URTI

PRESENTED WITH FEVER MILD, FLU AND COUGH; SIMILAR ISSUE IN THE HOUSEHOLD, ACTIVE AND
PLAYFUL; TAKING TOLERATING ORALLY;

NO LN, THROAT MILD HYPEREMIC BUT NO EXUDATES;

NO ADDED SOUNDS OVER LUNG FIELDS;

VITALLY STABLE;

LIKELY URTI;

NASAL CLEANISING EXPLAINED;

GOOD HYDRATION EXPLAINED;

WARM LIQUIDS;

ADVISED SYP TEMPERAMINE 5ML TDS 3DAYS;

RETUREN IF FEVER DON’T SETTLE AFTER 3DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

PHARNGITIS

PRESENTED WITH FEVER, SORE THROAT, ALTOUGH ACTIVE AND PLAYFUL; TAKING TOLERATING ORALLY;

NO LN, THROAT CONGESTED BUT NO EXUDATES;

VITALLY STABLE;

NO ADDED SOUNDS OVER LUNG FIELDS;

VITALLY STABLE;

LIKELY PHARNYGITIS;

NASAL CLEANISING EXPLAINED;

GOOD HYDRATION EXPLAINED;

WARM LIQUIDS;/ SALINE GARGLES IF POSSIBLE

ADVISED SYP TEMPERAMINE 5ML TDS 3DAYS;

SYP AUGMENTIN 156MG 5ML BD 5DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

GASTROENTERITIS (VIRAL) OPD

PRESENTED WITH FEVER MILD, LOOSE MOTIONS, ACTIVE AND PLAYFUL, TAKING TOLERAING ORALLY;
NO BLOOD/MUCOS IN STOOLS;

SKIN TUGOR NORMAL, NO SUKEN EYES; PLAYFUL CHILD;

NO DANGER SIGNS;

LIKELY ACUTE WATERY DIARRHEA(VIRAL);

ORS LOW OSMOLAR USAGE EXPLAINED AND REPLACE ONGOING LOSSES;

SYP ZINCAT 5ML OD 14DAYS;

SACHET RACEDO BD 3DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

GASTROENTERITIS (SHORT STAY)

PRESENTED WITH FEVER MILD, LOOSE MOTIONS, LETHARGY, TAKING REDUCED FEED;
NO BLOOD/MUCOS IN STOOLS;
SKIN TUGOR SLOW, NO SUKEN EYES; CONSOLABLE CHILD;
NO DANGER SIGNS;
LIKELY ACUTE WATERY DIARRHEA WITH MOD DEHYDRATION;
INJ ONSET 1.4MG IV STAT;
INJ CEFTRIAXONE 450MG IV OD;
INJ RL 300ML IV OVER 3HOURS;
REASSESS FOR ORAL INTAKE AFTER 1HOUR
ORS LOW OSMOLAR USAGE EXPLAINED AND REPLACE ONGOING LOSSES;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

DIARRHEA PERSISTANT/ROTA

PRESENTED WITH FEVER MILD, LOOSE MOTIONS OFF AND ON 2MONTH; PERIANAL SKIN EXCORAIATION;,
ACTIVE AND PLAYFUL, TAKING TOLERAING ORALLY;
NO BLOOD/MUCOS IN STOOLS;
UNVACCINATED CHILD;
SKIN TUGOR NORMAL, NO SUKEN EYES; PLAYFUL CHILD;
NO DANGER SIGNS;
LIKELY PERSISTANT DIARRHEA, POSSIBILITY OF ROTA/ FOOD ALLERGIES;
ORS LOW OSMOLAR USAGE EXPLAINED AND REPLACE ONGOING LOSSES;
SYP ZINCAT 5ML OD 14DAYS;
SACHET RACEDO BD 3DAYS;
SYP IZATO 2.5ML BD 5DAYS;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

PNEUMONIA MILD(OPD)

PRESENTED WITH FEVER, RESP DISTRESS AND COUGH, OTHERWISE PLAYFUL AND TAKING TOLERAING
ORALLY;

NO SIGNS OF DISTRESS AND MAINTAINING SO2 AT ROOM AIR;

NO DANGER SIGNS;

REPORTED TO HAVE CRACKLES OVER LUNG FIELDS; OTHERWISE VITALLY STABLE

LIKELY RTI;

ADVISED SYP TEMPERAMINE 5ML TDS 3DAYS;

SYP AUGMENTIN 156MG 5ML BD 5DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

PNEUMONIA MILD (SHORT STAY)

PRESENTED WITH FEVER, RESP DISTRESS AND COUGH, OTHERWISE PLAYFUL AND TAKING REDUCED FEED
ORALLY;

MILD DISTRESS AND MAINTAINING SO2 AT ROOM AIR;

NO DANGER SIGNS;

REPORTED TO HAVE CRACKLES OVER LUNG FIELDS; OTHERWISE VITALLY STABLE;

LIKELY RTI;

ADVISED SHORT STAY ADMISSION;

IV CEFTRIAXONE 400MG IV OD;

INJ PARACETAMOL 8ML IV SOS;

NEB WITH NS 2CC BD;

REASSESS FOR SO2, ORAL INTAKE AND RESP DISTRESS;

TO BE REDISCUSSED;
DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

PNEUMONIA (ADMISSION)

PRESENTED WITH FEVER, RESP DISTRESS AND COUGH, IRRITABILITY AND NO TAKING ORALLY;

RESP DISTRESS AND MAINTAINING SO2 AT LOW FLOW O2;

REPORTED TO HAVE CRACKLES OVER LUNG FIELDS;

LIKELY RTI;

ADVISED ADMISSION;

CBC, CRP AND XRAY CHEST;

IV CEFTRIAXONE 400MG IV OD;

INJ PARACETAMOL 8ML IV SOS;

NEB WITH NS 2CC BD;

INJ 0.45%DS 250ML IV TDS;

REASSESS FOR SO2, ORAL INTAKE AND RESP DISTRESS;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

BRONCHIOLITITS

PRESENTED WITH FEVER, FLU AND COUGH, PLAYFUL AND ACTIVE AND TAKING TOLERATING ORALLY;

MILD RESP DISTRESS AND MAINTAINING SO2 AT ROOM AIR;

REPORTED TO HAVE RONCHI/CONDUCTING SOUNDS OVER LUNG FIELDS;

LIKELY BRONCHOILITIS

ADVISED NEB WITH NS 2CC STAT;

REASSESS FOR SO2, ORAL INTAKE AND RESP DISTRESS;

ADVISED NASAL CLEANSING AT HOME;

SYP TEMPERAMINE 3ML TDS 3DAYS;

SYP ACEPHYL 2.5ML BD 5DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

REACTIVE AIRWAY DISEASE

PRESENTED WITH FEVER, FLU AND COUGH, PLAYFUL AND ACTIVE AND TAKING TOLERATING ORALLY;

MILD RESP DISTRESS AND MAINTAINING SO2 AT ROOM AIR;

REPORTED TO HAVE RONCHI/CONDUCTING SOUNDS OVER LUNG FIELDS;

SIMILAR RESP ISSUE IN THE PAST, ATOPY IN THE PAST/ IN FAMILY???;

LIKELY REACTIVE AIRWAY DISEASE;/ACUTE EXERBATION;

ADVISED NEB WITH VENTOLIN 0.5ML + NS 2CC STAT;

REASSESS FOR SO2, ORAL INTAKE AND RESP DISTRESS;

ADVISED NASAL CLEANSING AT HOME;

SYP TEMPERAMINE 3ML TDS 3DAYS;

SYP ACEPHYL 2.5ML BD 5DAYS;

SACHET MYTEKA HS 5DAYS;

EVALUATE FOR TRIGGER FACTORS AT HOME AND DOMESTIC PRECUATION EXPLAINED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

OTITIS MEDIA

PRESENTED WITH FEVER, EAR ACHE AND EAR DISCHARGE, ALTOUGH ACTIVE AND PLAYFUL; TAKING
TOLERATING ORALLY;

NO LN, THROAT NO EXUDATES; EAR DISCHARGE FROM EAR;

VITALLY STABLE;

LIKELY OTITIS MEDIA;

EAR CLEANISING AND TOILET EXPLAINED;

GOOD HYDRATION EXPLAINED;

PRECUATION FOR EAR EXPLAINED;

ADVISED SYP CALPOL 5ML TDS 3DAYS;

SYP ZYRTEC 5ML BD 3DAYS;

SYP AUGMENTIN 156MG 5ML BD 5DAYS;

FOLLOW UP FOR OTOSCOPY AND ENT EVALUTION;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

UTI

PRESENTED WITH DYSURIA, FEVER AND VAGUE ABD DISCOMFORT; ALTHOUGH ACTIVE AND PLAYFUL,
TAKING TOLERATING ORALLY;

VITALLY STABLE;

POSSIBILITY OF UTI;

HYGEINIC MEASURES EXPLAINED;

TAKE ADEQUATE LIQUIDS ADVISED;

ADVISED SYP CALPOL 6ML TDS 3DAYS;

SYP NOVIDAT 125MG 6ML BD 5DAYS;

CRAN MAX SACHET BD 3DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

SCABIES

PRESENTED WITH SKIN RASHES AND EXCORIATION OF SKIN/ BURROWS??; ITCHING OVER BODY MORE AT
NIGHT;

SIMILAR ISSUES IN HOUSHOLD;

LIKELY SCABIES;

HYGIENIC MEASURES EXPLAINED;

CLOTHES AND LINENS TO BE WASHED WITH WARM WATERS;

SCABION LOTION BELLOW NECK HS AND LUKE WARM BATH IN THE MORNING;

SAME TREATMENT TO BE USED BY OTHER HOUSEHOLDS;

SYP RIGIX 5ML BD 5DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

FUNGAL INFECTION(TINEA)

PRESENTED WITH SKIN RASHES AND ITCHING OVER BODY, NO ATOPY, NO LICHENIFICATION OF SKIN;

LIKELY TINEA;

VITALLY STABLE;
ACTIVE AND PALYFUL;
TAKING TOLERATING ORALLY;
HYGIENIC MEASURES EXPLAINED;

SYP RIGIX 5ML BD 5DAYS;

CREAM TRAVOGEN TDS 7DAYS;

EMOLIANTS AND GOOD SKIN HYDRATION ADVISED;

FOLLOW UP IN DERMA OPD;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

URTICARIA

PRESENTED WITH SKIN RASHES AND ITCHING OVER BODY, MILD ATOPY, MILD LICHENIFICATION OF SKIN;

LIKELY URTICARIA;

VITALLY STABLE;
ACTIVE AND PALYFUL;
TAKING TOLERATING ORALLY;
HYGIENIC MEASURES EXPLAINED;

SYP RIGIX 5ML BD 5DAYS;

AVOID FRAGRANCE AND ANTISEPTIC SOAPS;

EMOLIANTS AND GOOD SKIN HYDRATION ADVISED;

FOLLOW UP IN DERMA OPD;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

GASTRITIS

PRESENTED WITH NAUSEA, 1-2 EPISODES OF VOMITING AND ABD DSICOMROT;

NO FEVER, NO SIGNS OF ACUTE ABD;
TAKING TOLERAITNG NOW;
VITALLY STABLE;
ACTIVE AND PLAYFUL;
ADVISED SOFT DIET AND AVOIDANCE OF FAT MEAL;
ADVISED SYP ACICON 2ML BEFORE FEED TDS 3DAYS;
DIETARY PRECUATION EXPLAINED;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

POU(ENTERIC)

PRESENTED WITH FEVER 4-5DAYS WITHOUT ANY OBVIOUS FOCUS, DEC ORAL INTAKE, LETHARGY;

MILD LETHARGY, REDUCED ORAL INTAKE;

COATED TONGUE??;

WORKUP ADVISED;

CBC WITH MP SLIDE; CRP; URINE RE AND CS; BLOOD CS;

IV MEDICATION WRT ENTERIC ADVISED;

INJ CEFTRIAXONE 1G IV OD;

INJ PARACETAMOL 14ML IV SOS;

INJ OMERAZOLE 15MG IV;

0.45DS 500ML IV TDS;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

AVH

PRESENTED WITH FEVER 5-7DAYS WITHOUT ANY OBVIOUS FOCUS, MILD COUGH; DEC ORAL INTAKE; MILD
LETHARGY, REDUCED ORAL INTAKE; JUANDICE; NO ALOC; NO SIGNS OF ENCEPHLOPATHY;

COATED TONGUE??;

LABS SHOWING STB 7.28; INDIRECT 5.9; SGPT 1270;

WORKUP ADVISED;

CBC WITH MP SLIDE; CRP; HAV IGAM; BLOOD CS; PT/APTT; USG ABD;

IV MEDICATION WRT ENTERIC ADVISED;

INJ CEFOTAXIME 350MG IV TDS;

INJ PARACETAMOL 13ML IV SOS;

INJ OMERAZOLE 13MG IV BD;

0.45DS 300ML IV TDS;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

SEPSIS MILD OPD

PRESENTED WITH FEVER, DEC ORAL INTAKE AND LETHARGY; NNR GOOD, TAKING AND TOLERATING
ORALLY; ACTIVE AND PLAYFUL
MAINTAINING SO2 AT ROOM AIR;
RO SEPSIS;
SYP NOVIDAT 125MG 1.5ML BD 5DAYS;
PANADOL 1/2 DROPPER TDS 3DAYS;
SYP DOMEL 1ML BEFORE FEED TDS 5DAYS;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

SEPSIS (MILD)

PRESENTED WITH FEVER, DEC ORAL INTAKE AND LETHARGY; NNR FAIR, REDUCED INTAKE, MILD
LEHTARGIC;

MAINTAINING SO2 AT ROOM AIR;

RO SEPSIS;

ADVISED CBC, CRP AND BLOOD CS;

INJ CEFOTAXINE 110MG IV TDS;

INJ AMIKACIN 35MG IV OD;

7.6% COM FLUID 300ML OVER 24HOURS;

GCS AND NNR MONITORING;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

EOS

DELIVERED AT TERM WITH MOANING AND GRUNTING WITH MILD ACRO-CYANOSIS AND LETHARGY; NNR
NOT GOOD, MILD LEHTARGIC;

MAINTAINING SO2 AT LOW FLOW;

RO SEPSIS;

ADVISED CBC, CRP AND BLOOD CS; XRAY CHEST;

VIT K 1MG IM STAT;

INJ CEFOTAXINE 110MG IV TDS;

INJ AMIKACIN 35MG IV OD;

10%DW FLUID 150ML OVER 24HOURS;

GCS AND NNR MONITORING;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

PT/EOS

DELIVERED PRE-TERM WITH MOANING AND GRUNTING WITH MILD ACRO-CYANOSIS AND LETHARGY; NNR
NOT GOOD, MILD LEHTARGIC;

MAINTAINING SO2 AT LOW FLOW;

PT/RO SEPSIS;

ADVISED CBC, CRP AND BLOOD CS; XRAY CHEST;

VIT K 1MG IM STAT;

INJ CEFOTAXINE 100MG IV TDS;

INJ AMIKACIN 30MG IV OD;

INJ AMINOPHYLINE 40MG IV LOADING DOSE;

10%DW FLUID 120ML OVER 24HOURS;

GCS AND NNR MONITORING;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

NORMAL NEW BORN

DELIVERED AT TERM WITH MILD MOANING WITH MILD ACRO-CYANOSIS; NNR GOOD; ACTIVE;

MAINTAINING SO2 AT ROOM AIR;

VIT K 1MG IM STAT;

2 TRAIL OF SUCCESSFUL ORAL FEED;

GCS AND NNR MONITORING;

CORD CARE EXPLAINED;

BREAST FEEDING COUNSELLED;

VACCINATION COUNSELLED;

D MAX DROP PO CONTINUE;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

HIE/SEPSIS

DELIVERED AT TERM WITH DELAYED CRY AT BIRTH AND MOANING AND GRUNTING WITH MILD ACRO-
CYANOSIS AND LETHARGY; NNR NOT GOOD, MILD LEHTARGIC;

MAINTAINING SO2 AT LOW FLOW;

RO SEPSIS/HIE;

ADVISED CBC, CRP AND BLOOD CS; XRAY CHEST;

CALCULATE SARNAT SCORING;

CONSIDER USG CRANIUM;

VIT K 1MG IM STAT;

INJ CEFOTAXINE 110MG IV TDS;

INJ AMIKACIN 35MG IV OD;

10%DW FLUID 150ML OVER 24HOURS;

GCS AND NNR MONITORING;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

MAS

DELIVERED AT TERM WITH HX OF MECONIUM PASSAGE INTRAUTERINE; WITH MOANING AND GRUNTING
WITH MILD ACRO-CYANOSIS AND LETHARGY; NNR NOT GOOD, MILD LEHTARGIC;

MAINTAINING SO2 AT LOW FLOW; ADVICED CPAP 5/8 PRESSUE;

RO SEPSIS/MAS;

CHECK PRE AND POST DUCTAL SO2;

ADVISED CBC, CRP AND BLOOD CS; XRAY CHEST;

VIT K 1MG IM STAT;

INJ CEFOTAXINE 110MG IV TDS;

INJ AMIKACIN 35MG IV OD;

10%DW FLUID 150ML OVER 24HOURS;

GCS AND NNR MONITORING;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

PYOMENINTIS

PRESENTED WITH HIGH GRADE FEVER AND FITS; RECEIVED IN STATUS EPILEPTICUS; NO HX OF TRUMA, NO
HX OF DRUG INTOXICATION; NO PREVIOUS HX OF FEBRILE FITS, SEIZURES;

REPORTED TO HAVE NECK STIFFINESS AND INCREASED TONE;

INJ DIAZEPAM ALREADY GIVEN;

ADVISED O2 AT 1LIT/MIN;

RECOVERY POSITION, NG AND GENTLE SUCTIONING;

NEUROPROTECTIVE MEASURES;

MENINGITIS/ FEBRILE SEIZUES +;

INJ DEXA 3.5MG IV TDS;

INJ CEFTRIAXONE 900MG IV BD;

INJ VANCO 360MG IV TDS;

INJ PARA 18ML IV TDS;

INJ OMERAZOLE 15MG IV OD;

0.45DS 1300ML OVER 24HOURS;

CBC, CRP. S/E AND BLOOD CS;

GCS AND OBERVE FOR REBOUND FITS;

TO BE REDISCUSSED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

COLIC

PRESENT WITH IRRITABILITY AND BORBOGRIMUS; ALSO DEC STOOL FREQUENCY OFF AND ON;
CONSOLABLE; TAKING TOLERAING FEED; VITALLY STABLE;

NO SIGNS SUGGESTIVE OF ACUTE ABDOMEN;

COUNSELLED REGARDING CRUDE NATURE OF AILMENT;

BURPING EXPAINED;
ABD MASSAGE EXPLAINED;

ADVISED SYP ACICON 1ML BEFORE FEED TDS 5DAYS;

SKILAX DROPS 2 PO TDS 3DAYS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

ANEMIA

PRESENTED WITH PROGRESSIVE PALLOR; MILD AGITATION, OTHERWISE ACTIVE AND PALYFUL; PALLOR HB
REPORTED 5.2;

NO HX OF PREVIOUS BLOOD TX; NO FAMILY HX OF BLOOD TX; HX OF PICA??

NO VISCEROMEGALY; MILD TACHYCARDIA;

ADVISED CBC WITH RETICS, PBF; HB ELECTROPROESIS; BLOOD GROUPING AND CM;

TX PCV 120ML OVERE 6HOURS WITH 12MG LASIX MID TX;

VITAL MONITORING DURING TX;

DEWORM ON DISCHARGE??;

FOLLOW RETICS, RBC INDECIES; HB ELECTROPROESIS;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;

SIGN OFF FROM ON GROUND DOCTOR.

WORM INFESTATION

PRESENTED WITH WORMS IN STOOLS; HX OF PICA??;

NO SIGNS SUGGESTIVE OF ABD OBSTURITION /ACUTE ABD;
ACTIVE AND PLAYFUL;
VITALLY STABLE;
TAKING TOLERATING ORALLY;
BEHAVIOURAL MODIFICATION ADVISED;
SYP ZENTEL ONE STAT REPEAT AFTER 15DAYS;
IRON SUPPLEMENTS ON FOLLOW UP;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

DOG BITE
PRESENTED WITH DOG BITE (STAY DOG, NOT KNOWN STATUS); CAT III WOUND OVER THE BUTTOCKS WITH
BLOOD AND LECERATION MARKS;
OTHERWISE VITALLY STABLE;
ACTIVE CHILD;
ADVISED TO WASH WOUND WITH SOAP WATER FOR 15MIN;
TETANUS TOXOID 0.5ML IM STAT;
RAV 0.1ML B/L DELTOID ID;
REMAINING RAV AT 3,7,14DAYS;
RIG 500IU AROUND THE WOUND;
WOUND CARE ADVISED;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

MALARIA STABLE

PRESENTED WITH FEVER WITH SHIVERING; MP SLIDE REPORTED +IVE FOR VIVAX;

OTHERWISE STABLE;

ACTIVE AND PLAYFUL;

TAKING TOLERATING ORALLY;

ADVISED SYP FEBROL 5ML TDS AND SOS;

SYP ARTEM 30/180 3.5ML BD 3DAYS;

TAB PRIMAQUINE 7.5MG PO OD 15DAYS;

MOSQUITO NETS AND REPELLANTS ADVISED AT HOME;

PREVENTION WRT STAGNAT WATER ADVISED;

DANGER SIGNS EXPLAINED;

FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

THALASEMIA
PRSENTED WITH REGULAR BLOOD TX; LIKELY THALASEMIA MINOR TX FROM 5YEARS OF LIFE; NOW ON
15DAYS TX;
COUNSELLED REGARDING EVALUATION OF HYPERSPLEENISM;
HB LOW;
VITALLY STBLE;
TAKING TOLERAING ORALLY;
ALERT AND ACTIVE;
IRON CHELATION COUNSELLING AND MONITORING ADVISED;
TX 250ML PCV WITH 25MG LASXIX MID TX;
VITAL MONITORING DURING TX;
ADVISED SYP CALCIUM P 5ML BD 15DAYS;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.

MUCOSITIS

PRESENTED WITH FEVER MILD, FLU AND ORAL ULCER;

TAKING TOLERAING ORALLY;
ACTIVE AND PLAYFUL;
VITALLY STABLE;
MUCOSITIS;
DEC SPICIES AND SOFT DIET ADVISEED;
SYP TEMPERAMINE 2.5ML TDS 3DAYS;
DACTARIAN GEL TDS 5DAYS;
VIDALYN L DROPPER OD 15DAYS;
DANGER SIGNS EXPLAINED;
FOLLOW UP ADVISED;
SIGN OFF FROM ON GROUND DOCTOR.