DOPR

SUMMARY(DISCHARGE)
DEPARTMENT OF PEDIATRICS
ROHILKHAND MEDICAL COLLEGE , BAREILLY

NAME BABY FATIMA AGE 2 MONTHS SEX FEMALE

FATHER SHANU CR. 2025281399 UNIT 4

NO

DOA: 10/07/25 DOD 16/07/25 UNIT OPD THURS/SOS

DAYS

ADDRESS: - BARIELLY, UP

UNIT INCHARGE- DR. ARIF HUSSAIN (ASSOCIATE PROFESSOR )

DR. VEDIKA BHAT (ASSOCIATE PROFESSOR)

DR. AZEEM (SR)

JUNIOR RESIDENT:
DR. MAHESH (JR3)
DR. DARA SINGH(JR2)
DR. DIVYA (JR2)
DR. VISHAL( JR1)
DR. UTKARSH( JR1 )

DIAGNOSIS-TWIN-2/PRETERM(CORRECTED GESTATIONAL AGE- /NOW WITH FAILURE

TO THRIVE/SEPSIS/?MENINGITIS/SEVERE DEHYDRATION WITH SHOCK /PRE RENAL
ACUTE KIDNEY INJURY /DYSELECTROLYMEIA WITH SEPTIC ILEUS WITH G.I
BLEEDING(MALENA) WITH MODS

ANTHRO ON ADMISSION ON DISCHARGE

WEIGHT 1600 GMS 1740 GRAMS

LENGTH 48 CMS 48 CMS

HEAD CIRCUMFERENCE 33 CMS 33 CMS

RESUSCITATION NEEDED AT BIRTH: NO
IMMUNIZATION HISTORY: IMMUNIZATION DONE AT BIRTH
BIRTH HISTORY: TWINS/PRETERM/LSCS/CIAB
BABY’S BLOOD GROUP –O +

HOSPITAL STAY-: PATIENT WAS OUTBORN AND WAS ADMITTED IN NICU WITH
COMPLAINTS OF FEVER SINCE 1 DAY, LOOSE STOOL SINCE 1 DAY, ABDOMINAL DISTENSION
SINCE 1 DAY VOMITING SINCE MORNING & DIFFICULTY IN BREATHING WITH CHEST
INDRAWING , FAST BREATHING ,PATIENT WAS ADMITTED IN NICU AND WAS SHIFTED TO
CPAP .ON ADMISSION,VITALS WERE HR-178/MIN, RR-74//MIN , SPO2- 94% ON CPAP ,
TEMP.36.6, CRT-<3 SECS. S/E: R/S-B/L BREATH SOUNDS PRESENT WITH B/L CONDUCTIVE
SOUNDS+(ICR &SCR PRESENT), CVS-S1,S2 HEARD , NO MURMUR, P/A- SOFT,
DISTENDED ,LIVER PALPABLE 4 CM BRCM NO SPLENOMEGALY , BOWEL SOUNDS SLUGGISH,
CNS -LETHARGIC, ANTERIOR FONTANELLE DEPRESSED , SIGNS OF SEVERE DEHYDRATION
PRESENT , ORAL MUCOSA [Link] WAS MANAGNED ON THE LINES OF SEVERE
DEHYDRATION AND SEPSISS.
PATIENT WAS KEPT NPO, OG IN SITU ,FOLEYS IN SITU AND O2 SUPPORT BY CPAP (FIO2 40%
PEEP 5) IV FLUIDS , IV ANTIBIOTICS (INJ CEFOTAXIM ,INJ AMIKACIN) INJ CALCIUM
GLUCONATE , INJ SODA BICARBONATE ,AND OTHER SUPPORTIVE TREATMENT WAS
STARTED. ROUTINE INVESTIGATIONS WERE SENT CBC S/O HB-9.1 MCV-69.3, PCV-29.6
PLATELETS-8.89 , TLC-35,030 AND DLC: B/P/L/E/M: 00/57/25/02/04 CRP-1.19, SERUM
CALCIUM -9.1 LFT: [Link] TOTAL/DIRECT-0.37/0.10 SGOT-167, SGPT-268 [Link]-
7.9 [Link]- 4.3, [Link]-453. RFT- [Link]-340 [Link] 2.4 [Link]-129
[Link]-8.2 [Link]-103 ,PT-19.4 INR 1.51,HYPERKALEMIA WAS MANAGED WITH
IV CALCIUM,I.V BICARBONATE AND BETA AGONIST NEBULISATION ALONG WITH
POTASSIUM FREE FLUID , URINE R/M WAS DONE S/O URIC ACID CRYSTAL
PRESENT ,PROTEIN +2. PUS CELLS 3-4 ,RBC -8-10 REPEAT HB WAS S/O 7 GM/DL ,PATIENT
NOT MAINTAINING SATURATION AND HAVING SEVERE RESPIRATORY DISTRESS HENCE WAS
INTUBATED AND SHIFTED TO VENTILATOR SUPPORT ( FIO2 -60% ,PEEP -5 , PCV -10 , PSV -8
Ti-0.6 RR -30). IVI DOPAMINE STARTED@10MCG/KG/MIN I/V/O FEEBLE PERIPHERAL
PULSES,AND BRADYCARDIA, 1 PART (25ml) OF PRBC TRANSFUSED AND 1 PART OF FFP
TRANSFUSED I/V/O DERANGED PT/INR. ANTIBIOTICS WERE UPGRADED TO INJ LINEZOLID
AND INJ [Link] SURGERY REFERENCE WAS TAKEN IN VIEW OF
ABDOMINAL DISTENSION AND SLUGGISH BOWEL SOUNDS ALONG WITH N.G BLEED, WAS
S/O NO ACTIVE INTERVENTION REQUIRED.
PATIENT WAS WEANED OFF VENTILATOR SUPPORT, REPEAT CBC WAS DONE WHICH S/O HB-
8.6 TLC 18,380 PLATELET 4.39 RBC -3.91 PCV 28.1 MCH 22 MCV 71.9 MCHC 30.6 . PT- 14.9
INR -1.12,SUPPORTIVE TREATMENT [Link] WAS MAINTAINING SATURATION
WITH IMPROVED ABG HENCE WAS SHIFTED TO BUBBLE CPAP. PATIENT HAD ONE EPISODE
OF ABNORMAL BODY MOVEMENTS A/W TIGHTENING OF ALL 4 LIMBS, UPROLLING OF
EYEBALLS,EPISODE WAS ABORTED BY INJ MIDAZ AND INJ LEVERA WAS STARTED .REST
CONTINUE SAME TREATMENT. USG CRANIUM WAS DONE S/O BRAIN PARENCHYMA
SHOWS SLIGHTLY RAISED PERIVENTRICULAR ECHOGENICITY SUGGESTIVE OF HIE
(PERIVENTRICULAR LEUKOMALACIA GRADE 1 ) ,SUPPORTIVE TREATMENT
[Link] WAS SHIFTED ON O2 BY NASAL PRONGS,ANTI EPILEPTICS INCREASED
I/V/O MULTIPLE EPISODES OF SEIZURES,PATIENT WAS ADVICED LP BUT ATTENDANT’S
[Link] HAS ONE EPISODE OF HYPOGLYCEMIA SO GIR WAS INCREASED TO
6MG/KG/[Link] CULTURE WAS POSITIVE S/O PROTEUS VULGARIS SENSITIVE TO INJ
MEROPENEM,INJ PIPTAZ, PATIENT HAD 4 EPISODE OF UPPER GI BLEED (MELENA). USG
W/A WAS DONE S/O NO SIGNIFICANT ABNORMALITIES , 1 PART OF PRBC WAS
TRANSFUSED, PT- 14.5 INR -1.09 CRP 0.26 LFT BILIRUBIN TOTAL 0.4 DIRECT 0.2 SGOT 95
SGPT 131 PROTEINS 5.2 ALBUMIN 3 ALKALINE PHOSPHATASE 186 CBC WAS S/O HB 7.4 TLC
26,580 PLATELET 3.48 RBC 3.39 PCV 23.5 MCH 21.8 MCV 69.3 MCHC 31.5. INJ
FLUCONAZOLE WAS [Link] SURGERY REFERENCE WAS TAKEN AND INJ
METROGYL,INJ TRANEXA AND DRUGS WERE [Link] AGAIN HAD AN
HYPOGLYCEMIA EPISODE HENCE GIR WAS INCREASED TO 8ML/KG/[Link] ADRENALINE
WAS STARTED I/V/O FEEBLE PERIPHERAL PULSES AND BRADYCARDIA,REST TREATMENT
WAS CONTINUED.1 PRBC WAS TRANSFUSED,ECHO WAS ADVICED,HOWEVER ATTENDANT
REFUSED FOR THE [Link] UREA AND [Link] WAS IN DECREASING [Link]
KFT WAS DONE UREA 84 CREATININE 0.76 SODIUM 141 POTASSIUM 4.6. CHLORIDE 103 , 1
PART OF PACKED RBC WAS TRANSFUSED I/V/O HB 7.4 .REST CONTINUE SAME
TREATMENT .2 EPISODES OF BLOODY STOOL WAS PRESENT, SURGERY REFERENCE TAKEN
AND CONSERVATIVE MANAGEMENT WAS ADVICED. PATIENT IMPROVED [Link] ADR
WAS GRADUALLY TAPERED AND STOPPED,IVI DOPAMINE WAS [Link] DOPAMINE
WAS TAPERED AND [Link] KFT WAS DONE WHICH S/O UREA 77 CREATININE 0.72
SODIUM 137 POTASSIUM 4.2 CHLORIDE 96 .3 EPISODES OF BLOODY STOOLS
[Link] PATIENT IS ON IV FLUIDS,I.V ANTIBIOTICS AND I.V
ANTIEPILEPTICS,GASTRIC SURGERY REFERANCE WAS TAKEN VERBALLY(AS PATIENT IS NOT
PAYING FOR CONSULTATION) THEY SAID THAT BABY NEED UPPER G.I ENDOSCOPY THAT
COULD NOT BE DONE IN OUR SETTING IN VIEW OF NON AVAILABILITY OF REQUIRED SIZE
ENDOSCOPE,PATIENT PRESENTLY OFF OXYGEN,OFF INOTROPES BUT REQUIRE FURTHER
HOSPITAL STAY I/V/O COMPLETION OF ANTIBIOTICS FOR GRAM NEGATIVE SEPSIS AND
FURTHER EVALUATION OF GI BLEED,ATTENDANT WERE EXPLAINED SAME, PATIENT
ATTENDANT REFUSED AND WANT THE PATIENT TO BE DISCHARGED,HENCE PATIENT IS
BEING DISCHARGED AND REFERRED TO GASTROSURGEON AT GOVERNMENT MEDICAL
COLLEG/HOSPITAL FOR FURTHER MANAGEMENT.
VITALS AT THE TIME OF DISCHARGE
HR-84/MIN
RR-42/MINSPPO2-98%@RA
 TEMP-36.8C
CRT-<3SEC
PERIPHERAL PULSES WELL PALPABLE

ONGOING TREATMENT –
NPO AT ROOM AIR ON I.V FLUIDS WITH OG IN SITU
1. INJ MEROPENEM- CONTINUED
2. INJ LINEZOLID – CONTINUED
3. INJ METROGYL - CONTINUED
4. INJ PIPTAZ-CONTINUED
5. INJ FLUCONAZOLE- CONTINUED
6. INJ PHENOBARB- CONTINUED@5MG/KG/DAY
7. INJ LEVERA – CONTINUED@60MG/KG/DAY
8. INJ PANTOP 12 HOURLY

ADVISE ON DISCHARGE –

REFERED TO GASTROSURGEON FOR FURTHER EVALUATION AND MANAGEMENT OF GI BLEED

● OAE/BERA AND ROP SCREENING ADVICED

● MRI BRAIN I/V/O USG CRANIUM S/O PERIVENTRICULAR LEUCOMALACIA GRADE 1
● EARLY INTERVENTION AND DEVELOPMENTAL ASSESSMENT ON FOLLOW UP

JR1 JR2 JR 3 AP ASSOC. PROF. UNIT INCHARGE