SUBJECTIVE

Patient details:
• NAME : MRS.XY
• AGE : 52 YEARS
• SEX : FEMALE
SUBJECTIVE : A 50 years old female patient was admitted to female
medical ward with complaints of decreased urine output since 3 months,
pain in abdomen since 1 week , burning micturition since 3 days and
fever since 3 days.
 OBJECTIVE
• SPO2 :98% at RA
• GFR :23.375
• PR :94bpm
• Temp 101 F
 LABARATORY PARAMETERS
.
PARAMETERS OBSERVED VALUES REFERENCE RANGE

Haemoglobin 8.8 12-16g/dl

Red Blood Cells 2.8 3.5-5.6 x 106

PCV 24.5% 33-43%

Chloride 116 97-107meq/L

Serum Creatine 2.5 0.6-1.2 mg/dl

Serum Urea 95 20-50mg/dl

 ASSESMENT
Based on the subjective and objective data the patient was
diagnosed with the
• URINARY TRACT INFECTION
• CHROIC KIDNEY DISEASE
TREATMENT
GENERIC NAME OF THE DOSE ROUTE FREQUENCY INDICATION no.of days
DRUG
INJ CEFOTAXIME 1gm IV TID UTI 5days

T.PARACETMOL 500mg PO SOS FEVER 5days

T.IRON&FOLIC ACID 50mg PO BD ANAEMIA 5days

T.SPIRONOLACTONE 50mg PO OD CKD 5days

INJ.PANTOPRAZOLE 40mg IV OD APD 5days

T.AMLODIPINE 5mg PO OD HTN 5days

 PLAN
GOALS OF THERAPY
• To Reduce signs and symptoms
• To bring abnormal values to normal
• To reduce further complications
• To improve quality of life.
GOALS ACHIEVED
• Patient was apparently normal
• Fever was reduced
DISCHARGE MEDICATION
GENERIC NAME DOSE ROA FREQUENCY No of days

T.IRON & FOLIC 50mg PO BD 7days

ACID

T. 50mg PO OD 7days
SPIROOLACTONE

T.PANTOPRAZOL 40mg PO OD
E

T.CEFIXIME 200mg PO BD
PATIENT COUNSELLING
• Drink cranberry juice
• Increase vitamin C intake
• Exercise regularly
• Avoid excess salt intake
• Consult physician if any ADR are reported.