Clinical Summary Report

Baby Shareen Ashfak Aurora

Infant Clinical Course, Investigation Summary & Consultant Review Points

DOL 20
Date of Birth17 Aug 2026
Age20 Days
Gestational Age36w6d
Birth Weight2.70 kg — AGA
DeliveryLUCS
Blood GroupA+
Maternal HistoryGDM on Humalog insulin
Prepared ByFather — MBBS 5th Year Student

01Patient Profile & Birth History

Birth Profile
Patient
Baby Shareen Ashfak Aurora
DOB / Current Age
17 Aug 2026 / 20 Days
Day of Life
DOL 20
Gestational Age
36w6d
Delivery
LUCS
Birth Weight
2.70 kg — AGA
Blood Group
A+
Maternal History
GDM on Humalog insulin
Report Date
08 Sep 2026

02Chronological Timeline & Clinical Course

Birth → DOL 20
17 Aug 2026 · D0
Birth & Initial Neonatal Course

Delivered by LUCS at 36w6d with birth weight 2.70 kg (AGA). Hypoglycemia was noted during the early neonatal period.

D1–D10
Early Neonatal Observations

Fluctuating neonatal jaundice, weak suck, two reported deep-sleep episodes (D5 and D7), and intermittent bicycling-type leg movements were observed.

D10–D14 · NICU Admission
Hyperbilirubinemia & IDM — Consolidated Episode

Admitted to OGSB Hospital (Mirpur) for hyperbilirubinemia and IDM. Intensive phototherapy was given for approximately 40 hours. A rebound bilirubin rise occurred and phototherapy was restarted. The infant was subsequently discharged stable.

Bilirubin Course During NICU AdmissionTSB trend
20.94D10 · mg/dLAdmission baseline
9.85D12 · mg/dLPost-phototherapy
12.25D13 · mg/dLRebound rise
7.30D14 · mg/dLDischarge level
D14
NICU Discharge

Discharged clinically stable following treatment. Medications started: V-Plex, Folison, D-Vine and Compiron.

D16–D19
Outpatient Follow-up

Follow-up period was clinically stable with TSB 7.30 mg/dL documented on D16. Mild progressive abdominal distension and increased yellow-stool frequency were reported.

08 Sep 2026 · D20 · Today
Pediatric Review & Current Investigations

Reviewed by Dr. Sharmin Afroze at Shishu Hospital. Digital EEG and Echo were advised. Today's TSB is 5.88 mg/dL; serum electrolytes: Na 142.6 mmol/L and K 5.40 mmol/L (flagged high). Digital EEG was performed at Popular and the report is pending.

Overall clinical course: The reported course includes early neonatal hypoglycemia, neonatal jaundice requiring NICU phototherapy with subsequent improvement, IDM background, intermittent abnormal-appearing movements/deep-sleep episodes, and recent outpatient gastrointestinal observations. Current evaluation includes EEG, echocardiographic assessment as advised, bilirubin monitoring and serum electrolyte review.

03Master Investigation Summary

Key Results
Date / DOLInvestigationResultClinical Context / Note
27 Aug · D10TSB20.94 mg/dLPre-treatment baseline; NICU admission for phototherapy.
27 Aug · D10CBCHb 13.0; Platelets 6.39 lakhDocumented baseline CBC.
27 Aug · D10TSH / FT4TSH 2.27; FT4 28.96Documented thyroid profile.
29 Aug · D12TSB9.85 mg/dLPost-phototherapy follow-up.
30 Aug · D13TSB12.25 mg/dLRebound rise; phototherapy restarted.
31 Aug · D14TSB7.30 mg/dLImproved; discharged stable.
02 Sep · D16TSB7.30 mg/dLStable follow-up value.
08 Sep · D20TSB5.88 mg/dLCurrent value; continued downward trend.
08 Sep · D20Serum Na142.6 mmol/LCurrent electrolyte result.
08 Sep · D20Serum K5.40 mmol/L · HIGHRequires clinical interpretation; consider sample hemolysis versus true elevation in the clinical context.
08 Sep · D20Digital EEGPendingPerformed at Popular; report not yet available.
08 Sep · D20EchoAdvisedRecommended at pediatric review; completion not documented here.

04Current Medications

As Documented
Drop V-Plex
4 drops daily × 3 months
Tab. Folison
¼ tablet on alternate days × 3 months
Drop D-Vine
5 drops BD × 1 year
Drop Compiron
Step-up dose

05Key Clinical Questions for Consultant Review

Review Points
01

Digital EEG: How should the EEG be interpreted in light of the reported past hypoglycemia, deep-sleep episodes and intermittent abnormal-appearing movements?

02

IDM follow-up: What ongoing monitoring and precautions are appropriate for an infant of a diabetic mother?

03

Abdominal / stool changes: What is the clinical significance of the recent mild abdominal distension and increased yellow-stool frequency, and when should further assessment be considered?

04

Potassium 5.40 mmol/L: Does the mildly elevated value warrant repeat testing, particularly to assess possible sample hemolysis versus a true elevation?

05

Travel fitness: Is the infant clinically fit for the planned Narail trip in 2 days, and are any travel-specific precautions required?