CODE 1H


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
: 202308364

UHID 20230234677

Pay Type

Credit AROGYA SREE)

ل

Age/Gender 46 Years/Male

Address

Discharge Type: Relieved

Admission Date: 22/02/2023 02:40 PM

Name of Treating Faculty

DR. SRI RAMULU (PROFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

A 45 YR OLD MALE WHO WAS APPARENTLY ASYMPTOMATIC TILL NOV2018, THEN HE HAD COMPLAINTS OF MULTIPLE JOINT PAINS FOR WHICH HE WENT TO LOCAL RMP WHERE HE WAS DIAGNOSED WITH CHICKENGUNIYA AND STARTED ON MEDICATION AS PATIENT DID NOT GET RELIEF HE WENT TO A LOCAL HOSPITAL WHERE HE WAS DIAGNOSED WITH PYELONEPHRITIS AND UNDERWENT TREATMENT FO IT. INSPITE OF ROUTINE FOLLOWUP THE PATIENTS CONDITION WORSENED AND HE LANDED UP IN CKDFOR WHICH HE WAS ADVISED HEMODIALYSIS AND HE REFUSED FOR IT AND HE WAS MANAGED CONSERVATIVELY SINCE DEC 24 2022 HE HAD REDUCED APPETITE, LOW BACK ACHE AND VOMITING. HIS CREATININE WS 21 MG/DL-ADMITTED-RT IJV-4+6-

DURING HIS COURSE IN HOSPITAL HE WAS TAKEN FOR 4HEMODIALYSIS SESSIONS K/C/O HTN SINCE 6 YEARS

K/C/O DM SINCE 8 YEARS

OFE

PATIENT IS CICIC

NO PALLOR, ICTEUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA

TEMP-98.7F

PR-88 BPM

RR-16 CPM

BP-150/90 MMHG

Investigation

CBP

HB 7.4G/DL

TC-5,600CELLS/CUMM

RBC-2.47 MILL/CUMM

PLT-1.68LAKHS/CUMM

SMEAR-NCNC

RFT

UR-136MG/DL

CR-12.7MG/DL

CA+9.1 MEQ/L

P. 3.1 MEQ/L

NA+135MEQ/L

K+4.28 MEQ/L

CL-105MEQ/L

SEROLOGY-NEGATIVE

TB-0.78 MG/DL

DB-0.20MG/DL

AST-10IU/L

ALT-10IU/L

ALP-228IU/L

TP-6.0G/DL

ALBUMIN-3.7G/DL

SERUM IRON-68 MG/DL

CUE-ALBUMIN +++

SUGARS+

USG

RT KIDNEY -7.3 X 4CMS, CMD LOST

LEFT KIDNEY -7.4 X 4.3 CMS CMD LOST

IMPRESSION-BIL GRADE III RPD CHANGES

2D ECHO

NO LVH

LV IS DILATED

GOOD LVSYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

NO RWMA

EF-62%

MILD MR, TRIVIAL TR WITH PAH, TRIVIAL AR

NO MSIAS

Treatment Given(Enter only Generic Name)

1. TAB TELMA 80 MG/OD

2. TAB. OROFER XT PO OD

3. TAB. NICARDIA 20 MG PO QID

4. TAB SHECAL 500 MG PO OD

5. TAB. LASIX 80MG PO TID

6.INJ. EPO 4000 IU SC ONCE WEEKLY

7.INJ. IRON SUCROSE IV ONCE WEEKLY

8. TAB.METAPROLOL 25 MG IOD

Advice at Discharge

1. TAB TELMA 80 MG/OD

2 TAB. OROFER XT PO OD

3. TAB. NICARDIA 20 MG PO QID

4 TAB SHECAL 500 MG PO OD

5.TAB. LASIX 80MG PO TID

6.INJ. EPO 4000 IU SC ONCE WEEKLY

7.INJ. IRON SUCROSE IV ONCE WEEKLY

8.TAB METAPROLOL 25 MG/OD

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 Enquines 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 PGANTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date 04/03/23

WARD-NEPHROLOGY

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