                                                                            Trela

                                                                                        Hospital
                 ATIENT INFORMATION
                Baby SAI ANJANAA                           Shivan                                                    OP/IP No.           OP654542
                SENTHILKUMAR                               CHID #             12618106945                            Visit Date          13/09/2023 17:42
                DOB           30/08/2016
                                                                                                                      STATUS           : Approved
                AGB               7Y
                GENDER            FEMALE

                                                                    Outpatient Visit Summary
                                                           Department of Paediatric Neurology
            VISIT INFORMATION
            Ref                 RNTE299233
           Type                 Follow-up
            Amended By : Dr Shivan Kesavan , MBBS, MD(Pediatrics), DM(Pe                                     Neurology)
            VITALS
            Vital                                          Value
           Hbdy Temperature                                 36.1 ·
           Pulse Rate                                        102 beats/min
           SPO2                                             97 %
           BMI                                              15.32 kg/m2
           Weight                                           22.8 kg
           Height                                           122 cm
          OPD FOLLOW UP
          Part B (To Be Filled By Physicians )
           Clinical Examination & Notes Summary                 Reviewed
          Provisional Diagnosis                                 Idiopathic focal epilepsy
          Investigation Recommended                             None
         Result Review                                         EEG- Normal sleep and awake
                                                               MRI Brain NAD
         Follow up / Admission Plan                             1 month
         Plan Of Care                                          Syp VINLEP (5ml/300mg) 1.5 ml-0-1,5 ml x 1 week, 2.5 ml-0-2.5
                                                              ml to continue
                                                               Adverse effects explained- STOP if rash+
                                                               Video of event if recurs and review earlier SOS
                                                              Seizure first aid as explained
                                                              MIDAZOLAM NASAL SPAY (5mg/ml) 3+3 puffs if seizure >> 5
                                                              minutes
                                                                                              ( Sp)




                                                                                                                                  Dr Shivan Kesavan .
                                                                                                                               Department of Pediatirc -
                                                                                                                                       Neurology




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                                                  Dr. Rela Institute & Medical Centre

C Works Road. Chromepet                                        www.relainstitute.com                                      24x7 Emergency Care:+91 44 6666 7788
nai-600 044                                                  wecare a relainstitute.com
                                              A Unit of JR Super Speciality Hospitals Pvt. Ltd                                       Appointment:+91 44 6666 7777
 Nadu, INDIA.                                                                                                                     General Enquiry:+91 44 7111 1117

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