COLLEGE OF NURSING

ASSIGNMENT
ON
NURSING CLINIC

SUBMITTED TO: SUBMITTED BY:

 IDENTIFICATION DATA

NAME: Anjali

FATHER’S NAME: Sanjay

AGE: 15 years

SEX: Female

MARITAL STSATUS: Unmarried

RELIGION: Hindu

EDUCATION: 10th standard

OCCUPATION: Student

ADDRESS: V.P.O. Nangla, Jhajjar

CONSULTANT DR.: Dr. Ajay

WARD: 3

DATE OF ADMISSION: 6/7/2019

DIAGNOSE: Sepsis with thrombocytopenia

CHIEF COMPLAINT:

Fever -10 days

Pain abdomen – 2 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently well 10 days before when she developed fever. She was taken to a
private hospital but fever does not resolved. Then, she developed pain abdomen 2 days
before which was not resolved with medicines. Then patient was brought to PGIMS,
Rohtak. Patient was admitted on 6/7/2019 in ward no. 3.at around 10:30 am.

PAST HISTORY:

Not significant
VITAL SIGNS:
Pulse – 88 bpm

B.P. -124/80 mmHg

R.R. – 16 /m

Temp. 100 F

TREATMENT:

SR DRUG NAME DOSE ROUTE

NO.
1 Tab. PCM 500 mg Oral
2 Inj. Taxim 1 gm IV
3 Inj. Amikacin 750 mg in 100 ml NS IV

LAB TESTS:

Hb: 10 gm

TLC: 13000 cumm

Platelet : 1.45 lac/cumm

DLC: N60% L36% E2% M2%

Blood sugar: 110 mmHg

 IDENTIFICATION DATA

NAME: Gudiya

FATHER’S NAME: Sunil

AGE: 26 years

SEX: Female

MARITAL STSATUS: Married

RELIGION: Hindu

EDUCATION: 12th pass

OCCUPATION: Housewife

ADDRESS: Gandhi Nagar, Rohtak

CONSULTANT DR.: Dr. Ajay

WARD: 3

DATE OF ADMISSION: 8/7/2019

DIAGNOSE: Acute Gastritis

CHIEF COMPLAINT:

Pain abdomen – 3 days

Nausea & vomiting – 2 days

Indigestion – 2 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently alright about 3 days back when he developed the above mentioned
complaints. Pain abdomen mainly present in upper abdomen & it is non radiating. The
intensity of pain increases after having food.

PAST HISTORY:
No significant past medical or surgical history

VITAL SIGNS:

Pulse – 82 bpm

B.P. -130/80 mmHg

R.R. – 22 /m

Temp. 98.6 F

TREATMENT:

SR DRUG NAME DOSE ROUTE

NO.
1 Inj. Pantocid 40 mg IV
2 NS 500 ml IV
3 Inj. Emset 4 mg IV

LAB TESTS:

Hb: 11 gm

TLC: 5100 cumm

PC : 2.4 lac/cumm

DLC: N60% L36% E2% M2%

Blood sugar: 100 mmHg

Sodium: 139 mol/l

Potassium: 4.67 mmol/l