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    Case archive - bronchiectasis in RA (5-18 India)

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    3 views47 pages

    Case Archive - Bronchiectasis in RA (5-18 India)

    Uploaded by

    Justice Mavetera

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 47
    a a Satins FORTIS HEALTHCARE Limite . £232 Aoandoou, EM Bypear toe 4? Fortis (Q) Name NAMA RRO Kobain Tooter el-91 - 039 6678 4444 AGE: 67 Ye ua: FHL wes eam ee EMERGENCY DEPARTMENT ae ‘ASSESSMENT SHEET NAME: PNAMIPA RAD eel Mone ce MAME age by of vate 8S] Brat arta: 42a ot encoun, 1UO UHID No: LPO. No. + Triage Score 1 a 3 1 Allergies: None Yes If Yes, To are ~—— and Duration : 003) aes ——— — Fue — bow Gende. 5 Sis, fae — Conghe — predict ip bu Qmounl — hibel se Decrenaing aaliotow bait, in — oe eee Pah, een! Aduittd — ol] 4] 1@. liom ——? Kiubsielter - bast Medical & Surgical History: a4 % k]qo Cope z HN = CA as a5 — T. Ganaton Some Ts Ac, APS Odts iT. Modine Cae ee ea aD. ie ew klefo Copp Z HIN = CA arp Ce taead od Medication History : T. MONTAR, I = T. RACIPER, 40k Ay Ache we Dupiaine “ismb hyp “7. Ecospein Ay fio oD significant test done /ial tory reports hk) tea Physical Examination : == Head | Eyes! Ears Nose (Throat &] eo fae Heart: SS, cnatange: BJL Bacilan. crepe) » iAbaonen Sift, view -Undy , BS GD Extremities spine: VAD - Nouroiogica examination: EyVg Mg No naunolopical aake Advice: ©/2/io DX Sovvns Cops be THANG) { Treatment Any other findings Investigation Fortis eicac cue 4? Fortis Save alife. Save this number ADI pe HISTORY & PHYSICAL ASSESSMENT FORM © be filed by the Resident Medical Officer on admission) NAME: PNAMITA RAO Name. P. ns Ye AMITA Rie 5 Ace; 67 Year SEX: Female . nO, __Age:_67ovs__Sex:M UMD: FHL3S251447 IPID: 79701 HID nie 134 ye Bet: 144 IPID;___Date:_e/sfie_Bed No Danae Sj Du AS Te v_ Full Signature Soren Contrain Ful Sgnatre Souvike Barre | e — (Forni EMERGENCY CARE Aor (Gall:105711 o = Save a life. Save this number ORTIS HEALTHCARE LIMITED . oes spertn oe 4) Fortis @ PROGRESS NOTES Ig a Tung 1 Stal L Bue 1) Cat . LDA Liat ogress note should be duly signed clearly mentioning their names and designation FORTISHEALTICARE LIMITED . R ee a 42 Forti a | Patient Name | | DNamiva Lad [Fortis ewensencr cane Call:105711 hi Je Kuboetis == hth a pliers Aras er Pep NOTE 1) Progress note should be duly ¢; FA MEDIO0GN [iret ea mentor ti ‘ames and designation, is ‘ortis EMERGENCY cae] (€all:105711 Se progténs rhote should be duly signed clearly mentioning their names and designation HLA N FORTIS HEALTHCARE LIMITED Pee PEM Bypass Road, Kotla - 700107 GENCY CARE HET EEE Save allife. Sav PROGRESS NOTES 1) Progress note should be di FHL-A-MEDIOOSPN FORTIS HEALTHCARE LIMP 8 ayers 2 Secures @ioheatncare com (Fortis tnenaencr came (Call:105711 Save a life. Save this number } PROGRESS NOTES | DATE [TMET wa 3 1) Day. Soo Mg Fi a dle 5 i Bed feiss eae Be ee Lise — | Udo =. HN) f ante COPD I Rheunapeid asersiha WC wae D Cas buvaty ( trealrtat- bop pea! ch eons ~ eT 2 a Mi TE: teas Ke note should be aay signed sii ee r ination 4) Progress “pHuamenoosen 2 eat pss = Spl Ankers a LTD 0 Fortis @) Forti FOUTTS EMERGENCY CARE | fort Oaf105711 L. Save al Bonk’ Progress note should be duly signed clearly mentioning their names and designation PHL-A-MED/O037ON “ONTIS EMERGENCY CARE | "a, Call:105711 Cay mae Save a life. Save this number \_ procressnores (wi L : wh Thtaak zi =| a jNS “at 4 = -= a y Ta | ; = a = { Sapa + ir a an [oe See Fa airnd a E Pi— [aes ea —=—— — (Stee ie ea ste | I Lae TRO dot [se a c+ ~ td (2s a] = 5 Casa ed | | = EA | | Ka oy a ‘Progress note should be duly signed Tankebtedoglilt ‘names and designation. FHL-AMEDIOOS/PN a 4 —. TIS HEALTHCARE LIMITED. 5 ed (Bi Orme owt font rom 4 Fortis a ‘ort GENCY CARE | ras l att: i 0571 1 | Leos % Pro note shoul is eae Hébe duly signed clearly mentioning their names beats lesignation FORTIS HEALTHCARE LIMI ry £7 Acca: ex ps Rot Kos -TO107 4 Forti Svante . tele rebeacr com ce ae | Fortis emencencr cane | (Calt:105714 Save a life. Save thisnumber ( 2) paws. BAC PROGRESS NOTES i a | ‘DATE [we a hia a TB Thnwaane (M - a AB6 hous hnoprreriee p= go. a Det En eS 2) | to, = 92-2 Reep Mp ni feline 1S hes ee mT Si fe | Step Leste ade £ Ann : ogress ‘note should be uly signed clearly. mentioning their names.and designation. -AMEDIOOS/PN Lr“ —- ~ 4? Fortis DAILY PROGRESS NOTE CRITICAL CARE PNAMITA RAC Sex: Female 47 PID: 79701 Year 1135.25 snes 1 "ear a a Day | PATENT OATA Ga Hr) 7 eoicnmiONs: | Vic, Tapas, [0 _ ne Se pe | eed Tanr,__svom cr sw | sasexg:__Todayke:__24 Hr. 13J2aWro; 372 la VasopeessorRequicement 24HFNet | ovrout: az | ncreeing) 7 Osco (chalet Daa = PHYSICALEXAME "ABNORMAL | Ando Review tas Patient Typer311920 301 4 Appearance: CGuture Repor Reviewed (3 Yes) No ee Css un Grn css: Goat | De-escalaton onsdered Cy¥es ONO | cardiovascular: § ‘ens! Cultures/ Results ‘Antibiotics | Start | 3 Date eo |ramanane veg wet | casita: eel Genitourinary: iG Ur Sxtremites: net ba pacllles Cae Spall GF i Wound ‘nes ‘Date laced: Foley Tie: R/LU/ FEM SCL "A Une: R/LRAD/ FEM PACE R/L ARIA Dias YL DT Piece UFEM/scu Tee/Temp ih 42 Fortis DAILY PROGRESS NOTE CRITICAL CARE 4 Sedation: Yeo h6~ Midazolam /DezmetetomisinePropoo| Sedaton Hoiday / Break Yes 1 No ‘3 Neuromuscular Block: Yes / Ne Aacrtum /Vecuroniom Reeroniom cee eees Ranitidine (Enteral /Paraenteral 6 Nutrition : None Enteral: OG Tube /NG Tube NJ Tube Soft feeding tube /G/ tube / PEG Feedate Interrupted >ahours im past 24 hours Parenteral TPN /PPN Oral ciet Clear Liduids / Mechanical sft Regular (nolusing spect dets) ‘Nutmton team assessment updated in record Yes /No 8 Glucose control \ i= Insulin intsion Protocol Yes /No/ conventional 2Analegosia Fertany /Tramaac NNfe Paracetamol » Bvt Popa Sanard eV rors sfisccneepan AH Sogara Conpesson Geile Foot PUPS A recnqusbonih pana PTT CEM ran ISS tae e ecaton 1 Foley catheter Sicon ys Net vena Regular: Yes/No CComplaing requred : Yes/No. no justify {9 Severe Sepsis : Present ? Yes / No Protocol Ordered ? Yes PNO- Central ine placed ? Yes / No 'ScOV2 monitored Yes / No Value 2 Lactate / PCT? Yes/No Value?, ch oNev7 ae? Name ICU Registrar FADOLOGE STUDES a FDEHOTWEL ET a rT SSESSHENTT PAN fist—5 oot an ISSUES STAN t » Chore vefor (oP Chose vefy Hleredeid ptta> BBG [TESST ASESWENT GN SUPPLEMENT OSCR NCC] FERRE] pa couanrarn rawtor con: CJesoauoey CJocuny nano cee C) muonline ‘Name TCU Consultant La Sera [ory ~: § af » ~ avo i Regie ebchn (64) 4 Be ren ptr ent ™ A Gntombtion 9100 L Sere Gamo L chagt ag UM * ) Rams Urs tr, hymg-Carem « te. Oe Bk br brie, 60 Sake ———— pgp et | Dae 8 Ta FORTIS HEALTHCARE LimmTED Tere EM Bypees Road, Koka - 700107 eae 1-035-8808 4242 auites@forieheathcarecom ‘wr fortshealtncare com act er ntata | (Fortis enascr one (Call:105711 Save a life. Save this number | pagetens NOTES By Prorat nce shot bey signed clearly mentioRig turner “HL-A-MED/O03/PN FORTIS HEALTHCARE LIMITED F730 Anondapur, EM Bypass oad, Kolkata - 700107 fort 3 | Pavont name | : Save this nun number OGRESS NOTES UH i Dave [Tate wane | sicn | feb bas i - Ta. Aceon rt = Sephe thock. = post behold oda, @ 9:30 Ah =| Kdo-, Bre | 2309 T " : +_Adwenatord orth’ Ks Fy t foes sense tte ba | At barat cap (|! Oy (ve. osu —|9 I I Fl = 34F $Y nowy > fs = [ff tome [ A avery wry — iy Auk. cre y, ~ 5 I Sa Teeth tae Ee wo by pr FHL-A-MED/003/2N 42 Fortis DAILY PROGRESS NOTE CRITICAL CARE [Py a Meare Pon [ams i: | ene akeaa es Se 1 femodyncmmicatty Ato tole at | fia om img wer O Sdtantte Eetuloded. 2 yertodoy maorede ; Onstandng ues NIV gyaeugout the daly and a ovomagrt G2POP [PATENT ORTAa W]e "Eile ee Viais_ Tac afobiise 0 an 16 Foj Muncpeans™ D6 Jorn tar. S00 OP Sw pate eee eee eee |g ogee el 7 | ovr -D Increasing) OecrestngC) Chest Tube Oras: tog Ply - Xs | oLintor: Dg Bane ‘bite Redew " qoareious, alot! PeieotTyperg3o20 204 ppesrance: ‘tre Report Reviewed C3 Yes 2 No ae Ces Oun Cm Oss Cow | escalaon conser cardorascuar $1, 8.4 [ caus? feats al Puan ee Eo 6 | zea. 2oft TPS* aca So oranda] astentetinat A eae |oemouman: fomecturi. * Bh 4/4 eet 4 | extremities: NAD Bae gig NO gost | | | newologat €4V5 MG | stiarbecubia VENTILATION: Vent Day Mechanical Ventlation?) Yes 1 No oa te, ete m8 ae r ate: FI02:. lata ‘re: RAL RAD] FEM Sal gen 2 Yet No (Danie er 19 ins Xe | W/FEMysct 1cerTemp eae | oun a0 om 18009 N91 / AUN worsi014¢ C) awoomou 7] anaa(-] aoinsesse("] 49 40am saurwonrs09 |e = ee Comey a eee uname na BESSA HN —. yeubig, ARWIN 34 sensiGey N91 AweN ong en [eae prowl y tea Py Prd ba arty writen \ ose HN * crop? + wnayhonryrek: + (esha ©. 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J LNASANd er SLNIVIANOD | eon DOES s/o wimndg ‘SHMLIGIGYOWOD _LouHaseT _sspj0%as | TIL ‘sanssi sonainia sonorqnuy ‘ON aga SUNGLLva PS \ER4 OLD0q agus ANAWSsassy now SLUOI 35 * ava “9 Peron bday Pmou 2 “SR <5 © Hd. tbroane qo sanz oes ed '5 ol a | ens 8 Y59 ie SIAGV SaLNVLTNSNOD [3 a nt *a- a> ae bing pce) 22) > SSNOLLVOLLSIANI sTvuadTY 00018 318VON NOTABLE BLOOD REFERALS: INVESTIGATIONS: Na- 13¢ k~ 352 bye vn -@ cx Dag Mev rs a 7° ¥ y z CONSULTANT'S ADVICE |PLAN | Cs te, S Rees © bipse 2s on dis oh Ovmnra Pa pap © temlaen Seam acy wintnal gepplomoufal 0, (2) Ath ob kp= ofiy (£7 dye fp Sep DA Hy So (yp Ow. 4 e by Hu. @) S]GNATURE OF THE DOCTOR “a CONSULTANT'S SIGNATURE Bro Date Dy fos}ts RCU ASSESSMENT. SHEET DOCTOR: Ch'n may PATIENT: P. Aéntba Rew Issues, Copp +5 oo CoMorsipiries: OTN, chapman ees RESENT COMPLAINTS: ont, Ive 1/0: Other systems: BED NO: 2 Fortis onthe, 78) | afore | ___ Tene of ay BeBe. a Sal 2 Saba Gepeshonl | BOOT Nie | Come Plenk, drin ted Sze Antibiotics: eroids! Tast XR ojos he Tast HRC Sputum c/s Paaadsmenay | Pdond om ona, a | BALe/s | Chest drain/ pig tail | | (@rainage & date | inserted) be orenres ech Vitals: Poe Toft leas ee esp. Uosmmly AR 2B | mir Spy TALE a f 2 ~ Les chest: gt, V@siowaw Break, Bond Foleys: . Anb- cep 8 Ra — 1B i ——— eg ADVICE 4 ea ee | —GonSOLTANTs ADVICE: PLAN | / fe = | - | |© Stop. d Las eH Sy bbe Gee De ees " ® W. aotivotes Hi D> a |) | | Deartnne that pipes ae \ © Brie ae ky bel is PPP @rdeansttendy 2h enn Ven of OVEnns' si # | | Kap sn mintma aie ome” oH BIP RP Ae ~ointos, 6, é ee, -.-. red | oO Compen sake. Rasp. alleoain - 4 , | Cheek. a hyeio t | NO hae. u,; Unieetin 2. Guay wp | Nubritiens!. bur la. “p ® Bwos. ces cep Net, Uy Ze I | Pafen toler fs | @ vv. PB naa aes | ov plan Lov2 enema Pip CBatotmed) | ‘SIGNATURE OF THE DOCTOR wh INSULTANT'S SIGNATURET 1 i © keep os iuy © We. chek or 4) s- DATE RCU ASSESSMENT SHEET Docr, STOR: “Ton ome K PATIENT, P-Namita Rao Issurs é = ~ Componoated | COMoRBIDITIES PRESENT COMPLAINTS: j wel} ~Doing qweakness- Ak erte p- (0° |mio 5902-14 7O LA O/E: Vitals: 4 40/220 $2 Fortis BEDNO: 249, , AA mvonchiectas's 7 \wpd TORE (-940) ° Antibiotics: Diuretics i Steroids: [asec 90 | Mexopenoin —bé pln q tylistis 8 Last HRCT Sputum c/s ine c/s Blood c/s | BAL c/s Chest drain/ pig tail (Grainage & date inserted) Echo BIPAP: CBG: REFERALS: RQepert > ae \6, ae To~ 14.9919 Ea pal NOTABLE BLOOD INVESTIGATIONS: Lae | | ) cxR today. G 2 hour SpAre 1a HAR a CONSULTANT'S ADVICE by. Ain L Only Lpravent et face: aca 2p 2). | | 4 cH | ptaactone 2 ovelnighh - Brood id eo | | 2 4 cieoids S ee sep & iv abx | ce la kt replace’ = Tobamist vubs/ |¢> Bizoo doe NI? k clo ig) uae 4 a utood vapor 4 Qyecds atew dwratien 5) ois | yy CONSULTANT'S SIGNATURE, ee OF THE DOCTOR Barn. LL OOLOSOO™m™™”—~“ ~~ Date: asfefi on RCU ASSESSMENT ik Fortis SHEET Bs —_——_ Doctor: gevaw Byiertecee cid . -> | q Pies oS PATIENT: P.Nawite — pEDNo: 378 Antibiotics: Rae nea Ayoelen Nes + Diuretics aS } ISSUES: cela Arackorne Oe) G reepivald Plu. + Late —_— a type Bey at Steroids: + Breneteetner's [TastcxR uff. [Tast RCT COMORBIDITIES: yepy + ' ‘Sputum c/s i eevee Ra Oucinomar * PRESENT COMPLAINTS: Umber Blood c/s BAL c/s, Chest drain/ pig tail (Grainage & date inserted) Echo BIPAP: Foleys: CBG: Y 120 mgt dt INVESTIGATION FLOW CH 4 CHART Blood Group HB 'M 13-17, F12-15% a - Hot PCY M4050, F 56-46% TLC 10 thoull DLC Searienied Neutrophils | 40-80% tymphocytes 20-40% Eosinophils 1.6% Basophis <1-2% Monocytes 210%. ESR 0-15 (F-0- 20) mm Tsthour Platelets. 150-410thou/ ul RBCs 145-55, F38-48 milioneumm MCV. 83-101 femtoliters /cell coos 27-32 _picogram / cell ‘Albumin Not detected Sugar Not detected Pus Cells Not detected, RBCS Not detected, WBCs Not detected Casts Not detected Na 136-145 mel K 355.1 meal (ol 98-107 __ mEq/L. BUN 6-20 maidl UREA 14,9-38.34mq/al Creatinine M09-13,F0.6-11 mg/dl Bilirubin T 700-200 (Adults) 1LU/L. 4180- 1200 (Children) LU/L Biirubin D UPTO0.3_ma/dl ‘SGOT 15:37 LUI SGPT 30-65_LUJL ‘Aik, Phosphalase 50-136 (Adults) LU/L Total Proteins 648.2 gmidl ‘Albumin 3.45.0 aml Globulin 2.0-4.1 gral Calcium 8.6-10.1__gmidl Magnesium 1.8-2.4 _amidl Phosphorus: 25-49 gmidl 3.5-7.2 (M) mg/dl UES! 26.6.0 (F)_maidl Amylase 25-115 Ui Lipase 73-393 U/L. ‘TSH 0.27-4.2_l0)/mi 73 80-200 __ng/di T4 5.10-14.10 _u/dl HDAC < 5.7%, ‘CRP 03 Total cholesterol <200 LOL = 100) ‘VLDL 30 =u < 150 HDL 40 - 60 ‘CPKMB. TB LDH M 85 - 227, F 81 - 234 U/L CPK 20-192 idl TropT

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