diagnosis

1. DISCHARGE SHEET
PAEDIATRIC WARD
DHULIKHEL HOSPITAL, KAVRE
TYPE OF DISCHARGE: NORMAL DISCHARGE
PATIENT NAME: BABY OF KAMALA OLI
AGE: 14TH DAY OF LIFE/MALE
PATIENT ID: 79006179
DIAGNOSIS: TERM/PERINATAL ASPHYXIA WITH HYPOXIC ISCHEMIC
ENCEPHALOPATHY STAGE II/ EARLY ONSET NEONATAL SEPSIS
DATE OF ADMISSION: 2022/05/10
DATE OF DISCHARGE: 2022/05/23
CHIEF COMPLAINTS:
REFERRED CASE FROM SINDHULI HOSPITAL SINGLE, TERM, MALE BABY DELIVERED AT
40+5 WOG VIA EM LSCS FOR BREECH PRESENTATION WITH APGAR SCORE OF 4/10 AND
6/10 AT 1 MIN AND 5 MINUTES RESPECTIVELY. BIRTH WEIGHT - 3.6 KG ON 2022/5/9 AT 9:30
HRS. DID NOT CRY IMMEDIATELY AFTER BIRTH. RR WAS 100/MIN AND SPO2 WAS
MAINTAINED WITH 2L/MIN O2 VIA FACE MASK. THEN THE BABY WAS REFERRED TO
HIGHER CENTRE FOR THE NEED OF NICU. THE BABY PRESENTED IN DH ER AND
ADMITTED TO DH NICU IN VIEW OF TERM/PERINATAL ASPHYXIA WITH EONNS.
ANC VISIT:
REGULAR ANC VISIST AT SINDHULI
HAD TAKEN IRON, CALCIUM AND BOTH DOSES OF TT VACCINES
NO HISTORY OF GDM, GHTN, AND THYROID DISORDERS
NO HISTORY OF PV LEAKAGE, DISCHARGE, FEVER, UTI DURING PREGNANCY PERIOD
BIRTH HISTORY:
DELIVERED ON 2022/05/09 AT 9:30 HOURS AT SINDHULI HOSPITAL. APGAR SCORE OF 4/10
AND 6/10 AT 1 AND 5 MINUTES RESPECTIVELY.
DID NOT CRY IMMEDIATELY AFTER BIRTH, RR WAS 100/MIN AND SPO2 WAS
MAINTAINED WITH 2L/MIN O2 VIA FACE MASK. THEN THE BABY WAS REFERRED TO
HIGHER CENTRE FOR THE NEED OF NICU. THE BABY PRESENTED IN DH ER AND
ADMITTED TO DH NICU IN VIEW OF TERM/PERINATAL ASPHYXIA WITH EONNS.
ON EXAMINATION:
GENERAL EXAMINATION
GENERAL CONDITION: ILL LOOKING
NO PALLOR, ICTERUS, CYANOSIS, EDEMA
AF: AT LEVEL, SUCKING REFLEX: ILL SUSTAINED
MORO’S REFLEX: B/L COMPLETE AND SYMMETRICAL, TONE: NORMAL
UMBILICUS: HEALTHY
VITALS: HR 140/MIN RR 50/MIN T 36.5C SPO2 96% WITH O2 AT 2 LIT/MIN

2. SYSTEMIC EXAMINATION:
CHEST: B/L EQUAL AIR ENTRY, NVBS, NO ADDED SOUND
CVS: S1S2M0
PER ABDOMEN: SOFT, NON DISTENDED, NO ORGANOMEGALY
TREATMENT GIVEN DURING HOSPITAL STAY:
1. INJ. CEFOTAXIME 200MG IV TDS FOR 10 DAYS
2. INJ. AMIKACIN 50MG IV OD FOR 10 DAYS
3. INJ. AMINOPHYLLINE
4. INJ. LEVETIRACETAM @50MG/KG/DAY
5. INJ. PHENYTOIN @ 6.7 MG/KG/DAY
6. TAB PHENOBARBITONE @ 7 MG/KG/DAY
INVESTIGATIONS:
05/15 PH:7.34 PCO2:41.5 PO2:139 HCO3: 21.8
05/12: BLOOD CS: NO GROWTH
05/10 ABG: PH 7.2 PCO2 92.5 PO2 22.5 HCO3 28 PBS NORMAL
5/10 TC:15.8 N68 L22 M9E1 HB:14.7 PLT:276000
5/10(SINDULI HOSPITAL) HB:14.5 TC:12800 N67L21M10E2 BG: O POSITIVE
DISCUSSION:
BABY WITH ABOVE HISTORY AND CLINICAL FINDINGS WAS ADMITTED IN NICU. RELEVANT
INVESTIGATIONS WERE DONE. BABY WAS KEPT UNDER BUBBLE CPAP AND INRAVENOUS
ANTIBIOTICS WAS STARTED IN VIEW OF PERINATAL ASPHYXIA WITH EARLY ONSET NEONATAL
SEPSIS. TAB. PHENOBARBITONE WAS ADDED FOR JITTERINESS AT THE DOSE OF 7MG/KG/DAY.
BABY DEVELOPED SEIZURE AT 22 HOURS OF LIFE AND INJ. LEVETIRACETAM WAS LOADED AT
THE DOSE OF 40 MG/KG/DAY, THERE WAS MULTIPLE EPISODES OF SEIZURE AND INJ.
LEVETIRACETAM WAS KEPT AT MAINTENANCE DOSE @ 50 MG/KG/DAY AND INJ. PHENYTOIN @
6.7 MG/KG/DAY. FEEDING WAS STARTED ON SECOND DAY OF ADMISSION AND WAS GRADUALLY
INCREASED. BUBBLE CPAP WAS WEANED TO FACE MASK. AFTER 8TH DAY OF ADMISSION,
ANTIEPILEPTICS WERE GRADUALLY TAPERED. BABY WAS SHIFTED TO NEONATAL WARD ON 9TH
DAY OF LIFE. BABY WAS CLINICALLY STABLE, PASSING URINE ADEQUATELY AND
BREASTFEEDING WELL. HEARING AND VISION ASSESSMENT OF BABY IS NORMAL. HENCE BABY
IS BEING DISCHARGED FROM NEONATAL WARD. TECHNIQUES OF BREASTFEEDING HAVE BEEN
WELL COUNSELLED. BURPING TECHNIQUES HAVE BEEN TAUGHT.
ADVICE ON DISCHARGE:
1. SYP LEVETIRACETAM (5ML/500 MG) 0.9 ML PO BD @ 50 MG/KG/DAY TO CONTINUE
2. DROP MULTIVITAMIN 0.5 ML PO OD FOR 3 MONTHS
3. DROP ARBIVIT 0.5 ML PO OD FOR 3 MONTHS
4. EXCLUSIVE BREAST FEEDING FOR 6 MONTHS.
5. BURPING AFTER EACH FEED
6. IMMUNIZATION AS PER EPI SCHEDULE
FOLLOW UP: AFTER 2WEEK/SOS IN PAEDIATRIC OPD.
USG CRANIUM AND EEG ON FOLLOW UP.
CONSULTANT ON DUTY DUTY DOCTOR
DR. SAMEERA THAPA DR. SITESH KUSIYAIT