KATHMANDU MEDICAL COLLEGE TEACHING

HOSPITAL
Department of Pediatrics
Sinamangal, Kathmandu Nepal
Phone: 4476152, 4469064

DISCHARGE
Name: B/O PARTIKSHHA DAHAL
Sex/Age:3DOL /MALE Division of Neonatology
Address: IMADOL,LALITPUR
Consultant In charge:
Baby’s Hospital no: UNIT I-
DOB &TOB: 2079/08/23 & 9:39pm B.W: 1.6KG Prof. Dr Sunil Raja Manandhar
Date of admission: 2079/08/23 Asst. Prof. Dr. Sabina Shrestha
Date of discharge: 2079/08/26
Phone No:
DIAGNOSIS: SINGLE/ALIVE/PRETERM/32 +4WOG/MALE IN BORN PRIMI MOTHER VIA
EMERGENCY LSCS DELIVERY FOR TWIN PREGNACY IN LABOUR WITH TWIN IN TRANSVERSE LIE
WITHL WITH AS OF 6/10 AND 8/10 AT 1 AND 5 MIN RESPECTIVELY.
C/C:Fast breathing soon after birth.
BIRTH Hx: Single/Alive/Term/32+4WOG/male out born to primi mother emergency lscs delivery
for twin pregnacy in labour with twin in transverse lie withl with as of 6/10 and 8/10 at 1 and
5 min respectively.
MATERNAL Hx:
Age:24 years
Gravida/Parity:Primigravida
Spontaneous conception.
No h/o of PV leak/ bleed/foul smelling PV discharge/ Chorioamnitis
H/O hypothyroidism to mother under medication Thyronorm
No h/o GDM,Gestational HTN
Anomaly scan:Normal
Liquor status :Adequate
SUMMARY:

Anthropometry at Admission:
Weight at admission: 3kg Head Circumference: cm (10th - Length :cm (10th -50th centile)
(10th -50th centile) 50th centile)

VITALS AT Admission:
Temp:97F PR: 140bpm RR:50 /min SpO2:90% in RA CRT: CP/PP: Palpable
2sec
GC: ALERT
PILCCOD: NIL
HEAD TO TOE:
AF: Open at the level, overriding sutures present
CTA: AGA
R/S: NORMAL
MORO’S: B/L COMPLETE AND SYMMETRICAL
SYSTEMIC EXAMINATION:
Chest: B/L EQUAL ENTR,NVBS,Lower chest retraction ,xiphoid retraction nasal flaring
present,
GIT : Soft, non-distended, BS present
CVS: S1 S2 M0
CNS: AF open and at level
INVESTIGATIONS:
2079/08/26 2079/08/23 2079/8/24
BG A POSITIVE
HB/PCV 16.3/40.1 16.6 17.5/50.6
TC 8500 19300
DC N-55 L-34 N 70 L23
PLATELETS 269000 233000
CRP(Q) 3.8 2.8
CALCIUM(I) 1.06 1.23
TB/BD 5.2/0.5 7.7/0.5 11.4/0.6
UREA/CREATININE 16/0.8
Na/K 142/4
PERIHERAL SMEAR REPORT (2079/08/24):
RBC: NORMOCYTIC NORMOCHROMIC WITH
ANISOPOIKIOCYTOSIS.POLYCHROMATOPHILS
WBC: TOXIC GRANULES, BAND CELLS ARE NOT SEEN
PLATELETS:ADEQUATE ON SMEAR
I:T RATIO: 0
ANC:1 4475/CUMM
RETICULOCYTE COUNT: 5.2%
DC:N75 L22

TREATMENT AT HOSPITAL:

ANTHROPOMETRY AT DISCHARGE
Weight at discharge: 1.6 kg Head Circumference: cm Length : cm

Condition at time of discharge: baby is feeding well, passing urine/stool normally.

VITALS AT DISCHARGE:
Temp:98.3 F PR: 154bpm RR:54/min SpO2:96 % in RA CRT: 2sec CP/PP: Palpable BP:74/40
(49)
G/C: ALERT
PILCCOD: Nill
HEAD TO TOE: SYSTEMIC EXAMINATION
AF: Open at level Chest: B/L NVBS
Tone/cry: Normal CVS: S1 S2 M0
Grasp: (+) GIT: Soft, non-distended
CNS: AF open and at level
Rooting/Sucking: normal
Sutures: Overriding
Umbilical stump:healthy
ADVICE AT DISCHARGE:
 DROP CHOLIFORTE 0.5ML PO OD TO CONTINUE.
 Exclusive breastfeeding till 6 months of age.
 Do not give honey, Gripe water or top milk to the baby.
 Do not give bottle or soother to the baby.
 Vaccination as per immunization schedule

 FOLLOW UP:
 If the baby has any danger sign, take the baby to the nearest hospital or emergency care.
 Follow up in Pediatric OPD SOS.

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