CASE STUDY

Pt. Name M. R #

Ward Room#/ Bed No:

Age Wt. Kg Consultants Name

Ht: cm BSA: m2 Incharge Nurse

Presenting Complaints: -
Loose motion from 2days

History of Present illness: -

Being treated as barter syndrome remains admitted in
nephrology ward for 16 days, 5 days back discharged now presented to OPD with C/O loose
motion 4-5 days, greenish in colour. No blood or mucus. No high grade fever or vomiting . taking
NG feed 35ml+ 3H. Passing urine
Pt received in OPD, Dehydrated, Malnourished and advised to
admitted in Nephro ward. Labs done on 15/06/19 Na/15 , K /2.1

Past History: -

Birth History: -
SVD, No complications

Immunization History: -
Vaccinated

Nutrional History: -
No feed

Allergies (drug , food) No ______

Family History: - ______

Socioeconomic Status: - ______

Diagnosis:-
Barter Syndrome

General Examination: -

Abdomen: Normal shape Inverted Umblicus, No tenderness and ascities, Bowel sound present
Respiratory system: Normal
CNS: conscious
CVS: Normal heart sounds, No murmurs

Routine Medication:

SR # Name Of Medication Strength Dose Frequency Remarks

1 Inj. Cipro 30mg B.D

2 30mg T.D.S
Inj. KCL
3 Inj. Nulcer 5mg T.D.S

INVESTIGATION AND VITALS LOG SHEET

Parameter Date

Temp
BP
Pulse
RR

S/ elect
Na
K
Ca
Cl
CBC
Eosinophills
Monocytes
Lymphocyte
s
Neutrophils
WBC
Platlets
HCT
RFTs
LFT