Pediatric Emergency

Department

Sindh Government
Hospital Hyderabad

MR #: 10-21-0648167
Name: Miss RABIA
ZULFIQAR
Age: 10 Year(s) 0
Month(s) 0
Day(s)
Gender: Female
Triage P2
Category:
Admission Disposition
Date/TIme Date/Time
03-Oct-2021, 03-Oct-2021,
02:59 PM 06:38 PM
Discharge Admitted
Type:

Patient Lying
Condition:
Patient Fever
Complaint:
Diagnosis:
Infectious gastroenteritis and
colitis, unspecified (Provisional)
A09 ,Meningitis, unspecified
(Provisional) G03.9
Examination/History:
Presenting Complaints
Initial Impression: Initial
Impression, Appearance:
Conscious, Breathing: Normal,
Color: Normal, Initial
Impression: Non-Life Threating
Condition
History
Patient History: Patient History,
Sign Symptoms: fever for 2
days / vomiting for 2 days /,
Allergies: n, Medication: n, Past
History: n, Last Meal: an hour
ago, Events: fever / vomiting
Examination
Physical Examination Pediatric:
Physical Examination Pediatric,
General Look: Stable,
AIRWAY: Clear, Extermities:
Warm, CRT:: Less Then 2
Second, Pulse Central: Good,
Pulse Peripheral: Good, Any
Rash: No, Conscious Level:
Irritable, Dehydration: No,
Anemia Severity: No, HEENT:
n, LUNGS: clear, Heart: n,
Abdomen: n, Genetalia: n,
Neurological: n, Back Spine: n,
Musculoskeletal: n

Progress Notes:
vomitinng controled no fits observed in
er / vitally stable / labs sent / plan to
admit in ward for further managemnt /
received with febrile / still vomit
occured inj ome adde dirritable /
altered behaviour/ case dscused wth
oncall pg / managing as meningtiis .

Current Admission Medicine:

Omeprazole 40 Injectable In
Grammage, 20.00, Intravenous
0.9% Dextrose Saline 500 Injectable In
Drip, 1560.00, Intravenous
Paracetamol 1000 Injectable In
Grammage, 345.00, Intravenous
Ceftrioxone 500 Injectable In
Grammage, 2300.00, Intravenous
Ondansetron 8 Injectable In
Grammage, 3.40, Intravenous
Ceftrioxone 500 Injectable In
Grammage, 1150.00+ 1150.00,
Intravenous

Advice on Discharge:
.admit in ward
.continue antibiotics for 10-14
days
. iv dexa 0.15mg/dose every 6
hourly for 48 hours
. chase labs/csf dr and c/s
adviced
 Pediatric Emergency
Department

Sindh Government
Hospital Hyderabad

Vitals Last Vital First Vital

Pulse: 139 120
BP(S/D): 119/49
Temp: 36 37.6
RR: 29 26
Height:
Weight: 23 23

SPO2: 99 98

BS(R): 102

BS(F):
Gir:
BMI: 0 0

Pain Scale: 0
Yes null
Fall Risk:

Discharged Doctor HINA

By: KANWAL