DISCHARGE SUMMARY

Patient’s profiles:

Patient name : B/O Chew Chee Ying

IC : 841213085180
Age : Day 12 of life
Gender : Female
Birth weight : 1.26kg
Current weight : 1.265
DOA : 31/08/2018
DOD : 12/08/2018
DOB : 20/08/2018
G6PD : Deficient
CTSH : 4.39
GESTATION : Semi LSCS at 35 week 2 days for Asymmetrical IUGR with normal Doppler

Antenatal history
Mother is a 28 years old Dusun lady para 1+1
ABO : O positive
ANS : NR
ANC :
1) Asymmetrical IUGR with Normal Doppler
2) History of complete miscarriage in August 2017
3) History of admission for threatened pre-term labour at 32 weeks- Completed IM Dexamethasone
4) History of urinary tract infection at 32 weeks and 6 days. Completed Abx T.EES. Urine C&S no
growth.

Presented history
Mother initially came to PAC for complain of reduced fetal movement on 16/8/2018. Otherwise didn’t have
any contraction, no leaking liquor, no and URTI and UTI sign and symptoms.

Did scan by O&G team noted upon scan had asymmetrical IUGR with normal Doppler, thus planned for
Semi-LSCS.

Upon delivery of the baby, noted baby was born vigorous, good cry and good breathing effort. ONS suction
done show clear aspirate. Initial stimulation was also done. At 5 Minutes of life noted baby developed
SCR,ICR with RR : 54 , HR : 135 with grunting intermittently. Lungs was clear and abdomen was soft and not
distended. Placenta for HPE was sent.

Was then transferred to SCN and put on BIPaP fio2: 30 and rate 30. Was kept NBM with iv drips and was
started on IV C-Penicillin and IV Gentamicin.No Surfactant was given. Impression given at that time was

1) Prem at 35 week TRO RDS And SGA

2) Cover for Persumed Sepsis ( for unexplained IUGR)
Issues in SCN

1. Premature at 35 weeks with mild RDS covered for GBS pneumonia.

Baby initially was put on BIPap fio2 : 30 and rate of 30. Was on BIPap for 2 days.
Covered with IV C-Penicillin and IV Cefotaxime
Chest X-ray had mild RDS changes.
Fbc HB : 17.9 PLT : 169 WCC : 8.3.

At day 3 of life child developed intermittent grunting with with SCR And ICR and the baby was also
tachypnoic. Spo2 level was 93-94% under BIPaP
Intubated with ventilator setting rate 40, PIP 24/5 and Fio2 607.
Chest X-ray : pneumonic changes over Right lower zone and consodilation over left Upper lobe.
The dosage of antibiotics increased to IV C- Penicillin QID dosage.
Repeated FBC was WCC: 5.3 Platelet : 165.
At day four of life the baby self extubated. Was the put on back on BIPap Fio2 : 30 Rate : 30.
Changed to nasal prong air 2l/min at day 6 of life, and subsequently off NPo2 at day 10 of life.
Completed IV C-Penicillin and IV Cefotaxime for four days. Blood C&S had no growth.

2. Nosocomial Sepsis cover for Septic Ileus.

At 30 hours of life noted child had brownish aspirate.

Was then kept Nbm With IV Drips and was started on IV Ranitidine.
At 37 hours of life noted that baby developed abdominal distention, thus was given the impression
of Septic Ileus.
Abdominal x-ray : unspecific bowel dilatation.
Baby was then resumed back on feeding at 62 hours of life with a slow increament.

At day four of life, noted baby had ryles tube aspirate (milk curd) and the abdominal looked fullish.
Was kept NBM and stool for occult blood and Abdominal x-ray was requested.
Upon examination, distended abdomen, bowel sound was present.
X-ray reviewed noted a non specific bowel dilation.
Thus impression was made to be Nosocomial Sepsis cover for Septic Ileus
Completed IV meropenem for 10/7
Blood C&S : No growth
CRP : 1

3. To establish feeding
Establish full feeding at day 14 of life
Upon discharge, patient tolerating BF + CF EBM+HMF (TFI 178)

4. Prolonged Jaundice 2ry to G6PD deficiency.

Onset at day 2 of life
Highest on Intensive photo x6hours
Peak SBV 18.4 PL 15 IP 18
Latest SBV 11.4 PL 15 IP 18 (8/9/2018) Day 20 of life
Prolonged Jaundice workup taken:
UFEME PH 7.0, Blood 1+, Leucocyte 3+, others negative
Urine C&S No significant bacteriuria
TFT : TSH 24.9 T4 7.33
FBP pending
 5. Resolved Asymptomatic Hypocalcemia
Latest Ca 2.6

6. Ultrasound Brain 12/09/2018 - normal

INVESTIGATIONS

FBC 20/8 22/8 22/8 24/8 29/8 3/9 7/9 8/9

WBC 8.3 4.8 5.3 4.3 4.6 9.0 7.6 8.0
HB 17.9 18.3 16.6 16.1 17.3 17.3 13.5 13.4
HCT 53.9 51.8 48 47.3 49.3 48 36.4 37.1
PLT 169 71 165 156 153 158 284 275

RP 21/8 22/8 22/8 24/8 29/8 7/9

UREA 3.7 3.7 2.3 1.7 0.9 1.1
NA 136 138 139 134 Insuff 137
K 3.7 3.4 3.3 5 Insuff 5.8
CL 101 104 104 101 Insuff 103
CREAT 86 84 67 37 35

LFT 21/8 22/8 22/8 24/8 29/8 3/9 7/9 8/9

PROTEIN 58 56
ALBUMIN 23 26 26
TOTAL BIL 140 181 183 237 270 313 248 195
(8.4) (10.6) (10.7) (13.9) (16) (18.4) (14.5) (11.4)
PL 7 PL 9 PL10 PL 14 PL 15 PL 15 PL 15 PL 15
IP 10 IP 12 IP 13 IP 17 IP 18 IP 18 IP 18 IP 11.4
DIRECT 5.9 6.7 7.3 10.1 14.1 12.2 7
INDIRECT 134 174 176 260 299 256 188
ALP 189 252
ALT 9 10
AST 56

ELECTROLYTES 20/8 21/8 22/8 22/8 29/8 7/9

Ca 2.66 1.81 2.23 2.42 2.69 2.69
Po4 2.22 2.07 1.74 1.99 2.22
Mg 0.70 0.74 0.69 0.70 0.69

Coagulation Profile 22/8

PT 16.2
IPTT 35.6
INR 1.35

Mother HVS CNS no growth

CRP 29/8 : 1

Stool for occult blood

24/8 : negative
28/8 : negative

Blood C&S
20/8 no growth
23/8 no growth

NPA C&S
23/8 no growth

FBP
22/8 : no features suggestive hemolysis. WBC changes TRO underlying infection. Thrombocytopenia ?
cause TRO viral/drug/immune mediated cause
7/8 : pending

EBM C&S
5/9 :staphylococcus aureus

TFT
T4 : 24.9
TSH 7.33

UFEME
7/9 PH 7.0, Blood 1+, Leucocyte 3+, others negative

Urine C&S
9/9 No significant bacteriuria
MEDICATIONS
1. IV Meropenem 20mg/kg x10/7
2. Syp EES 2mg/kg x5/7
3. Syp Nystatin 50,000 U TDS
4. Syp MVT 0.5ml OD
5. Syp Folate 0.5ml OD
6. Syp appetone 0.5ml OD
7. IV Cefotaxime 50mg/kg x3/7
8. IV Ranitidine 1.8mg TDS
9. IV C-penicillin 180,000u BD x2/7
10. IV C-penicillin 180,000u QID x2/7
11. IV Vitamin K x2/7
12. IV Ca Gluconate 0.9mls in 0.9mls NS over 30 mins

PROGRESS IN WARD

His stay in SCN/NICU was relatively uncomplicated. He only had 1 episode of nosocomial pneumonia within
the 1st 2 weeks of life and was free of infection since.

Upon discharge, patient has good weight gain of 20g per day with latest weight of 1.84kg and vital signs are
stable.

On examination, child is active on handling with good perfusion, not in respiratory distress. Other systemic
examinations are unremarkable. CVS showed dual rhythm no murmur. Lungs are clear and per abdomen are
soft and not distended.

BLS and prem education given to mother.

PLAN ON DISCHARGE
1. Allow discharge
2. Trace FBP
3. G6PD education – given to patient
4. Biweekly weight monitoring at KK until >2.5kg
5. Advice for extra immunization
6. TCA peds clinic in 2/12 to review neurodevelopment
7. Continue supplements until TCA

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