3C DISCHARGE SUMMARY

O/w: no fever
NAURAH NURAFRINA no vomiting
NAME no loose stool
BINTI MOHD SUKRI
active as usual
LOT 2321 SIMPANG 4 LRG no Covid contact
ADDRESS
MASJID 36500 C/BALAI PK
PHONE Went to ABMC, started on Augmentin 1.18mg
0143124800
NO TDS x2/7 and Neb Salbutamol / Budesonide
IC 150705080340
RN 19288//22 At ED HTI, BP 89/58, RR 28 / HR 87 / Temp
DOA 04/09//22 36.4 / SpO2 100% under RA
DOD 07/09/22
FBC: TWC 9.2 / Hb 12.4 / Plt 308
7 years / Malay / Girl
Born term via SVD
Immunization up to age Upon arrival in ward 3C
4th hospitalization
Currently, saturating under RA
1st hospitalization on 06/08/22 due ti tonsillitis vitally stable
afebrile
2nd hospitalization on 30/08/22-01/09/22 for tolerating feeding
acute pharyngitis with poor oral intake and AKI
- completed C Penicillin for x3/7 and discharge
with antibiotic but not take since readmit to
O/E: sleeping, good PV, CRT<2sec, not
ABMC
tachypnic, no recession
- this admission mother keen to discharge i/v/o
Lungs: slightly reduced breath sound over right
grandmother passed away
lower zone
CVS: DRNM
3rd hospitalization
PA: soft, not distended
CXR: right lower zone consolidation
Final Diagnosis
Imp:
1. PARTIALLY TREATED
1. PARTIALLY TREATED
BRONCHOPNEUMONIA AND RIGHT
BRONCHOPNEUMONIA AND RIGHT
MIDDLE ZONE COLLAPSED
MIDDLE ZONE COLLAPSED
CONSOLIDATION
CONSOLIDATION
2. ALLERGIC RHINITIS
2. ALLERGIC RHINITIS

Plan:
P/w:
1. Keep FMO2 5L/min
1. Poor oral intake x5/7
2. Keep SpO2 >95%
- usually eat once daily, can finish 1 bowl
3. For IV Augmentin 480mg TDS
- now only eat half of bowl
4. Encourage orally as tolerated
5. Watch out for respiratory distress
2. Cough x6/7
- on and off
- chesty in nature
- no post tussive vomiting
Progression in the ward 3C
3. Rapid breathing x1/7
- on FMO2 5L/min
- (+) noisy breathing
- IV Augmentin 480mg change to syrup
Augmentin 230mg BD
- started on Nasal spray Budesonide OD
H/o sick contact with grandmother
- oral intake improving
Upon Discharge from 3C

Currently, stable under RA

vitally stable
afebrile
active as usual
tolerating orally well

O/E: active, alert, good PV, CRT<2sec, warm

peripheries, not tachypnic, no recessions
Lungs: clear, equal air entry
CVS: DRNM
PA: soft, not distended

Plan:
1. Allow discharge
2. Discharge with
- syrup Augmentin 288mg BD x3/7
- syrup Paracetamol 240mg PRN x3/7
- Nasal spray Budesonide II/II OD
3. TCA PC x1/12, to repeat CXR
4. Continue ENT follow up on 08/09/22

Investigation summary:

30/08 31/08 02/09

TWC 17.21 9.2

N/L 87.8/7.1 67/24

Hb 14 12.4

HCT 42.7

PLT 429 308

Urea 8.2 3.1

Na 140 139

K 4.3 3.7

Cl- 99 105

Cr 65 48