Bushra Unit 3

DOPR
DISCHARGE SUMMARY
DEPARTMENT OF PEDIATRICS
ROHILKHAND MEDICAL COLLEGE , BAREILLY
NAME BUSHRA AGE 15 YEARS SEX FEMALE
FATHER ANEES AHMAD UHID 2024451302 UNIT 3
DOA 06/11/2024 DOD /11/2024 UNIT OPD DAYS WED
ADDRESS:- MORADABAD , UP
UNIT INCHARGE -DR. NEETU GAUTAM ( ASSOCIATE PROFESSOR)
ASSISTENT PROF- DR. SOMESH GANGWAR
SR: DR. AZEEM
JUNIOR RESIDENT:
DR. VINITA JR3
DR. SHIVAM JR3
DR. MAHESH JR2
DR. SHIVAM JR1
DR. DIVYA JR1
DIAGNOSIS – DISSEMINATED TUBERCULOSIS WITH SEVERE ANEMIA WITH WIDAL POSITIVE
CHIEF COMPLAINTS : -FEVER ON AND OFF X 3 MONTHS
COUGH X 1.5 MONTHS
HOPI- ACCORDING TO THE ATTENDANT I.E. MOTHER, PATIENT WAS APPARANTLY WELL 3 MONTHS
BACK WHEN SHE DEVELOPED FEVER, SUDDEN IN ONSET CONTINUOUS, UNDOCUMENTED, ASSOCIATED
WITH NIGHT SWEATS,CHILLS AND RIGOR,FOR THESE COMPLAINTS SHE WAS GIVEN MEDICATION FROM
MULTIPLE PRACTITIONAR BUT DID NOT GET ANY RELIEF.
THEN 1.5 MONTHS BACK SHE DEVELOPED COUGH, INSIDIOUS IN ONSET, PROGRESSIVE,NO DIURNAL
VARIATION, PRODUCTIVE (YELLOWISH IN COLOUR), NOT ASSOCIATED WITH RUNNING NOSE
DIFFICULTY IN BREATHING CHEST PAIN, NOISY BREATHING SHORTNESS OF BREATH.
FOR THE COMPLAINT SHE WAS BROUGHT TO RMCH AND GOT ADMITTED.
HISTORY OF BLOOD TRANSFUSION 3 MONTH BACK
H/O SECONDARY AMENORRHEA SINCE 3 MONTH
HISTORY OF WEIGHT LOSS PRESENT
NO HISTORY OF TB CONTACT, PAIN IN ABDOMEN, BURNING MICTURITION, ALTERED BOWEL AND
BLADDER HABITS
PAST HISTORY- NO HISTORY OF SIMILAR ILLNESS IN THE PAST
FAMILY HISTORY- NO SIGNIFICANT FAMILY HISTORY PRESENT

ANTHROPOMENTRY ADMISSION SD/CENTILE IMPRESSION
WEIGHT 36 KG B/W 3RD TO 10TH NORMAL

PERCENTILE
HEIGHT 158 CM B/W 10TH TO 25TH NORMAL

PERCENTILE
BMI 14.421 KG/M2 <3RD CENTILE SEVERE UNDERWEIGHT
GENERAL PHYSICAL
EXAMINATION
VITALS-HR-110/MIN, RR-36/MIN(NF+,SCR+,ICR+), SPO2-98%@O2 BY
(ON ADMISSION) MASK, TEMP-99.4 F, BP-98/60MMHG
PALLOR,ICTERUS,EDEMA,LYMPHADENOPATHY- ABSENT
SYSTEMIC EXAMINATION R/S-B/L BREATH SOUNDS +, AIR ENTRY DECREASED IN LEFT

INFRAMAMMARY, INFRA AXILLARY, INFRASCAPULAR REGION,CREPTS+
(ON ADMISSION)
P/A-SOFT ,DISTENDED,LIVER JUST PALPABLE,BS+
CVS-S1, S2 +, NO MURMUR
CNS-E4,V5,M6, B/L TONE NORMAL, B/L DTR +2,B/L PLANTAR-

FLEXORS,B/L PUPIL NSRL
HOSPITAL STAY: ON THE DAY OF ADMISSION VITALS

HR-110/MIN, RR-36/MIN(NF+, SCR+,ICR+), SPO2-98%@O2 BY MASK, TEMP-99.4 F, BP-98/60MMHG
S/E R/S-B/L BREATH SOUNDS +, AIR ENTRY DECREASED IN LEFT INFRAMAMMARY, INFRA AXILLARY,
INFRASCAPULAR REGION,CREPTS+,P/A-SOFT ,DISTENDED,LIVER JUST PALPABLE,BS+,CVS-S1, S2 +,
NO MURMUR, CNS-E4,V5,M6, B/L TONE NORMAL, B/L DTR +2,B/L PLANTAR-FLEXORS,B/L PUPIL
NSRL.PATIENT WAS ORALLY ALLOWED,IV FLUIDS,IV ANTIBIOTICS(CEFTRIAXONE)AND OTHER
SUPPORTIVE TREATMENT WAS STARTED. BLOOD INVESTIGATIONS WERE SENT-WERE S/O HB-
9.2,TLC-13,270,PLATELET-3.49,MCV-58.4,MCH-18.1,MCHC-31.1,PCV-29.6,LYMPHOCYTES-06,POLY-
88,ESR-45,RETIC COUNT-2.6%,GBP WAS S/O-MICROCYTIC HYPOCHROMIC ANEMIA,USG W/A WAS
S/O HEPATOMEGALY,WIDAL POSITIVE ‘O TITRE’-1:160,REST ALL INVESTIGATIONS WERE WITHIN
NORMAL LIMITS.GYNAE REFERENCE WAS TAKEN I/V/O SECONDARY AMENORRHEA AND WAS S/O NO
ACTIVE INVTERVENTION NEEDED.SPUTUM FOR CBNAAT WAS POSITIVE FOR M.TUBERCULOUS
SENSITIVE TO RIFAMPICIN, HENCE ATT WAS STARTED ON 7/1124. ATTENDANT WAS ADVISED FOR
TUBERCULOSIS SCREENING FOR THE CONTACTS BUT GAVE REFUSAL, INH PROPHYLAXIS WAS
STARTED FOR THE FAMILY MEMBERS.PATIENT IMPROVED CLINICALLY. ATTENDANT WAS
COUNSELLED REGARDING THE NEED FOR CECT ABDOMEN INVESTIGATION TO RULE OUT
ABDOMINAL TB BUT ATTENDANT GAVE REFUSAL AND CONSENT WAS TAKEN FOR THE
SAME.GRADUALLY ORAL INTAKE IMPROVED HENCE IV FLUID WAS TAPERED AND STOPPED.PPD WAS
REACTIVE.AS THE PATIENT MAINTAINED SATURATION AT ROOM AIR, NO SIGNS OF RESPIRATORY
DISTRESS, HENCE THE PATIENT WAS SHIFTED TO ROOM AIR. NOW ON DAY OF ADMISSION-PATIENT
IMPROVED CLINICALLY, HENCE BEING DISCHARGED WITH ADVISE TO FOLLOW UP IN PEDIA OPD ON
WED/SOS.
TREATMENT GIVEN
● INJ CEFTRIAXONE X
● INJ FEVASTIN
● TAB AKT-4
● TAB BANADON
ADVISE ON DISCHARGED:
● TAB ZIFI 200MG X 1 TAB X P/O X 24 HOURLY

● TAB AKT-4 1 KIT PO 24 HOURLY X 1 MONTH(TO BE CONTINUED)
● H@7.8MG/KG R@11.8MG/KG Z@39MG/KG/DAY E@21MG/KG/DAY
● (INTENSIVE PHASE-08/11/24---09/1/25) CONTINUATION PHASE- (10/01/25-19/05/25)
● TAB BANADON 40MG HALF TAB X PO X 24 HOURLY (E/S/BBF)
● TAB PCM 650 MG X 1 TAB X P/O X SOS
● TAB PANTOP 40 MG X 1 TAB X P/O X 24 HRLY (EMPTY STOMACH) X 7 DAYS
● TAB A TO Z X 1 TAB X P/O X 24 HRLY X 1 MONTH
PLAN – FOLLOW UP IN PEDIA OPD ON 10/11/24 SAT/WED/SOS
JR1 JR2 JR3 SR AP UNIT INCHARGE

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DOPR

ROHILKHAND MEDICAL COLLEGE , BAREILLY

NAME BUSHRA AGE 15 YEARS SEX FEMALE

FATHER ANEES AHMAD UHID 2024451302 UNIT 3

DOA 06/11/2024 DOD /11/2024 UNIT OPD DAYS WED

UNIT INCHARGE -DR. NEETU GAUTAM ( ASSOCIATE PROFESSOR)

ASSISTENT PROF- DR. SOMESH GANGWAR

SR: DR. AZEEM

DR. VINITA JR3

DR. SHIVAM JR3

DR. MAHESH JR2

DR. SHIVAM JR1

DR. DIVYA JR1

DIAGNOSIS – DISSEMINATED TUBERCULOSIS WITH SEVERE ANEMIA WITH WIDAL POSITIVE

CHIEF COMPLAINTS : -FEVER ON AND OFF X 3 MONTHS

COUGH X 1.5 MONTHS

PAST HISTORY- NO HISTORY OF SIMILAR ILLNESS IN THE PAST

FAMILY HISTORY- NO SIGNIFICANT FAMILY HISTORY PRESENT

WEIGHT 36 KG B/W 3RD TO 10TH NORMAL

HEIGHT 158 CM B/W 10TH TO 25TH NORMAL

BMI 14.421 KG/M2 <3RD CENTILE SEVERE UNDERWEIGHT

SYSTEMIC EXAMINATION R/S-B/L BREATH SOUNDS +, AIR ENTRY DECREASED IN LEFT

CNS-E4,V5,M6, B/L TONE NORMAL, B/L DTR +2,B/L PLANTAR-

HOSPITAL STAY: ON THE DAY OF ADMISSION VITALS

● TAB ZIFI 200MG X 1 TAB X P/O X 24 HOURLY

● TAB PANTOP 40 MG X 1 TAB X P/O X 24 HRLY (EMPTY STOMACH) X 7 DAYS

● TAB A TO Z X 1 TAB X P/O X 24 HRLY X 1 MONTH

PLAN – FOLLOW UP IN PEDIA OPD ON 10/11/24 SAT/WED/SOS

JR1 JR2 JR3 SR AP UNIT INCHARGE

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