it contains good information about pneumonia and chest infection

1. SUPERVISOR:
Dr.SafiaAlrezami.

2. Patient information:-
Name of the patient:- S.A.A
Age:-60 yr.
Sex:-male
Occupation:- farmer
File no. 182
Admission date:-31-3-2014
Medical history:- not recorded
Congestive heart failure(CHF) + Hepatitis c virus(HCV)

3. Patient information:-
 The resultinformation
He was smoker but he has been quit smoking
since 15years
Smoking
He was chewed qat, but he has been quit
chewing for two years ago.
Chewing qat
No specific exercise. but, he is a workerexercise
He suffer from
hypertension , CHF , HCV .
Other disease(DM-BP-RENAL
DISEASE-HEPATIC DISEASE-
HEART DISEASE)
Dead 10 years ago with no family’s history of
disease.
Mother
Father

4. Physical examination:-
Not recordedGeneral survey
Not recordedHead and neck
Not recordedChest exam
O2 support , half sitting stateCardiac exam
Collect urine till 24 hrsAbdominal exam
creatnineurological
RBS , LIPID PROFILE , CBC , RBS , INR ,
PT.
neurological
Not recordedgynecological

5. Lab investigation :-
Normal rangeThe result
20-12-2013
Name of the test
5.5-8g/dl2.5g/dlT-protien
15-45 g /dl51g/dlurea
0.7- 1.1 mg / dl1 mg / dlcreatnine
13-18g/dl12.9g/dlHB
3.8 – 4 . 4 g / dl3.4 g / dlalbumin
4-10*106.6*10g/dlWBC
40-70%45%NEU
20-45%48%LYMPH
2-10%4%MONO
1-6%5%eosino
0-1%0baso
5,4-6,3*10^12/l4.2*10^12RBC
77-96fl86FLMCV
32-36g/dl32g/dlMCHC
26-32PG26PGMCH
150-450190*10^9/Lplate

6. Treatment:-

notesdoseG . nmedication
T . D . S1 gAmoxil inj.
B . I . D20mgLasix inj.
S . O . s100mgDetamol inj.
S . O . sNo-spa inj.
T . D . SFlagyl inj
T. D . S10 mgDytor tab
S . O . SFleet enema
O . D50mgAldactone tab
½ tab O . D8mgCovas tab
O . D100mgAspirin tab
O . D0.25mgDigoxin tab
B . I . DAnsymar syr

7. Drug discussion
Give your suggestions
