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  • Discharge Summary Report1632349167897

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    Dua Zaheer
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    This document summarizes the emergency department record of a 5-month-old female infant admitted for sepsis and severe protein-calorie malnutrition. Upon admission, the patient was conscious with normal breathing, color, and stable vitals. She was not feeding and had been experiencing inability to gain weight, loose motions, and vomiting for one month. Tests were ordered and she was admitted to the neonatal intensive care unit for IV fluids, antibiotics, and monitoring. Her condition was stable upon initial examination.

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    This document summarizes the emergency department record of a 5-month-old female infant admitted for sepsis and severe protein-calorie malnutrition. Upon admission, the patient was conscious with normal breathing, color, and stable vitals. She was not feeding and had been experiencing inability to gain weight, loose motions, and vomiting for one month. Tests were ordered and she was admitted to the neonatal intensive care unit for IV fluids, antibiotics, and monitoring. Her condition was stable upon initial examination.

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    © All Rights Reserved
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    4 views2 pages

    Discharge Summary Report1632349167897

    Uploaded by

    Dua Zaheer
    This document summarizes the emergency department record of a 5-month-old female infant admitted for sepsis and severe protein-calorie malnutrition. Upon admission, the patient was conscious with normal breathing, color, and stable vitals. She was not feeding and had been experiencing inability to gain weight, loose motions, and vomiting for one month. Tests were ordered and she was admitted to the neonatal intensive care unit for IV fluids, antibiotics, and monitoring. Her condition was stable upon initial examination.

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    © All Rights Reserved
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    of 2

    Pediatric Emergency

    Department

    Sindh Government
    Hospital Hyderabad

    MR #: 10-21-0632755
    Name: Miss HUNEZA
    SALEEM
    Age: 0 Year(s) 5
    Month(s) 0
    Day(s)
    Gender: Female
    Triage P2
    Category:
    Admission Disposition
    Date/TIme Date/Time
    23-Sep-2021, 23-Sep-2021,
    02:06 AM 03:18 AM
    Discharge Admitted
    Type:

    Patient Lying
    Condition:
    Patient Loose motions +
    Complaint: Vomitings
    Diagnosis:
    Sepsis, unspecified organism
    (Provisional)
    A41.9 ,Unspecified severe
    protein-calorie malnutrition
    (Provisional) E43 WITH AGE
    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: INABILITY
    TO GAIN WYT SINCE 1
    MONTH / LOOSE MOTION
    AND VOMIT SINCE 1 DAYS /
    NOT FEEDING SINCE 1
    DAY, Allergies: NIL,
    Medication: N.S, Past History:
    ONN AND OFF SAME
    COMPLAIN SINCE 2
    MONTHS, Last Meal: MILK
    TODAY MORNING, Events:
    NOT FEEDING
    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:
    Alert, Dehydration: No, Anemia
    Severity: No, Clubbing:
    Negative, Lymphnodes: Non
    Palpable, HEENT: N, LUNGS:
    B/L CLEAR, Heart: S1 S2
    AUD, Abdomen: SOFT NT,
    Genetalia: N, Neurological: N,
    Back Spine: N,
    Musculoskeletal: N

    General Treatement Order:


    Others Other: MONITOR FOR
    DISTRESS Doctor DUA
    ZAHEER 23/09/21,02:06
    Others Other: ADMIT IN NSC
    AND GIVE RESOMAL AND
    F-75 Doctor DUA ZAHEER
    23/09/21,02:06
    Others Other: SEND CBC /
    CRP / STOOL D/R Doctor
    DUA ZAHEER 23/09/21,02:06

    Progress Notes:
    patient is afebrile/no any distress/
    vitally stable/labs sent /planning to
    shift to ward for workup and furthur
    management.SAM CHILD WITH
    LOSSE MOTIONS /VOMITING /
    PULSES PERFUSION GOOD /
    VITALLY STABLEANTIBIOTIC
    COVER GIVEN
    Pediatric Emergency
    Department

    Sindh Government
    Hospital Hyderabad

    Current Admission Medicine:


    Cefotaxime 1000 Injectable In
    Grammage, 145.00+ 145.00+
    145.00, Intravenous
    Amikacin 250 Injectable In
    Grammage, 43.50, Intravenous

    Advice on Discharge:
    .admit in ward
    .continue maintainance fluids
    at...
    .continue antibiotics 5 days
    .chase lab reports and manage
    accordingly

    Vitals Last Vital First Vital


    Pulse: 139 135
    BP(S/D): 109/72
    Temp: 36 36
    RR: 31 36
    Height:
    Weight: 2.9 2.9

    SPO2: 99 98

    BS(R): 102

    BS(F):
    Gir:
    BMI: 0 0

    Pain Scale: 0 0
    Yes null Yes null
    Fall Risk:

    Discharged Doctor
    By: SIDRATUL
    MUNTAHA

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