6 years old, boy
FT, Vacuum BW : 2.68
CW : 20kg
Presented with
Loose stool 1/7 – frequency 3x
- Bristol 6
Vommiting 1/7- frequency x2
Abdominal Discomfort 1/7
History of eating outside food
Otherwise
tolerating orally well
No sob/chest pain/rapid breathing
No recent covid/dengue cases
On examination, alert concious, oriented, pink crt <2s, good pv
BP : 122/70
PR: 77 bpm
RR : 20
Temp 37.4
Spo2 : 97%
Lungs : Bi basal Crept
CVS : DRNM
PA : Soft Non Tender
CNS intact
Oral Cavity : Dry
IMP : Acute Gastroenteritis
Plan
Meds as prescribed
TCA Stat if s/sx worsening / if not improving
KIV for IVD
22 Years old, male
NKMI/NKDA
Presented with
Fever 1/7
RN 2/7
Cough 2/7
Sore throat 1/7
Muscleache 1/7
Covid at home negative
Otherwise
tolerating orally well
No sob/chest pain/rapid breathing
No GI Losses
No recent covid/dengue cases
No other active complaint
On examination, alert concious, oriented, pink crt <2s, good pv
BP : 133/72
PR: 77 bpm
RR : 20
Temp 37
Spo2 : 100%
Lungs : clear
CVS : DRNM
PA : Soft Non Tender
CNS intact
Tonsil : Injected, Grade 2, Multiple ulcer
IMP : Tonsillopharygitis
Plan
Meds as prescribed
TCA Stat if s/sx worsening / if not improving
22 Years old, male
NKMI/NKDA
Presented with
Cough > 2 weeks
- productive
Covid at home negative
Otherwise
No sob/chest pain/rapid breathing
No GI Losses
No recent covid/dengue cases
On examination, alert concious, oriented, pink crt <2s, good pv
BP : 133/72
PR: 77 bpm
RR : 20
Temp 37
Spo2 : 100%
Lungs : clear
CVS : DRNM
PA : Soft Non Tender
Tonsil : Injected, Grade 2, Multiple ulcer
IMP : Bronchitis secondary to Prolonged cough
Plan
T Prednisolone 30mg OD 5/7
Syp Zecuf 15mls TDS 5/7
T NAC 600mg OD 5/7
TCA 5/7, to review s/sx
- If phlegm clear, to start Syp Linctus 1mls TDS 5/7
- If phlegm still persist, for neb Pulmicort then Syp Ambroxol
Cicumcision notes
10 years old boy
CW :
Circumcision done
Plan
Syp Winofen 10mls TDS 5/7
Germacid Cream LA TDS 5/7
TCA if s/sx infection/fever/swollen
Both kidney are normal in size and parenchymal echogenicity
Renal calculus measuring 0.4 x 0.2 cm over left kidney
No hydronephrosis or hydroureter bilaterally
Urinary bladder distended, no calculus within
Liver Normal in size with heterogenous parenchymal echogenicity
Portal Vein Patent, no biliary dilatation, no focal liver lesion
Gall Bladder distended, calculus within; largest measuring 0.3cm
Head Injury Advice – TCA stat to ED for CT Brain/Reasseesment
Loss of consciousness
New deafness in one or both ears
Problems understanding or speaking
Loss of balance or problems walking
Blurred or double vision
Any weakness in one or both arms or legs
Inability to be woken
Any vomiting
Bleeding from one or both ears
Clear fluid coming out of your ears or nose
Any fits (collapsing or passing out suddenly)
Drowsiness when you would normally be wide awake
Severe headache not relieved by painkillers such as paracetamol
GERD Advice
1. Eat smaller meals.
2. Eat slowly.
3. Don’t lie down right after eating
4. Avoid: Alcohol, Caffeine, Carbonated beverages, Chocolate, Spicy foods, Fatty foods
5. Maintain an upright posture during meals and for 45 to 60 minutes after eating (to avoid
backflow of stomach contents)
6. Achieve and maintain a healthy body weight (added weight increases intragastric
pressure)
7. Elevate the head of the bed about 6 inches when sleeping
8. Stop smoking (smoking relaxes the lower esophageal sphincter)
9. Avoid eating within 2 to 3 hours of bedtime
10. Avoid clothing that is tight around the stomach area
Day 6 of life
DOB 27/2/24, 0037 via normal SVD
BW : 2.6kg
MBG : A+ve
G6PD : Normal
TSH : 3.041
Types of feeding : BFOD + FM
Frequency : 1 hourly, 30 mins to 1 hour
Stool Color : yellow
BO : > 10x - minimal
PU : > 10x
Active Complaint :
CW : 2.45kg
Active o handling, good hydration, AFNT
Jaundice : chest
Lungs : clear, no recession
CVS: DRNM
PA: Soft not distended
Umbilical Stump : Clean
TSB level : 214 - 308(LR)
Plan
Next TSB 5/3/24
Encourage BFOD
Eye Hygiene Advice – Conjuctivitis/Chalazion
- Wash your hands often with soap and warm water for at least 20 seconds.
- Avoid touching or rubbing your eyes. This can worsen the condition or spread it to
your other eye.
- With clean hands, wash any discharge from around your eye(s) several times a day
using a clean, wet washcloth or fresh cotton ball.
- Do not use the same eye drop dispenser/bottle for your infected and non-infected
eyes.
- Wash pillowcases, sheets, washcloths, and towels often in hot water and detergent;
wash your hands after handling such items.
- Stop wearing contact lenses until your eye doctor says it’s okay to start wearing
them again.
- Clean eyeglasses, being careful not to contaminate items (like hand towels) that
might be shared by other people.
- Clean, store, and replace your contact lenses as instructed by your eye doctor.
- Do not share personal items, such as pillows, washcloths, towels, eye drops, eye or
face makeup, makeup brushes, contact lenses, contact lens storage cases, or
eyeglasses.
- Do not use swimming pools.
Allergic Rhinitis
Mometasone Nasal Spray II/Ii TDS 5/7
T Dexa II/II OD 5/7
T Piriton !
