Day one-15.15 |
Delivered 7 days ago |
Chronically ill looking, pallor, Chest- AE down bilaterally, dull on percussion, S1, S2 normal, pus aspirated on both sides |
R/O (sic.Rule out) RVD (sic. HIV) |
CXR, FBC,ESR,LFT,ICD,VCT,ATT |
Day 2 |
VCT requested- Cotrimoxazole given |
Day 3 |
Follow up lab tests, VCT |
Day 4 |
No entry |
Day 5 |
Follow up lab tests, VCT |
Day 6 |
Follow up lab tests, VCT, consider ICD, Surgeon to see |
Day 7 |
Repeat lab tests, VCT, surgeon to see, trace lab results |
Day 8 |
Repeat lab tests, surgeon to see, trace lab results |
Day 9 |
Repeat CXR, follow up on lab results, surgeon to see |
Day 10 |
R/O RVD (sic HIV), follow up lab results, VCT, repeat U/E, LFT |
Day 11 |
FBC/ESR, Urgent HB, CXR, Surgical consultation, Lasix, CST, O2 therapy |
Day 12 |
Surgical consultation, CXR, Trace lab results |
Day 13 |
VCT |
Day 14 |
VCT, RPR, surgical consultation |
Day 15 |
VCT, RPR |
Day 16 |
Add slow K, Prednisolone |
Day 17 |
(Not seen in am) |
Certified dead at 14.26 |