DISCHARGE SUMMARY
Patient’s Name: Baby of PREMIN KUMARI IP NO.: AIMSIP295866
SAHU
Father’s Name : DIGAMBAR SINGH SEX : FEMALE
Address: SHAIKPET , HYDERABAD D.O.B : - 28/07/2023
D.O.D : - 31/07/2023
DOCTOR : Dr.SRI KRISHNA Birth wt: 2.950 kg
Discharge wt :2.770 kg
TERM/AGA/FEMALE
ANTENATAL HISTORY – A 26 year old G2P1A1 with term gestation
(40weeks+ 6days) with LMP- 15/10/22, EDD- 27/07/23 .Spontaneous conception.
Antenatal Scans – normal ; K/C/O Molluscum contagiosum since 4 days- Lesion
on Left labia minora and left inner thigh; Amniotic fluid –Normal.MBG- B
POSITIVE.
BIRTH HISTORY-A single, live, term, female baby delivered by Emergency
LSCS on 28/07/2023 at 12:15Pm with birth weight– 2.950 kg. Baby cried
immediately after birth, Umbilical cord clamped and cut at 60 Secs after birth – 2
arteries and 1 vein seen, APGAR score was 8 @1 min and 9 @5mins of life
respectively. Injection Vit K 1mg IM stat given. No visible congenital anomalies
seen. BBG: B POSITIVE
On Examination: Baby was pink and euthermic. Vitals: HR-141/min. RR:
54/min, SPO2 : 99% of all 4 limbs at room air. GRBS: 69mg/dl, all peripheral
pulses well felt. Skull – normal, spine – normal, genitalia–normal, B/L-femoral
pulses felt. Orifices-patent. CVS- S1S2+, regular, RS- BLAE+ clear, P/A-soft,
Bowel sounds present. CNS- Cry, Tone,Activity – good, AF at level.
Anthropometry: LENGTH : 49 cm ( 10th-50th centile)
BIRTH WEIGHT : 2.950kg (10th -50th centile)
HEAD CIRCUMFERENCE: 34 cm ( 10th -50th centile)
Course during the hospital stay: Baby was shifted to mother side and started on
direct breast feeding. Baby accepted feeds well, passed urine and stool normally.
At present baby is on direct breast feeding, passing urine and stool normally. Baby
remained euglycemic and haemodynamically stable throughout the hospital stay.
Hence being discharged with the following medical advice
Investigations at 73 hours of life-TSB: 8.73 mg/dl, Direct conjugated Bilirubin:
0.27mg/dl; Unconjugated bilirubin: 8.4mg/dl.TSH Report to be collected on follow
up.
IMMUNISATION HISTORY: BCG, OPV, HEPATITIS B GIVEN
Condition at discharge: At present, baby is accepting feeds well; passing urine
and stools regularly.Vitals: Temp – 98.4 F, HR- 148/min, RR- 48/min, CFT <3sec.
SPO2- 99% all 4 limbs at room air. CVS- S1S2+, regular, RS- BLAE+ clear, P/A-
soft, CNS- Cry, Tone, Activity –good. Baby remained euglycemic and
hemodynamically stable through out the hospital stay and hence being discharged
with the following medical advice.
Discharge Advice:-
1. EYE CARE, CORD CARE AND WARM CARE
2. EXCLUSIVE DIRECT BREAST FEEDING EVERY 2ND HOURLY
FOLLOWED BY BURPING TILL 6 MONTHS OF AGE.
3. VITAMIN D3 DROPS (1ML=400 IU) 1ML PER ORAL ONCE DAILY
X TILL 1 YEAR OF AGE.
4. IMMUNISATION AS PER SCHEDULE.
5. TSH REPORT TO BE COLLECTED ON FOLLOW UP.
6. TO FOLLOW UP FOR JAUNDICE AT THE OPD.
7. TO FOLLOW UP FOR GROWTH AND DEVELOPMENT AT THE
OPD
8. REVIEW IN PAEDIATRIC OPD AFTER 2 DAYS(2/08/2023)/SOS.
DANGER SIGNS - Any sudden changes in baby’s usual patterns of behavior like
: Increased sleepiness, Increased irritability,Poor feeding,
Any of the following:
• Breathing difficulty
• Blueness around the lips, mouth, or eyes.
• Fever over 99.6 F or low temperature < 97F
.• Vomiting or diarrhea.
• Dry diaper for > 12 hours.
•No bowel movement for > 4 days.
• Black or bright red color in stool.
Consult your paediatrician and rush to the hospital immediately in case of any danger signs as
mentioned above, Apollo general Hospital is at your service 24hours a day, 365 days of the year.
DOCTOR’S SIGNATURE
