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    Naiya Singh 2

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    divya

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    Naiya Singh 2

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    5 views4 pages

    Naiya Singh 2

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    divya

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    DISCHARGE

    DISCHARGE SUMMARY
    DEPARTMENT OF PEDIATRICS
    ROHILKHAND MEDICAL COLLEGE , BAREILLY

    NAME MOHD. HAMZA AGE 5 YEARS SEX MALE

    FATHER JUNAID AHMAD CR. NO 2024443486 UNIT 3

    DOA 27/11/2024 DOD /2024 UNIT OPD WED/ SOS


    DAYS

    ADDRESS:- BAREILLY, UP

    UNIT INCHARGE - DR NEETU GAUTAM (ASSOCIATE PROFESSOR)

    DR. SOMESH GANGWAR (AP)

    DR. AZEEM (SR)

    JUNIOR RESIDENT- DR VINITA (JR3)

    DR SHIVAM (JR3)

    DR ANUBHAB (JR2)

    DR DIVYA (JR1)

    DIAGNOSIS -PNEUMONIA

    CHIEF COMPLAINTS – :

    1. FEVER X 2 DAYS

    2. COLD &COUGH X 2 DAYS

    3. DIFFICULTY IN BREATHING X 1 DAY

    HOPI-
    PAST HISTORY-

    BIRTH HISTORY- SINGLE/TERM/MALE/LSCS/CIAB.

    FAMILY HISTORY- NO SIGNIFICANT FAMILY HISTORY

    IMMUNIZATION HISTORY- IMMUNIZED AS PER AGE; DOCUMENT NOT AVAILABLE.

    ANTHROPOMENTRY ADMISSION SD/CENTILE IMPRESSION

    WEIGHT 12 KG <3RD CENTILE SEVERE UNDERWEIGHT

    HEIGHT 98 CM <3RD CENTILE SEVERE WASTING

    HEAD 56CM NORMAL


    CURCUMFERENCE

    LEFT MID UPPER 15 CM NORMAL


    ARM
    CIRCUMFERENCE

    BMI 12.495 -3SD TO -2 SS MODERATE wasting


    KG/M2

    GENERAL PHYSICAL
    EXAMINATION ● PR -148/MIN, RR- 42/MIN, BP 104/60MMHG, TEMP-98.8F, SP02-
    99%@O2 BY MASK
    (On Admission) ● PALLOR- PRESENT
    ● CLUBBING, EDEMA – ABSENT
    ● ICTERUS, LYMPHADENOPATHY- ABSENT

    SYSTEMIC P/A- SOFT, NON-TENDER,NO ORGANOMEGALY ,BOWEL SOUND PRESENT,


    EXAMINATION R/S- B/L AIR ENTRY EQUAL,B/L RONCHI+, CVS- S1 S2 PRSENT, NO
    MURMUR HEARD, CNS- CONSCIOUS & ORIENTED, B/L TONE NORMAL,
    (On Admission)
    B/L POWER NORMAL, B/L PUPIL NSRL, B/L PLANTAR FLEXOR, B/L DTR 2+
    HOSPITAL STAY-
    PATIENT ADMITTED WITH ALL ABOVE-MENTIONED COMPLAINTS IN RMCH. ON ADMISSION
    PATIENT’S VITALS WERE PR -120/MIN, RR- 36/MIN, BP 100/60 MMHG, TEMP- 102.2F F, SP02-
    99%@RA AND ON S/E - P/A- SOFT, NON-TENDER, BOWEL SOUND PRESENT, R/S- B/L AIR ENTRY
    EQUAL, NO ADDED SOUNDS, CVS- S1 S2 PRSENT, NO MURMUR HEARD, CNS- CONSCIOUS &
    ORIENTED, B/L TONE NORMAL, B/L POWER NORMAL, B/L PUPIL NSRL, B/L PLANTAR FLEXION,
    B/L DTR 2+. ROUTINE BLOOD INVESTIGATIONS WERE ADVISED AND DONE S/O HB 9.1, TLC
    2890, PLT 0.40, PCV 27.6, MCH 30.8, MCV 93.6, POLY 52, LYMP 43, EOSINOPHILS 1. SERUM
    BILIRUBIN TOTAL 1.86, DIRECT 0.69, SGOT 31, SGPT 14, PROTEIN 4.8, ALBUMIN 2.6, ALP 148,
    UREA 20, CREATININE 0.8, NA 137, K 3.8, CL 108, CRP POSITIVE(24MG/DL), DENGUE IGM
    POSITIVE, MP BY CARD POSITIVE (P.VIVAX), TYPHI DOT NEGATIVE, URINE R/M WITHIN NORMAL
    LIMIT. PATIENT WAS TREATED UNDER PROVISIONAL DIAGNOSIS OF DENGUE FEVER WITH
    WARNING SIGN WITH MALARIA (P. VIVAX) AND WAS ORALLY ALLOWED AND KEPT ON IV
    ANTIBIOTICS, IVF, ANTI MALARIAL DRUGS AND OTHER SUPPORTIVE TREATMENT. ON DAY 2 OF
    ADMISSION, PATIENT WAS ADVISED FOR G6PD TEST BUT GAVE REFUSAL FOR THE SAME.
    PATIENT IMPROVED CLINICALLY AND SYMPTOMATICALLY, TOLERATE FEED WELL, NO FRESH
    COMPLAIN, NO EPISODES OF VOMITING AND NO FEVER SPIKES, HENCE SAME TREATMENT WAS
    CONTINUED. ON DAY 3 OF ADMISSION, REPEAT CBC WAS SENT S/O HB 9.5, TLC 2910, PLT 0.65,
    PCV 27.7. NO FRESH COMPLAIN. REST SAME TREATMENT WAS CONTINUED. ON DAY 5 OF
    ADMISSIONAS, PATIENT IMPROVED CLINICALLY AND SYMPTOMATICALLY, NO FRESH
    COMPLAINT, TOLERATE FEED WELL, PASS URINE STOOL ADEQUATELY HENCE PATIENT IS BEEN
    DISCHARGED AND ADVISED FOR FOLLOW UP IN PEDIA OPD ON WED / SOS.
    TREATMENT GIVEN –

     I/V FLUIDS

     INJ AUGMENTIN. X

     TAB LANZOL JR

     NEBS WITH SALBUTAMOL

     NEBS WITH BUDECORT

    ADVICE ON DISCHARGE:

    DIET AS ADVISED

    PLENTY OF FLUID AND ORS

    TAB ZIFI 100 MG X 1 TAB X P/O X 12 HRLY X 2 DAYS @10MG/KG/DAY

    TAB PRIMAQUINE 15 MG X 1 TAB X P/O X 24 HRLY X 11 DAYS

    TAB LANZOL J X 30 MG X 1 TAB X P/O X 24 HRLY (EMPTY STOMACH) X 7 DAYS

    TAB EMSET 4 MG X 1 TAB X P/O X SOS

    TA PARACETAMOL 500 MG X 1 TAB X P/O X SOS

    PLAN

    ON FOLLOW UP IN PEDIA OPD ON WED 30/10/2024; REPEAT CBC ON FOLLOW UP.

    JR1 JR2 JR3 SR AP UNIT INCHARGE

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