DISCHARGE SUMMARY
ID No.: 0803051132 NAME : BABY .KAVYASHREE DOA :02.06.2005
AGE : 3 YEAR SEX : FEMALE DOD :11.06.2005
DIAGNOSIS :
S/P pericardial path closure of atrial septal defect with central Fenestration + patent ductus arteriosus ligation + plication of
Anterior- posterior tricuspid valve commissure Non compaction of ventricle
Bi ventricular dysfunction
BRIEF HISTORY :
3 year old Kavyashree underwent atrial septal defect closure with patent ductus arteriosus ligation with us on 29.04.2005 and was discharged on 12.05.2005 She presented to us with history of fever and dyspnoea. She was admitted to PICU for further management.
CLINICAL EXAMINATION:
HR – 140/min, regular
No gallop, peripheral pulses felt
RR- 60-80/min
Rapid and shallow respiration
No gradient
B/L AB+. Mild crepitation in infra axillary region
INVESTIGATIONS:
Blood Group - O Positive; Hb – 8.8 gms/ dl; PCV – 26%; Total leucocyte count – 16,100 cells/ cmm
Neutrophils – 50%; Lymphocytes – 42%; Eosinophils – 06%; Sodium –134 mEq / L; potassium – 4.7 mEq/L Calcium – 8.8 mEq / L; Serology – Non reactive
CXR : Gross cardiomegaly, increased lung vascularity , sternal sutures seen
COURSE IN THE HOSPITAL:
The child was put on O2 and Lasix and Dopamine. Blood transfusion was given at 60 ml /hr over 3 hours. She was continued on Dopamine and Dobutamine and tapered slowly. Electrolyte imbalance was corrected She was given a course of antibiotics and was shifted to the ward after stabilization. Routine blood investigation were sent. Urine culture showed no growth.
CONDITION ON DISCHARGE:
Symptomatically better.
ADVICE:
Review after 2 weeks
Fluids – 600ml / day
MEDICATIONS:
Syp. Digoxin 60 mic twice daily 5/7 days
Tab. Aldactone 6.25 mg twice daily
Tab. Metinex 0.5 mg on alternative days
Tab. Lasix 10 mg twice daily
Tab. Envas 2.5 mg ¼ tab twice daily
Syp. Polybion 5ml once daily.
DR . SNEHAL KULKARNI, MD DNB
