Pediatric Emergency

Department

Sindh Government
Hospital Hyderabad

MR #: 10-21-0653917
Name: Miss ZAINAB
MOSIN ALI
Age: 3 Year(s) 0
Month(s) 0
Day(s)
Gender: Female
Triage P2
Category:
Admission Disposition
Date/TIme Date/Time
06-Oct-2021, 07-Oct-2021,
11:03 PM 03:24 AM
Discharge LAMA
Type:

Patient Lying
Condition:
Patient Lethargic
Complaint:
Diagnosis:
Infectious gastroenteritis and
colitis, unspecified (Provisional)
A09
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: UNABLE TO
HOLD NECK AND
HEADACHE FOR 3 DAYS,
Allergies: NA, Medication:
FOR AGE, Past History:
MEASLES,, dairhea 3 days
back, Last Meal: 4HRS, Events:
HEADACHE AND UNABLE
TO HOLD NECK
Examination
Physical Examination Pediatric:
Physical Examination Pediatric,
General Look: Unstable,
AIRWAY: Clear, Extermities:
Warm, CRT:: Less Then 2
Second, Pulse Central: Good,
Conscious Level: Drowsy,
Dehydration: No, Clubbing:
Negative, Lymphnodes: Non
Palpable, HEENT: UNABLE
TO HOLD NECK, LUNGS: BL
CLEAR, Heart: NORMAL
HEART SOUND, Abdomen:
SOFT NT, Genetalia: N,
Neurological: lethargic, Back
Spine: n, Musculoskeletal:
WEAK

Progress Notes:
PT NOT PHYSICALLY FOUND SO
DOING LAMA FROM THE
SYSTEM ON ADMIN REQUEST

Current Admission Medicine:

Ors 1.000000 Sachet, 1.00, Oral

Vitals Last Vital First Vital

Pulse: 129 122
BP(S/D): 106/65
Temp: 36 36
RR: 33 30
Height:
Weight: 8 8

SPO2: 99 98

BS(R): 102

BS(F):
Gir:
BMI: 0 0

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

Discharged
 Pediatric Emergency
Department

Sindh Government
Hospital Hyderabad

By: Doctor
MUSTANSUR
SIYAL