CODE 0F


This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent


Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input

This Blog also reflects my patient-centred online learning portfolio.

Your valuable input on the comment box is welcome

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.



DEIDENTIFIED DISCHARGE SUMMARY

202249937

UHID : 20221146102

Pay Type

Credit AROGYA SREE)

Age/Gender: 71 Years/Male

Address

Discharge Type: Relieved

Admission Date: 29/11/2022 02:03 PM

Name of Treating Faculty

DR. SRI RAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CJO SOB SINCE 2 MONTHS

LOIN PAIN SINCE 2 MONTHS

HOPI

PT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVOLOPED SOB OF GRADE 2 WHICH WAS AGGRAVATED ON ERECTION AND RELEIVED ON MEDICATION

NO HIO ORTHOPNEA /PND/CHEST PAIN PALPITATIONS/DECREASED URINE OUTPUT

K/C/O DM 15 YEARS

K/C/O HTN SINCE 10 YEARS

K/C/O CRF 2 YEARS

GENERAL EXAMINATION:

NO PALLOR, ICTERUS, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

PR-968PM

RR-18CPM

BP-140/90MMHG

SPO2: 990N RA

GRBS: 102

CVS: S1, S2-

RS BAE, NVES

P/A: SOFT, NON-TENDER, BS+

CNS: NAD

Investigation

USG ON 29/11/22

IMPRESSION: GRADE 3RPDCHANGES IN BIL KIDNEYS WITH RENAL CORTICAL CYST IN RT

KIDNEY

2D ECHO

DILATED RA, LA AND LV

MILD CONCENTRIC LVH

EF 60%, GOOD LV FUNCTION

GRADE 1 DFIASTOLIC DYSFUUNCTION

MODERATE ME, MODERATE TR WITH PAH Treatment Giver Enter only Generic Name)

T DYTOR 100 MG PO BD

T NICARDIA 20 MG TID

T TELMA 80 MG PO OD

TOROFER XT PO OD

TARKAMINE 0.1 MG PO TID

INJ EPO 4000 IU S/C ONCE WEEKLY

INJ. IRON SUCROSE 100 MG ONCE WEEKLY

T SHELCAL PO OD

Advice at Discharge

T DYTOR 100 MG PO BD

T NICARDIA 20 MG TID

T TELMA 80 MG PO OD

TOROFER XT PO OD

TARKAMINE 0.1 MG PO TID

INJ EPO 4000 IU SIC ONCE WEEKLY

INJ. IRON SUCROSE 100 MG ONCE WEEKLY

T SHELCAL PO OD

REVIEW AFTER 2 WEEKS OR IN CASE OF SOS

Follow Up

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration: The medicines prescribed and the advice regarding preventive aspects of care when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date: 10/1/2023

Ward:CKD

Unit:NEPHROLOGY

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