Transcript By Corporate FVR TEAM Diarrhea / acute gastro enteritis

By
Corporate FVR TEAM
Diarrhea /
acute gastro
enteritis
• Verify the initial admission complaints of
the patient
• Frequency of the stools , quantity of the
stool
• Indication for hospitalization
• verify for Dehydration symptoms
• To verify Vitals at the time of admission
• Line of management
• Whether patient took out patient treatment
if so details of the treatment
Fever
•Verify the indication of hospitalization
•Verify the temperature , vitals ,
dehydration status
•Verify Exact duration of fever
•To verify TPR chart
•To get Positive investigation reports
•Reports of outpatient treatment ,if any
•To verify indication for
hospitalization
•Verify for vitals at the time of
admission
lower respiratory • To verify the resp rate ,saturation
level-02 saturation
infection
• To verify whether oxygen /
nebulisation given
• To verify the x ray or ct chest report
• To rule out whether any underlying
bronchial asthma, copd
Typhoid
Leptospirosis
• Indication for hospitalization
• verify for fever , vitals ,
dehydration status
• Exact duration of fever /TPR
chart
•Positive inv reports diagnosis, blood
culture rpt ( confirmatory )
• Indication for hospitalization
• To verify for fever , vitals ,
dehydration status of the patient
• Exact duration of fever/ TPR
chart
• Positive inv reports diagnosis
• MAT TEST rpt ( mandatory )
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Persistent vomiting
Dehydration
Abdominal tenderness
Hepatomegaly
Ascites
edema
Dropping trend of platelets to <50000
 Comorbid conditions: Heart disease, Bronchial
Asthma, DM, HTN,
Peptic Ulcer, Hemolytic anemias,
Pregnancy, Infancy,
Old age,. along with ns1 antigen.

Dengue : Mucosal bleed
 Respiratory distress
 Pleural effusion
 Hypotension/shock
 Oliguria
 Rising Haematocrit> 60%

If any one of the above condition is met, then
admission is indicated
Chronic
kidney
disease
•How and when was the symptoms started
• What was the initial symptom
•When was it first diagnosed?
• First consultation report and creatinine value at
the time of diagnosis
• Serial urea and creatinine values with
hemoglobin rpt , usg , ct rpt
• Any biopsy done if yes result ( mandatory )
•Any past history of kidney disease
• If dm /ht - what was the duration
Hypertension
• How and when diagnosed as
hypertension
• Initial consultation report and
medications given
•What was the current medication taken
•Ecg, Rft, echo reports
Acute
pancreatitis
• Usg or ct report along with Liver function
test reports , s.amylase, s.lipase
• To verify whether patient has any
previous history of similar pain and
admission details
• To check for alcohol history
Diabetes
• How and when was the dm diagnosed
• Exact duration of DM
• All past inv reports
• HBA1C reports
• Treatment taken so far for DM.
Asthma
•To enquire regarding exact duration of
asthma
•To verify whether patient was taking any
steroid treatment if yes duration
• Whether any PFT report available all past
medications including x ray previously taken
•PRESENT- x ray , ct report /
•oxygen given / any nebulisation done
Heart Disease
/CAD
• Exact duration of heart disease
•To ask any previous
episodes/hospitilisation for similar
illness
• Previous ECG, Echo,Tmt ,Cag report
•( If available) HISTORY OF asprin intake
• Plan of management.
•Whether Pt Had Any Rheumatic Fever
Heart Disease • Past H/O Hospitalisation FOR RH.FEVER
•Any Penicillin prophylaxis taken before ,If
/RHD
Yes – Duration
•Echo Report
• Holter monitor report
Heart disease / • Any regular intake of any anti arrythmic
conduction drugs
defects
• Any past history of Syncope ,Tia,
Palpitation
• Verify the exact circumstance of injury
• Whether two wheeler vs two wheeler , or four wheeler
• Whether patient was riding or sitting in the back
• Whether pt. was under influence of alcohol, If late night
suspect alcohol Mlc/Ar copy, check x-rays.
Back Pain
• To verify Indication for
hospitalization
• If trauma look for any other Soft
tissue injury
• Exact duration of symptoms
• confirm whether previous
hospitalization done
• To verify the previous treatment
details.
•
• Etiology for giddiness
• To ask whether Patient a known case
of DM/HT/IHD or any other systemic
disorder
Giddiness
• CT or MRI reports
• Any other medication for vertigo or
any other illness
Knee
Replacement
• To verify How and when did the
knee pain started for the patient
• All past treatment records
including medicines taken for
• To verify Pre operative , post
operative x ray
• Verify for Vitals ,fever at the time of
admission
• Verify for Usg report and urine
routine analysis
Urinary Infection • Cbc report ,urine culture
• To verify for any history of calculus
• To verify whether any treatment or
investigation previously done for
urinary infection
Stomach Pain
• To verify for exact duration of
Pain
• Whether pt had previous similar
pain
• Whether any endoscope was
done(with report)
• To verify whether patient was on
any proton pump inhibitors
• Any investigation or treatment
taken with records
• Current Usg report
• To verify for alcohol history
Head Injury
• Exact mode of injury like any fall
from height( what was the height )
• Any associated leg fracture
• To rule out any suicidal attempt
• Any AR / MLC / FIR copy done
• To collect the Ct or Mri report
• To verify any alcohol history if RTA
• To verify treatment plan.
Burns
• Exact Circumstance how burns occurred
for the patient
• To verify if any mlc / fir done
• Exact duration of the abdominal pain
Acute
appendicitis
• To verify for fever , vomiting , cbc
count ,
• To verify for vitals on admission
• Investigation - usg report or ct report ,
• Whether any previous abdominal
surgery was done if so all those details ,
any other co morbid conditions for the
patient
Cholelithiasis /
gall bladder
calculi
•Exact duration of abdominal pain
• First/past consultation report
• Cbc count with usg abdomen
report or ct scan report /Ercp/Mrcp
Calculus of
kidney and
ureter
• Exact duration of the pain
• First consultation report for the pain
• Usg or ct evidence for the calculus
• Verify whether patient had done previous
surgery ( laser therapy ) or medical
treatment for calculus
Benign
neoplasm of
uterus / fibroid
uterus /dub
• What was the initial complaint ( like heavy
bleeding or abdominal pain with duration )
and duration since when the patient had
those problems
• First consultation report and the usg done at
the time with prescription report
• Duration of dub /medical treatment for dub
/usg rpt
• Any previous gynaecological consultation
was done for the patient for any complaints.
Hernia
• What was the exact type of hernia ( whether
inguinal , umbilical , incisional or femoral
hernia )
• Exact duration of hernia symptoms with the
first consultation report
• Usg report
• Any past history of any previous abdominal
surgery done if yes all those details including
cesearean surgery
• If the patient is a child ask mother when the
swelling was noticed
Neoplasm
of the
breast
• Verify the patient when exactly did the
patient noticed the swelling
• First consultation report for the same
• Mammogram report , fnac and hpe
report
• Whether pt had done previous surgery or
treatment for the other breast in the past
Haemorroids
• To verify for the exact duration of pain ,
bleeding per rectum for the patient
• Any medical management taken for the
same
• Any past history of previous surgery done
for hemorrhoids ( laser surgery /stapler
surgery ),
• Proctoscopy report
Deviated
nasal septum
• What was the initial complaint for the
patient
• What was the medical treatment taken
• Ct scan reports / x ray para nasal sinus

Exact Duration of the Abdominal pain.
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To verify for Fever, Vomiting, CBC count,
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To verify for Vitals on Admission.
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Investigation - USG Report or CT Report,
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Whether any previous Abdominal Surgery
was done if so all those details, any other
co-morbid conditions for the patient.

Exact Duration of Abdominal Pain

First / Past Consultation Report

CBC Count with USG Abdomen Report or CT
Scan Report /Ercp/Mrcp.
 Exact
Duration of the pain

First Consultation Report for the pain

USG or CT evidence for the calculus

Verify whether Patient had done previous
surgery ( laser therapy ) or medical
treatment for calculus.
 What
was the initial complaint ( like heavy
bleeding or abdominal pain with duration )
and duration since when the patient had
those problems
 First consultation report and the USG done
at the time with prescription report
 Duration of DUB /Medical Treatment for
DUB / USG Report
 Any previous Gynecological consultation was
done for the patient for any complaints.
 What
was the exact type of hernia ( whether
inguinal , umbilical , incisional or femoral
hernia )
 Exact duration of Hernia Symptoms with the
First Consultation Report.
 USG Report.
 Any past history of any previous abdominal
surgery done if yes all those details including
cesarean surgery.
 If the patient is a child ask mother when the
swelling was noticed.
 Verify
the Patient when exactly did the
patient noticed the swelling.

First consultation Report for the same.

Mammogram Report , FNAC and HPE Report.

Whether Patient had done previous surgery
or treatment for the other breast in the past.
 To
verify for the exact duration of pain,
bleeding per rectum for the patient.

Any medical management taken for the same

Any past history of previous surgery done for
hemorrhoids ( laser surgery /stapler surgery )

Proctoscopy Report.
 What
was the initial complaint for the
patient
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What was the medical treatment taken

Ct scan reports / x ray para nasal sinus
 AS
PER FOR RTA CASES ( PREVIOUS SLIDES )
 LOOK
FOR OTHER INJURIES , IN THE OTHER
SITES LIKE BRUISE , LACERATED WOUND

LOOK FOR X RAY FILM ,
 ANY
PAST HISTORY OF PREVIOUS FRACTURE
 ANY
EVIDENCE OF OLD HEALED FRACTURE
 WHEN
WAS THE INJURY OCCURRED
 ANY ASSOCIATED INJURIES LIKE HEMATOMA ,
BRISE
 IF POLICY IS IN 1 ST YEAR , GET ALL THE
DETAILS OF INJURY LIKE WHEN IT OCCURRED ,
FIRST CONSULTATION PAPER ( ACL TEAR CAN
BE OPERATED UP TO 6 MONTHS )
 MRI RPTS ( LOOK FOR THE DATE OF MRI )