P S G HOSPITALS Page 1 / 5

Peelamedu, Coimbatore - 641 004

Phone : 0422-2570170,259882

DEPARTMENT OF PAEDIATRICS

DISCHARGE SUMMARY
Name : DHARANESH.T Age : 3 yr(s)
Dept : PAEDIATRICS 2 Sex : Male
Ward : PA1C- Admn Date : 13-MAR-21
OP No : O21000094 IP No : I21007437 Discharge Date : 15-MAR-21

DOCTORS
DR NEELAKANDAN MD
PROFESSOR & HOD

DR RAJESH.N.T MD
ASSOCIATE PROFESSOR

DR INDUMATHI.C MD, DCH, MRCPCH (UK)

ASSISTANT PROFESSOR

CASE SUMMARY :

PRESENTING COMPLAINTS
THIS 3 YEARS 11 MONTHS OLD BOY A CASE OF MENINGOENCEPHALITIC SEQUELAE ON
TRACHEOSTOMY AND GASTROSTOMY CAME FOR REVIEW
NO H/O SEIZURES
NO H/O FEVER
NO H/O NEW DEFICITS
NO H/O GI DISTURBANCES

PAST HISTORY
H/O ACUTE MENINGOENCEPHALITIS WITH SEQUELAE / HYPERTENSION DURING JAN 2021.H/O
GASTROSTOMY AND TRACHEOSTOMY DURING THAT HOSPITAL ADMISSION

IMMUNISATION
IMMUNISED AS PER NIP SCHEDULE
PNEUMOCOCCAL,INFLUENZA VACCINES NOT GIVEN

DEVELOPMENT
ATTAINED AGE APPROPRIATE DEVELOPEMENTAL MILESTONES BEFORE JAN 2021.FOLLOWING
ACUTE MENINGO ENCEPHALITIS AT PRESENT CHILD HAS
GROSS MOTOR:PARTIAL HEAD CONTROL
FINE MOTOR:DOES NOT HOLD OBJECTS
SOCIAL:DOES NOT RECOGNISES PARENTS, RANDOMLY SMILES AT TIMES

For Emergency please contact Emergency Department PSG HOSPITAL - 0422 - 2570170, Extn. 5100 or Dial 1056.
 DISCHARGE SUMMARY Page 2 / 5
FAMILY HISTORY
NO HISTORY OF SIMILAR COMPLAINTS IN THE FAMILY

OTHER RELEVANT HISTORY :

INVESTIGATION
BioChemistry

Lab Ref No : 21B048769 Date : 15-MAR-21

PROFILES
Sodium (Plasma/Serum) 139mEq/L.
Potassium (Plasma/Serum) 4.04mEq/L
Chloride (Plasma/Serum) 100mEq/L
Bicarbonate (Plasma/Serum) 22.6mEq/L
Ionised Cal (Plasma/Serum) 1.291m mol/L

Clinical Pathology

Lab Ref No : 21P039199 Date : 15-MAR-21

HAEMATOLOGY
TOTAL RBC COUNT 4.16x10^6/uL
HEMOGLOBIN 10.6g/dL
HEMATOCRIT ( PCV ) 33.5%
MCV 80.5fL
MCH 25.4pg
MCHC 31.5g/dl
RDW 19.0%
TOTAL WBC COUNT 7.3x10^3/uL
NEUTROPHIL % 57.2%
LYMPHOCYTE % 30.0%
MONOCYTE % 10.2%
EOSINOPHIL % 1.9%
BASOPHIL % 0.7%
ABSOLUTE NEUTROPHIL COUNT 4.2x 10^3/uL
ABSOLUTE LYMPHOCYTE COUNT 2.2x 10^3/uL
ABSOLUTE MONOCYTE COUNT 0.7x 10^3/uL
ABSOLUTE EOSINOPHIL COUNT 0.1x 10^3/uL
ABSOLUTE BASOPHIL COUNT 0.1x 10^3/uL
PLATELET COUNT 374x10^3/uL
MPV 8.4fL
PCT 0.315%
PDW 16.7%

X RAY : NOT DONE

ECG : NOT DONE

WEIGHT
KG 12.9CM(ON 3RD CENTILE)

LENGTH: 90CM (LESS THAN 3RD CENTILE)

For Emergency please contact Emergency Department PSG HOSPITAL - 0422 - 2570170, Extn. 5100 or Dial 1056.
 DISCHARGE SUMMARY Page 3 / 5
H.C
47.5CM(BETWEEN 3RD AND 50TH CENTILE)

GENERAL EXAMINATION
ON EXAMINATION,
THE CHILD IS ASLEEP, AFEBRILE, E4 VT M4 GCS:8T/15
PERIPHERIES: WARM
PERIPHERAL PERFUSION GOOD
HYDRATION: GOOD
NO SIGNS OF RESPIRATORY DISTRESS / DEHYDRATION
NO PALLOR / ICTERUS / CYANOSIS / CLUBBING / EDEMA/ LYMPHADENOPATHY

VITAL SIGNS
PR: 130/MIN
BP: 90/60 MMHG
RR:26 /MIN
SPO2: 100 IN RA
TEMP: 98.6F

SYSTEM EXAM
CVS - S1,S2 +, NO MURMURS
RS - BILATERAL NORMAL VESICULAR BREATH SOUNDS
NO WHEEZE / CREPITATIONS
P/A - SOFT, NON TENDER
NO PALPABLE ORGANOMEGALY
CNS -
FLEXURE POSTURE PRESENT
HIGHER MENTAL FUNCTIONS:COULD NOT BE ASSESSED
NOT RECOGNIZES PARENTS

CRANIAL NERVES: I-NOT TESTED , II-B/L PERL 3MM ERTL, III,IV,VI-DEM+LEFT EYE PTOSIS+ , V-TOUCH
SENSATION OVER FACE +, CORNEAL CONJUCTIVAL REFLEX +, VII-NO OBVIOUS PALSY, VIII-NOT
TESTED , IX,X- GAG REFLEX + , XI,XII- NOT TESTED

MOTOR SYSTEM:

TONE: RIGHT LEFT

UPPERLIMB INCREASED INCREASED
LOWERLIMB INCREASED INCREASED

POWER: RIGHT LEFT

UPPERLIMB 3/5 3/5
LOWERLIMB 3/5 3/5

REFLEX:
EXAGERATED DEEP REFLEXES,ANKLE CLONUS+
B/L PLANTAR-EXTENSOR
NO BLADDER AND BOWEL CONTROL,OTHER SYSTEMS NORMAL
SENSORY:TOUCH SENSATION +
NO SIGNS OF INCREASED ICT.

IN HOSPITAL MEDICATIONS
T.LABETALOL 25MG 1-0-1
T.BACLOFEN 2.5MG 1-1-1

For Emergency please contact Emergency Department PSG HOSPITAL - 0422 - 2570170, Extn. 5100 or Dial 1056.
 DISCHARGE SUMMARY Page 4 / 5
IN HOSPITAL MEDICATIONS
SYP.KEPRA 100MG/ML 3ML-0-3ML
SYP.CALCIMAX 5ML-0-5ML
SYP.ZINCOVIT 5ML-0-5ML
SYP.RANTAC 2.5ML -0-2.5ML
SYP.TRIFER 2.5ML----0----0
ENZOHEAL OINTMENT FOR L/A AROUND TRACHEOSTOMY STOMA SITE

ALLERGIES
NO KNOWN ALLERGY TO FOOD AND MEDICATION

COURSE IN HOSPITAL : UNEVENTFUL

DISCUSSION
MASTER DHARANESH , A 3 YEAR 11 MONTH OLD BOY A CASE OF POST MENINGITIC SEQUELAE ON
TRACHEOSTOMY AND GASTROSTOMY CAME FOR REVIEW.
ON EXAMINATION, THE CHILD WAS AFEBRILE,GENERAL CONDITION FAIR,GCS-8T/15.VITALS WERE
STABLE, SYSTEMIC EXAMINATION SHOWED CNS-FLEXED POSTURE,LEFT EYE PTOSIS+,BLINK REFLEX
PRESENT,HYPERTONIA IN ALL 4 LIMBS,DTR EXAGGERATED WITH ANKLE CLONUS,B/L PLANTAR-
EXTENSOR,NO BLADDER AND BOWEL CONTROL,OTHER SYSTEMS NORMAL.
COMPLETE BLOOD PICTURE SHOWED ANEMIA AND ELECTROLYTES NORMAL. PAEDIATRIC SURGEON
OPINION OBTAINED AND GASTROSTOMY BUTTON CHANGED,ENT OPINION OBTAINED AND
TRACHEOSTOMY CARE GIVEN.AS HIS BP IS STABLE LABETALOL IS TAPERED AND HE IS ADVICED TO
CONTINUE OTHER MEDICATIONS AS ADVISED.

CONDITION AT DISCHARGE : HEMODYNAMICALLY STABLE

FINAL DIAGNOSIS
POST-MENINGOENCEPHALITIC SEQUELAE

ADVICE ON DISCHARGE
DIET AS ADVICED
REGULAR PHYSIOTHERAPY
TRACHEOSTOMY AND GASTROSTOMY CARE AS ADVICED

MEDICATIONS
T.BACLOFEN 2.5MG 1-----------1----------1
SYP.KEPRA 100MG/ML 3ML--------0---------3ML
SYP.CALCIMAX 5ML--------0---------0
SYP.ZINCOVIT 5ML--------0-----------0
SYP.TRIFER 0------0--------------3.5 ML

T.LABETALOL 25MG 1------0------1/2 X 5 DAYS FOLLOWED BY

For Emergency please contact Emergency Department PSG HOSPITAL - 0422 - 2570170, Extn. 5100 or Dial 1056.
 DISCHARGE SUMMARY Page 5 / 5
MEDICATIONS
T.LABETALOL 25MG 1/2---0-----1/2 X 1 WEEK/ TILL REVIEW

ENZOHEAL OINTMENT FOR L/A AROUND TRACHEOSTOMY STOMA SITE

WHEN TO OBTAIN URGENT CARE

FEVER
VOMITING
SEIZURES
PERSISTENT COUGH

REVIEW DATE
REVIEW IN PAED-2 OPD AT 30.03.2021

SUMMARY PREPARED BY
PG:DR.SRINIDHI,DR.ARUNA,DR.MEENU
CRRI-DR.SIRPI

SUMMARY CHECKED BY
DR.INDUMAHI.C
ASSISSTANT PROFESSOR

COPY TO REFERRING DOCTOR :

DR.INDUMATHI C
( Reg. No. 78851)

For Emergency please contact Emergency Department PSG HOSPITAL - 0422 - 2570170, Extn. 5100 or Dial 1056.