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Summitted "To ,
,Simmi Mam

-fof medpo
ge of cussinq

Submitted by,

miss Rohini Mesmsam

8sc uSinq y e a
LheLked
ed-po OCoilegR
o cusSI na, adagpu
 Patfent Biodata
Ngme Rohit Ashok Katolee
Age - 29 year
sec Male

Address Vasdhman nagpr nag pus

Religion Hind
Maital statys - Umamed

Occupathon - qvate job

SouTCe of health Care deu esD Hospt
Date of addmissiOn8~ 0z13|2021
e uisional dignosis- Right e föachure
Date of SusgesY - -o S| 3 20
20
Dqe of Care Stasted -03/0 9|20
Date oF Cae end ed - 12
03/2o2
 Chief Complaint
admitHed
as
oo New
R o h i t AshoK Katole
eseaTch a
of pain
Cenres
nagpus uith
Hospital
Hos pit al a nd +he
and Se Hing the Compla1nt
he is and
hayin feve also
in ure in ght leg

Hisos of nes s
resent cedicaN histos
hos pital COvth theMRohit admtted in
cheif the
SCellnq and compiaint
Complaint OF
of Pain
njueis in Right le Aftespan
inveshgdtion doCtoss ec Aftes thhe
the
diag
the le
nosisthatfsactue
hat fsactue in
Past Medica Hi stos
medica histos Pahent harc no
any past
Sent Susgica histosy
acture He is
opesated fos bnng
ast Ssufgica Histovy
No On
ustos past Susqica
 arrily ushcs
He
isbelonqs to Toint
family Hert art
in his family membes in h. familyfamily and
ana
thest ic
auy elate no his
tosy of any eneh C
disease an
familyCOm position
Name of fam
5
ily membess CReiation
ilesh NQDeai
Ketqtion
Se
Education Heath staty
tole fathers
fame-s Dealth
ms SaVihi
oO15 othes
Katole E)| G pass Heathy
m Sum1tkolole 2t
8-5Dthes Dnduted Health
m)
Kumug Ratole 261 SiSter in
saduted Heathy
ms Rohit Katole
299s
M)Pahen
Tadut oad hiaffic
moh it Katole 32y5
Brohes acudent
Brothes $aduated Healthy
m
hsh Cuin
katole 30y SiStes's in 12th
a
pass Healthy
 amily sce

(Deaith ) misaní ato le

umud
athole
atoie Rohit Katoe
d ohit s hon
2CyY Paheot
() (21)D K atole

Ayush Katole

male
Panent
Omaie
O
Femaie
Death mal
 Conomical tatus
in vgsdhman ms Kohit Katole rts

all
'lagpuf
facolitmes tsentin pahentsin hs oun
house
in pathentr house hiS
Monithy
1nCome is ho,000
home. A0,000- Hehas leVentrle

Pessonal Habits
90e habit s -
ad habits
Readinay
S moKinoa
neus papes
 Physica ramination
Cgenesal_appeasance and behanou
Josish ment C e nonshed
Body fiutd 8 Moclsate
Healtth He is housing Road raffiC

Acthn Dull OAccident

ental Stgtus
Con Cio DuS ness
s
ConscIou s
Osient qtion
CAey Onent to me plauL
S pech -oloma
and pesson
A tten tion patient is attend ed

&enesal Pasametess
Height 1 Cm=
l6ocm-LCoo
G1
m
Genera In patient
pusom e fer cloma Remask
G4 60 Sligbtly
Oufuteght
BrMI
(H(6 2 m2
 Vta signs
Pusome es Tn patient alomal nferen ce
Tempst tuye 997F Tma
pulse 88 blm toto193 Nma
Respisa tion 22 brtath 6 22brtath Omal
BP min Imin
io omm 2P'mm rmal

Head and fa ce
S Calp

fac Cieanliness qnd no

dandsaf
feas
Shape O Cane
SRul
Eyes -21.ScmCniomm
Cnuomn y)
ay) Synern
Symerm ca
ca

Enybou oma
Coma
Eyelashes - olona
oma
-

Eylieos aloma
Cye baus l0mal S1S Sie
STee

Comuchya
COmiO
oomal
pulpils Oma
diteed to tiaht
 los -
tctema eaT Uomal
ent
ypanic membi ane Uo diSc ha sqe ís pres
Heaing lomau
ose 8-
actesna nose SymemCa
clommcu
ttemal ppeg SanCa
-
Josmls Cuo dSthgsge
Mouth and phayor_
Hyds tion Hydsated
Teeth Colous CAJhiheh
Odus-faul Smei iS bsent
CWet
Tonque -ulcer is preSent
CK
Thyroid qand not enalasgment
lymph odes ot pal pable
-
st
Kespi saoyy ate
Nomal(22 min)
Hegst Sourd- lub dulS
Scund potsent
Heast aR Noma
Chest eapansirC noma
Qnd Kelqeqnon
 Abdome0-
Ab dominal Pain PTC.sent in nght side
Pain do(eTA)
tattmithes
uppe him1ies
Symmety Symmemca
legons Absent
Rage of Motion Noma

OLe echomihes-
Symme Nom a
Tange of oth o Sloy (because of ad ta
e accident
accident
S pine defomithe Supplne defomhty
defomity
not pesent iS
S
 Tnvestigation

TnyestigaResuutt lomal Rang Sofe-senCe

fho
4 2$ m oma
Hb.
88CumiCs
MCu m al
MLH 30 Plco- 26 33 S
am oma
Toral KBCG 456 milhons omma
Count milions

HCT AS. Ao So|. Nomal

Total 3 oo
C BCs CumM Hoo-looo Cu Nomma
Count

Tota 2 19
Plattets
Counts Cumm S4laES|Cum aloma
-M

McHC 314 2. 3o-3G S- Noma

 seat ment
alussiNg

DuS Dose Sie fque Achon fect RespontHh

o gm Ticy
Bactena check the
1 .S m TV BTV BP
Tnfecthon diagnOSIS
Tnjechdn 5 m PrtVenhon andae of
Neuromys
the pahent
Cuuas disos
-des Someh
e SesizaesidentiEy

Client befo s
mediCajon

Check the
2 Tab SbO ofa 0P Anti pysehc fom of Da
Pam Dizzin ess ayaulable ang
head ach loss the ca-fy Co
Oopehte ect méth od
Of adminS
Scthon

usseS must

2oo 0S a Bp Present ba- Check the

3 Tab CHeal infec
t10n/dith- PhySiCtqn

Ce Feine non/ d i ° of des iY

Caucu sea ginng
Va metrng icathon
HCadech
patient
 Nussing DiAnosis
fatient complaint
Ssing Diagnosis
Seves pain
Pon Compiaint hat
He is hay inq, Seves pao
n accident site
Pathent Complqint had
s havny He alalknq dffficuly
diHiculty în relaed 0+o acidet
CalRinng
.fathent Complqint
he is not
Feelng to
thatTmbalance nuohona
oss of appetmer
eat Pattem less than body
qusm ent
Anociery Aciety eated o
SS0 miu haspitaluzation
iStusb S1ee piny Patfs
Dto the
hos pirali zah
thon
 aUTSin o cobm
Aagnos oa Tnfesvenh Ranoia Tnpierment
Ctena On E Vau ahon
shost e Patent hon
Aabyectne- ya ToeduPathent A Ssess est +he To know
dat co t h e be
AS$esSec
elatedto may enes al con bastine en sal cord
phtnento a d tsa Pain Tele dihon
onthe ofF
pahent aatu hon o F the AFS
the g n t
about pa 1nFHe acu
Ong Patent
oRigt dent To relief- emleo pain
e check Nital To knou hecxed ent s aA
fom sght and recos) t a l ana at
obect e 1 Pan honof tr cosdedA Comtesta
data Pahent
Pronde
T o bse rre extsa prliow Toreduc Pnnde
om the exSa pillow Re
Panent is and Comfos Pain
and com fos
having pam tnesS ah
ness
On acudent pa
PDnde the To
seduce ps yded the
Site dissaction spa hon
thesoph Pain
e
hesph
n edica
tion to tne 1otie
Carm TO
Panent pe ci om R in
ne parn
bed by the Pa pe b k
Ph an os pecbA
YePn
doctos s
 entj
dignosi Come
Come inRTVantion Rahoal
a inttsvantion Rahonal m pie men
ubjecti Dis shost tEm
data trubedmplanning Pathent ssess
Assess tahon tYaluation
sleepin
Sleepina slee pina may be en the ToknoW
Toknou Asseds
Asseds ed AFeT
Patien patem Pd te Sal condi basiine the gensal AFes
abbuu seief om honof m pte menta
the istu Pahent the dato
Conth on hon athent
Sleepind hos pital sbed slee Check
of the patentSayy
oa italTo Ce el
tha
distysbezaion To tlief
Ping pattes and the ensa knou-checKel/itay Com fo
Pctrem st Co d and th
om distsu tondihon
objectixt sb Sleeping
data pmde the To sedur Coded seie seie f
atten Comfosableonm Ponded t em
cdiSu
Pament looX Sleep OTn fortable D
posihon to
the patent Pas tthom Sleepina
ng
distusb du toPate
the pahent m
to Hos pitaii
Zano n pDnde the To reduce
qut en poncled the
Vosfom isom
ment quutenvorm
ent

medTorte
Cotion to Tortlie¢ n med
ne fyom theCan on tothe
patient distube Paient P
Cnbed
by doctosSate
Steepinc
m bed by dec
 endiagnoisoa Intesyani Kata Tmplemen
Cea On
tatio Eva luatiog
Subect re
Imbala n Shosi te
data otlated tooa PatientAses the To Kno
s
fssesSethe
hsses Aftesinmple
stheLA ftes imoie
paten tt say hapi tali- ay be Prtsent bashne res end Con
s th odles
s tah on Smpre múef HoofCondithon
pathent data of dithon of
Pa mentati on
nen tati on
the
amount of uh honhonal
Pathent
PahentPathent ient PathentSay
a checVt hetk To+Ch e cked Com fostab
food ntare imbalan inbaulClNand stctd KnDw ena
and
e

Ob'jectie Cofdi
esa CoMdi
secosded
ded i e
ponde eff Psom
Pom
data
a TOKnoun
Heatth edu educe pronded uittona)
I see that Health edu Pattm
tlief fsom Cation on om the
Coti on abot
Patientis alu oton about Num oun
hona uo
Aeal Cuo a inbcla Honal homa
PaHcm
PaHem PCHem
ned aoct
OuS e medi med Jirtn medi
Cation CaaanDthepahe
Canonto ot
Ane paheot he pahon be
Prcnbe To stief prtn by
ph Ca
"Phqicig m the hicignT
cuion
o Aocto
docto a dshu
bed paten
 Nussees notes day
Sd a
Date hme USSes note s
am pati ent l a s admittd
3103|2o
10 l o d O
ed maRi ne S done
am
ita sicns CheuKed
and Recof ded
oanM
clothineX ant lvtn to
Pahent
H'eight and oleaht
checke and COsde
 usseS Dotes 2nd
day
ate hme Nusses notPS
am 8ed ma Rin done
9am pOint a s sent in
infesthgahonn ttab)
fos blood Samplee
o dmh mediCation dien to
Pcttient
ita Sia checKe
 UsSCS no tegS 3" day
Time NOtes
08|202 8am Bed n gking done
BP checKed and
6eCosded
1P Ch eaRe and
seCosd ed
Ogm
Vita SiC ChecK
2 Pm RBCs Cchecked
medicahon aien
+o
pathen aspes
docto6 S Osdes
 Heath Cducahon
Nusse s ponde heatth educath on aho urt
he Aqht e cciedent patheot
iet diet is one oi the most
impoStant fac
affe chng ovn
naht ea time and nht dose
(es Cise Este scise is most im post ant the
Patient
est and sleep By taRing the
ill im prort. pauhent-dianosis
MeaiCation Intsactthe lloess to ttK
anon of
of
iqnt dose ed
medi
medio ez plaig
plai side eff
effect
ct ds aa
folow up nuiseç do a6odexamingthon
fthe Pattent that pathent So, the
nd disease
Tform Thepatient
pesSoa hine
membeTS qbout the disease
and patient maintatn the Persona
o
Qn al9o how
af
hyqm pesTonaj
hevnpoytance of
And t
 onclusion
Rohit Kotale (as admited
SmHRS Vasdhman nagpu t ale
Cod CUith Chief Complaiot
sthdpediC
Swell ng Ctnd 1Oint
pain
pain ht e inYCSh g a h o docto
aftt
jun facud on thiS
hctt he has
dlanosi
e
Riant
3

3
ohrt