PATIENT PROFILE

Name of the client : Sayed Ahamed

Age : 58y
Sex : Male
Ward :1MCU
Unit : Vth Unit
MRD number :1076926
Marital Status : Married
Religion : Muslim
Educational Qualification : 8th std
Occupation : Real estate Business
Family Income : Rs 5000/-
Address : S/o Abdul Sathik
22, Muthulinga Devar Street
Ankusamy servai compound, P.P.kulam
Madurai
Source of Information : Son
Date and time of admission : 10.10.2015 at 6.30 am
Medical Diagnosis : T2 DM | DKA | CKD with carbuncle
Care study Started : 14.10.2015
Date of care study completed : 26.10.2015
Reason for admission : Patient came with the complaints of carbuncle,
High Blood Sugar, High urea and cleat
nine. Refued from Saravana hospital for
heamodyalisis
HISTORY OF PRESENT ILLNESS
Patient was having loss of appetite, Indigestion and an obsess in the
left lateral chest wall got admitted in Saravana Hospital at Maruthupandi Nagar.
There patient was diagnosed as a case of CKO incidentally. He was put on dialysis
(hem dialysis) through femoral approach and he was referred from there to our
hospital.

PAST HEALTH HISTORY

Patient is a known case of type2 Diabetic Mellitus since 7years. On
regular treatment Taking tablet for mine 500mp of Got admitted at Saravana
Hospital for high Blood Sugar 20days back Received treatment and gone home.
Again 10days back patient got admitted in Saravana Hospital for a carbuncle at
the left lateral side of the chest thus he was diagnosed as CKD incidentally. Hem
dialysis was done and from there patient got admitted 1hour hospital. Having no
history of HIV,CAD,TB, Asthma and epilepsy. Not having any history of allergies

SOCIOECONOMIC HISTORY
Type of housing : Terraced house. Having 3bedroom one hall one
Kitchen, one Bathroom latrine attached and one
Common Bathroom and latrine floor marionette
Own /Rented : Rented house Monthly pay up the rent of Rs6000/-
Value facility : Inside the house they are having Bore well water
And taking municipal water from the street pipe
Drainage facility : Closed type of Drainage System available
Cross Ventilation : Electrified and sufficient
Disposal of refuse : By Dumping method
Lighting facility : Electrified and sufficient
Pet animals : Nil
Garden : Nil

FAMILY HISTORY
He belongs to nuclear family. Having two son and daughters There is
no history of having any kind of disease among the family members like
hypertension, diabetic, militant, Jaundice and mental linen congenital anomalies ,
and common communicable diseases
GENOGRAM

60yr 58yr

Keynote

Male

Female
58yr 54yr
8th std 4th std
deceased

32yr 29yr
28yr 24yr ITI
Client
BBA B.Sc phy B.Sc Maths
PERSONAL HISTORY
Place of Birth : Sakkimangalam
Personal experience at different ages : uneventful
Relationship with Neighborhood and family,
friends and relatives Adequately having
Values and belief practices on
Religious folios very orthodecial worshipped 5times 1day
Food types and value : Take up mixed died
Language spoken and understood : Tamil
Social and recreational preference : Watching TV
Smoking, drug abuse, alcohol habits : Nil
Activities of daily Living : He takes the responsibilities of
home and does all the house
hold work and apart from his
real estate work.

MARITAL HISTORY
Married at the age of 25 not a consanguineous marriage Having four
children
PHYSICAL ASSESSMENT
Appearance : Looks unshaved and untidy conscious but
confused drowsy and puller
Head
Scalp : Normal and dandruff free
Hair : Whitish black
Nose : Normal
Eyes : Vision Normal
Ears : Having good hearing capacity
Mouth
Tongue : Coated
Lips : Dry
Teeth : No dental carries
Neck : Normal
Chest : Symmetrical at the left lateral side of the
Chest having big carbuncle wound dressed
Up. Tachypnoic R.R 36/mt take up shallow
breaths
Heart : S1 S2 Sounds audible No Murmur
Abdomen : Distanced on the Rt side having
Performed dialysis catheter and P.Dimgoing
Genitor urinary : Having foy’s catheter inside on continuous
Bladder careenage drawing show colored
urine
Extremities upper : Range of motion Normal. Having IV line
line on both the bands On the Rt forearm
Having thrombophelebites from the Inside
Lower : Bilateral pedal edema present. Having
Some skin disease. Color of the skin
Changed.

SYSTEM REVIEW
Central Nervous System : Conscious but confused making some
Noise atomies oriented
Respiratory System observation : Chest binaurally symmetrical having
dyspnoea, take up shallow breathing
RR 36/mt. Bilateral breathing in good and
Basal bronchi present
Percussion : Romance Normal

Cardiovascular system
Inspection : No JVP elevation, visible carotid
pulsates noticed
Palpation : pulse 106/mt thread
Auscultation : Heart sounds auditable, no added sounds
Percussion : Has Normal Resonance
Gastro intestinal system : Abdomen distended no surgical scar
Inspection : Having peritoneal dialysis Catha in site
At the right side of the abdomen on
Peritoneal dialysis
Auscultation : Bowel sounds hearted and it is normal
Percussion : Dull
Bowel movements : Present Yellow colored
Musutlo skeletol system : No congenital abnormalities no shorting
Of limbs no paresis and paralysis range of
motion Normal
Endocrine system : Having positive tolerance to cold and Hot.
He is a known case of type 2 Dm since 7years .
on regular treatment.
Lymphatic system
Genitourinary system
Integumentary system
: No generalized lymphatic nonparty and
Local lymphadenopathy
: No ulcer infection and discharge from the
Genital organ. On continuous bladder
Drainage. Urinary catholic in site.
Urine output 600ml /day. In spite of
Peritoneal dialysis
: Skin Turgot normal. Having skin infection
On the both legs. Some pigmentation in seen
Bilateral pedal edema present

Vital Signs
Temperature : 37.40c
Pulse : 90/mt
Respiration : 36/mt
Blood pressure : 130 /70 mm of Hg
Pain : Having pain in the wound (abscess site)
02 Salutations : 96%

INVESTIGATION

Name of the Patient value Normal value Remarks

 investigation
HB -7.7 g 7.3g 7.7g, 7.3g 12 to 14g Decreased

TC -21200 21200 5.5 to 10.5 w/l Decreased

P increased
Dc P83 L10 E7 P60 L35 E5
L decreased
ESR 58mm for 1hour 10mm for 1hour Increased

Platelet 5.68 lak/m 2 to 3.5 lak/m Increased

High,480.300,650,
Blood sugar 80 to 129 mg/d Increased
168,550 mg/d
Serum electrolytes
Na+ 158,152 mg/d 135 to 145 mg Increased
K+ 6.84, 4.3mg/d 3.5 to 5 mg Increased
C- 106,128 mg/d 105 to 110 mg Increased
Serum calcium 1.06 mg/d 8.5 to 10.5 mg/d Decreased

Hco3 3.6 mg/d 20 to 25mg/d Decreased

PH 7.26 7.45 Decreased
Blood gas
PCO2 8.3 30 to 35 8.3
ECG Normal - Normal
USG Abdomen
Medical renal disease - Abnormal
&pelvis
Urine - albumin ++ Nil Abnormal

Sugar Trace Nil Abnormal

Deposit 1-3

Acetone Negative Nil Normal

DRUGS
Freque
S.No Name of the Drug Dose Route Action Side effect Remarks
ncy
 Iron Constipati
1 Tab FST 1 Oral BD
supplementary on

Calcium Calcium
2 Tab calcium 600mg Oral Tds
supplementary deposits

Breaks fat Watch for

3 Tab Atrovastin 20mg Oral Hs Tiredness
deposition side effect

Fatigue,
4 Inj.Ceptriaxone 2g IV BD Anti biotin
giddiness

Nausea
5 Inj. Metronidazole 500mg IV Tds Anti microbial
vomiting

H2+ion receptor Indigestio

6 Inj. Ranitidine 50mg IV Bd
antagonist n

Inj.Calcium Slowly Calcium Calcium Watch for

7 10ml IV
gluconate bolus Supplementary deposits side effect

Salbutamol
8 BD Varo dilator Confusion
Nebulizer

HumanAtrapid Slow Insulin hypoglyce

9 As
50units in 100m/ns drip supplementary mia
Sodium bi
Tab Sodium Hyper Watch for
10 1tablet Oral Tds carbonate
bicarbonate ventilation side effect
supplementary
Inj.pipirarillin Nausea
11 500mg IV Tds Anti microbial
20bartum vomiting