Patient ID
UHID-1004
Age / Gender
54 yrs / male
Department
Surgery
Discharge Type
referred
Admission Date
09/07/2026
Discharge Date
14/07/2026
⚠ 5 fields not dictated — please review before signing
Reason for Admission
Head surgery due to a crack in the head.
Presenting Complaints
Not documented — pending manual review.
Admitting Diagnosis
Crack in the head.
Hospital Course
Day 1: Bed rest. Day 2: Blood was taken for tests. Day 3: Surgery completed.
Procedures Performed
Head surgery.
Investigations Summary
Not documented — pending manual review.
Final Diagnosis
Crack in the head.
Discharge Medications
| Medication | Dosage | Route | Frequency | Duration | Instructions |
|---|---|---|---|---|---|
| Elzemic | 250 | — | — | — | — |
| Dihydric | 122 | — | — | — | — |
Condition at Discharge
Stable.
Vitals at Discharge
Blood Pressure
—
Pulse Rate
—
Temperature
—
Respiratory Rate
—
SpO2
—
Weight
—
Allergies
NOT DOCUMENTED — verify with patient/family before discharge.
Discharge Instructions
Diet: Progress diet from clear liquids to a regular diet as tolerated; avoid heavy or oily food for the first week.
Activity: Avoid heavy lifting (>5 kg) and driving for 2 weeks. Gentle walking is encouraged to prevent complications.
Wound Care: Keep the surgical wound clean and dry. Watch for redness, swelling, discharge, or fever, and do not remove dressings without medical advice.
Seek Emergency Care If: Return immediately for wound bleeding or discharge, fever, severe abdominal pain, or inability to pass urine or stool.
Follow-up: Follow up in the next 15 days.
Digital Signature
Signed by Dr. Priya Sharma • MCI-2024-00123
Raw Transcription
Doctor name is Priya Sharma patient name is XYZ he the reason of admission was the head surgery crack had been crack There was a crack in the head and we should have we did a surgery for that and it is diagnosed right now the procedure follow is day one bed rest day two the blood was taken for the test day three the surgery completed the medications for the discharge are Elzemic 250 and Dihydric 122 and the follow up plan is in the next 15 days and the condition at discharge is stable.