~ HID: ANM 1.

0000425799

Discharge Summary
i Dept. of PAEDIATRICS
General Information
UHID ANM 1.0000425799

IPID ANMIP65653

• Ward/Bed No

Name

AtJe
SEVENTH FLOOR J WARD , J WARD,Bed no:7044

Baby Of GAYATRI MADKAIKAR

0Yr 6Mth 21Days

Sex Male

Address 3A-123 KAVERI KALPATARU RIVER SIDE OLD PANVEL,Navi Mumbai,Maharashtra

Primary Dr. ASHOK GAWDI AND DR. SHRIKANT TIWARI

Consultant PAEDIATRICS

Date of 15-Mar-2021
Admission

Date of 17-Mar-2021
Discharge

Diagnosis
-• I I
ACUTE GASTROENTERITIS WITH MODERATE DEHYDRATION.

Clinical Examination
BP NORMOTENSIVE Pulse 120/min.

R.R 34/min RS CLEAR

Temperature AFEBRILE CVS S1 S2 HEARD

CNS CONCIOUS, DULL

History of Present Illness

CHIEF FEVER SINCE 1 DAY
COMPLAINTS LOOSE MOTIONS SINCE 1 DAY
VOMITING SINCE 1 DAY

CHILD WAS APPARENTLY ALRIGHT 1 DAY BACK WHEN HE DEVELOPED FEVER

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Present Illness MULTIPLE EPISODES LOOSE MOTIONS AND VOMITING

SINCE 1 DAY WITH POOR ORAL INTAKE.
CHILD WAS MODERTELY DEHYDRATED ON ADMISSION.
AND IRRITABLE.
HENCE ADMITED FOR FURTHER MANAGEMENT.

Course In The Hospital & Discussion

COURSE IN THE CHILD ASSESSED IN ER,IV BOLUSES GIVEN IN/O DEHYDRATION. RELEVANT

• HOSPITAL: INVESTIGATIONS SENT,

AND SYMPTOMATIC TREATMENT STARTED. CRP WAS RAISED HENCE IV ANTIBIOTICS
STARTED.
CONDITION OF THE CHILD IMPROVED GRADUALLY. LOOSE MOTIONS REDUCED,
VOMITING STOPPED.
FEVER REDUCED.
ORAL INTAKE IMPROVED.
ACTIVITY OF THE CHILD IMPROVED.
CHILD IS HEMODYNAMICALLY STABLE HENCE DISCHARGE GIVEN.

Significant IV FLUIDS
medication given INJ TAXIM
ENTEROGERMINA
SYP ZINCONIA
INJ PAN
I'
INJ EMESET
LACTASE DROPS

• Patient's condition on discharge

Hemodynamic
Condition:
STABLE Temperature AFEBRILE

Pulse 120/min. BP NORMOTENSIVE

RR 30/min

ADVICE ON DISCHARGE
Discharge 1)SYP ZIFI (50 MG/5ML) 3'. 5 ML TWO TIMES A DAY FOR 5 DAYS
Medication
2)ENTEROGERMINA 1 AMPOULE TWO TIMES A DAY

3)2 AND D DROPS 0.5 ML ONCE A DAY FOR 12 DAYS

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4)LACTASE DROPS 5 DROPS BEFORE EACH FEED THREE TIMES A DAY FOR 7 DAYS

5)SYP ONDEM 2.5 ML SOS IF VOMITING

Follow Up FOLLOW UP AFTER 5 DAYS WITH DR ASHOK GAWDI/ DR SHRIKANT TIWARI IN OPD

INSTRUCTIONS ON DISCHARGE
Please come to IF REPEAT EPISODES OF

•
the hospital or VOMITING OR LOOSE MOTIONS
contact your OR LETHARGY.
doctor
inmediately If-

"In case of following (as applicable) please consult your doctor immediately"

- Worsening of any symptoms

- Onset of new pain or worsening of previous pain

- New onset of fever or fever persist

, - Breathing difficulty

- Altered level of consciousness

•
- Chest pain, dizziness or fainting

- Allergic reaction

Dr.AS D DR. SHRIKANT TIWARI

PAEDIATRICS
Prinary Consultant