NIDA NAEEM

ASSIGNMENT #1

Course Title:Management Information System in Healthcare

MBA – Spring 2014

PATIENT#1:

1.58 years old female patient K/C of DM was admitted with C/O L Breast lump on 27/01/2014. 2. Patient had this condition from 1 month. According to the patient, she was in usual state of health 1 month back then she noticed Lt Breast lump with no any sign or symptoms. 3. Patient had Lt Breast Tru cut Bx on 14/12/2012. Patient underwent Lt Breast SLNBx and Lt Mastectomy on 28/01/2014. 4. No active complaints. 5. Physician's notes: Patient received oriented and conscious, No active complaints. Nurse notes:Vitals checked and TPR marked. Medications given as per day order. No any active issues. 6. Patient was discharged on 29/01/2014 from female surgical ward after 2 days of admission. 7. Discharge orders were available in the discharge slip. Discharge instructions: Continue medications as prescribed. Follow up on Saturday 01/02/2014 to attend general surgery OPD.

PATIENT#2:

1. 26 year old female was admitted with complain of Lt Breast lump. 2. Patient had this condition from 2 months. According to the patient, she was all right 2 months back then she noticed a swelling in her Lt Breast. 3. Patient underwent Lt Breast SLNBx on 25/02/2014. 4. Patient did not face any active issues. 5. Physician's notes: Patient is conscious and cooperative Active issues: none Patient is vitally stable. Nurse notes: Vital signs checked and TPR marked. 6. Patient was discharged from female surgical ward on 25/02/2014. 7. Discharge orders were available on discharge slip.Discharge instructions: Continue medicines as prescribed Remove dressing after 48 hours.Follow up after chasing H/ p to attend General Surgery OPD. Follow up with Oncologist.

PATIENT#3:Answer#1:

Patient was admitted in Accident and Emergency Ward on 6 Nov-2013 at 5:30 pm due to fall on floor (At home) and Swelling in right ankle- Deformity positive. Distal Neurovascular intact-vitally stable.Answer#2:55-year-old male came to the ER with the history of fall in the morning and swelling in right ankle.Answer#3:Patient was diagnosed as Rt Tibia/Fibula Fracture. The patient has its surgery on 7/11/2013 and ORIF RT Tibia Fibular procedure was attempted and Spinal Anesthesia for RT tibia and Fibula ORIF. Answer #4: Patient did not experience any complication during this admission.Answer#5Physician’s progress notes:On Bed therapeutic doneNWB out of bed mobilizedDressing and wound normalPlan to dischargeNurse notes:Bedding done, dress changed, I/V care done, vitals checked and marked.All medications given according to doctor’s order. No active issuesAnswer# 6:Patient discharged from the orthopedic ward at 9-nov-2013(6:40pm) after 3 days of treatment.Answer# 7:Discharge instructions:Take medications as plannedNo physical sportsAvoid lifting heavy thingsDo not bend or climb stairsPACU DISCHARGE FORM:Vitals: B.P:120/80mmHg, HR: 90/min, R/R20/minAirway: oralConscious level: AwakePain Score: none