Lumbini Medical College & Teaching Hospital Ltd.
Tansen-7, Prabhas, Palpa
☎+977-75-411201, 411202
DISCHARGE SUMMARY
Name: DIVYANSHI BISTA Hos No/Inpatient No: 81025044 / 313824
Age/Sex: 9 Mth MONTH/FEMALE SSN No: 738068380
Address: Tansen Date of Admission: 2081/07/11 (2024/10/27) AD
Ward: PAEDIATRIC WARD Date of Discharge: 2081/07/16 (2024/11/01) AD
Contact_No: 9867371775 Discharge Instruction: As out Patient
Admission Diagnosis:
ACUTE URTRICARIA SECONDARY TO SEPSIS
ICD: Final Diagnosis:
EB00. 0 ACUTE URTRICARIA SECONDARY TO SEPSIS
Clinical Narrative:
A 8 months female, developmentally normal, nutritionally sound, immunized as per National
Immunization Schedule presented to Emergency with history of Fever for 1 day and Bilateral
Lower Limb Swelling for 1 day. According to the informant, the baby was apparently well one day
back when she developed fever, acute onset, on and off type Maximum temperature recorded was
101°F . There was no diurnal variation. The fever was not associated with chills and rigors. There
was history of Bilateral lower limb swelling. The swelling was acute onset, pitting type, presented
unto middle 1/3rd of both legs. It was associated with redness all over the body. There was no
history of shortness of breath, swelling of lips, abnormal body movement, abdominal pain, nausea
and vomiting, loose stools, crying during micturition, fever, cough or chest retraction.
Past History: No history of similar illness in the past. No history of hospitalization. No history of any
chronic illness.
Birth History: She was born via spontaneous vaginal delivery with weight of 3200 grams. Post
natal period was uneventful.
Family History: No history of similar illness in the family. No history of chronic illnesses in the
family.
Drug and Allergic History: There is no history of allergies to drugs.
At the time of admission
On Examination:
General condition : Illness looking, conscious, alert.
No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema or Signs of Dehydration.
VITALS: Pulse rate-130 BPM; Respiratory Rate:32 Cycles/M; TEMPERATURE 97°F ,SPO2: 94% in
Room Air
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM; Bilateral Equal Air Entry with Normal Vesicular Breath Sounds.
CVS: First and Second Heart sounds heard with no murmur.
P/A: Soft, non distended, non tender, no organomegaly, bowel sounds heard.
CNS: Grossly intact, no signs of meningeal irritation.
COURSE DURING HOSPITAL: During 3 days of hospital stay she was admitted to Pediatric General
Ward. The general condition and vitals of patient were monitored regularly. Baseline Investigation
was done. The patient was managed with IV antibiotics, H2 blockers, NSAIDS, and Antihistaminics.
Currently the fever has subsided, patient is feeding well and is passing stool and urine normally.
The vitals are within normal limit so the patient is being discharged on oral medication.
At the time of discharge:
O/E general condition : Active, Alert ,
No Pallor, Icterus, Cyanosis, Lymphadenopathy, Edema or Signs of Dehydration
VITALS: PR- 130 BPM; RR: 30 B/M: TEMPERATURE: 97°F ,SPO2 :98% IN ROOM AIR
RESPIRATORY SYSTEM: Bilateral Diffuse wheeze present.
CVS: First heart sound and Second heart sound heard with no murmur.
P/A: Soft, non distended, non tender, no organomegaly, bowel sound present
CNS: Grossly intact
ANTHROPOMETRY: HEIGHT: 62CM, WEIGHT: 8.9KG, HEAD CIRCUMFERENCE: 41CM LENGTH FOR
AGE (-2 to -3 SD) WEIGHT
FOR LENGTH (2 TO 3 SD), HEAD CIRCUMFERENCE FOR AGE (0 to -2SD)
Reason For Admission:
FOR FURTHER EVALUATION AND MANAGEMENT
Treatment:
Treated with IV antibiotics, H2 blockers, NSAIDS, and Antihistaminics.
Condition On Discharge:
Improved
CT/MRI/USG Finding:
2081/07/12 USG: NO SIGNIFICANT ABNORMALITY
Investigation:
Test Result Date
L.F.T Total Bilirubin(0.9), ALP(122.0), S.G.O.T(46.0), S.G.P.T(26.0), Direct 2081/07/11
Bilirubin(0.2)
ESR ESR(32) 2081/07/11
F T3,T4, THS fT3(3.64), TSH(1.34), fT4(1.22) 2081/07/11
ANA TEST ANA TEST(NEGATIVE) 2081/07/11
Peripheral Blood Smear NEUTROPHILIC LEUKOCYTOSIS WITH REACTIVE THROMBOCYTOSIS 2081/07/12
Examination
BLOOD CULTURE AND NO GROWTH (AFTER 72 HOURS ) IN BLOOD SAMPLE 2081/07/14
SENSITIVITY
Consultant Incharge: Dr. UMA DEVI CHHETRI,
Future Plan : F/U AFTER 2 WEEKS IN PEDIA OPD(SUN ,TUE,THURS)
Follow up Date : 2081/07/30
Follow up time : 9:00 AM
_______________________ _______________________
Report Typed By Consultant Name
Dr Bivek Yadav Dr. SAURAV SHRESTHA,
NMC No: 28163 NMC No: 11215
I have seen the discharge summary and discharge advice has been explained to me in the language I understand.
__________________________________
Recipient of Discharge Summary
Name:
Relation:
