed, cecum and terminal ileum smeared with altered blood. CT abdomen with contrast was normal with prominent splenic varices. Details in the report.

Patient was advised CT angiogram for assessment of coeliac axis. He was discharged stable on Tab. Ferrous Sulphate 200mg TID, Tab. Folic acid 5mg OD, Cap. Esvin 40mg OD and advised to follow up in MOPD with CBC report in two weeks.

All Reports were handed over to the patient along with the discharge summary on his discharge from the hospital on 18-1-2014, List of the entire test advised is attached. 





Dr. Ghazala Suhail 

Deputy Medical Superintendent 

Dow University Hospital, Ojha Campus

Karachi.



Ref. No/MS/DUH /2014-06-   Dated: 27th June, 2014




INTERNAL OFFICE ORDER



With the approval of the Competent Authority, Dr. Saeed Uddin Qadri, SMO-(Urology) is hereby attached with Lt. Col ( R ) Dr. Naeem Akhtar Qureshi who is performing the urological procedure in the absence of      Prof. Majid Rana (Rtd).

He will be directly reporting to Lt. Col ( R ) Dr. Naeem Akhtar Qureshi for all purpose. 

 







Dr. Khursheed Alam Khan

Additional Medical Superintendent

Dow University Hospital, Ojha Campus

Karachi.










    Dated: 15-7-2014

Report


One case was brought by nursing department that Mr. Muhammad Rizwan using patients MR. No for investigation for his own purpose.

The case was investigated by Nursing Superintendent. Then Mr. Rizwan accepted his mistakes in written attached with the file.

File forward to the M.S for further necessary action.     


                          





Administrator 

Dow University Hospital, Ojha Campus

Karachi.



Comments of Medical Superintendent:-


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