CODE 24


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

202404356

UHID

20240143705

Pay Type

Credit AROGYA SREE)

Age/Gender 58 Years/Male

Address

Discharge Type: Relieved

Admission Date: 28/01/2024 05:06 PM

Name of Treating Faculty

DR SRIRAMULU [HOD]

Diagnosis

STAGE V CHRONIC KIDNEY DISEASE

Case History and Clinical Findings

C/O SOB SINCE 1 DAY

DECREASEDSLEEP DECREASED APETITE SINCE 3 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS AGO THEN HE DEVELOPED

DECREASE APETITE ABDOMINAL DISCOMFORT NAUSEASINCE 3 DAYS AGO

NO VOMITINGS NO ABDOMINAL PAIN

H/O DISTURBED SLEEP SINCE 3 DAYS

SOB GRADE II

H/O DECREASED URINE OUTPUT

K/C/O DM SINCE 4 YRS

K/C/O CKD SINCE 4 YEAR ON CONSERVATIVE MANAGEMENT

NOT A K/C/O HTN, CVA, ASTHΜΑ EPILEPSY

OIE

PT IS C/C/C

PR:88BPM

BP: 180/90 MMHG

RR:17

SPO2:98% ON RA

CVS S1 S2 NO MURMURS

RS BAE+NVBS

PIA SOFT NON TENDER

CNS NFND

Investigation

CBP HB TCN LEMB PLT SMEAR RFT UR CR UA CA+2 P NA+K+ CL-HIV HBSAG

HCVNameValueNameValue

RFT 28-01-2024 05:24:PM

UREA

197 mg/dl

CREATININE

14.1 mg/dl

URIC ACID

3.1 mg/dl

CALCIUM

10.1 mg/dl

PHOSPHOROUS

6.1 mg/dl

SODIUM

133 mEq/L

POTASSIUM

4.1 mEq/L

CHLORIDE

99 mEq/L

HBsAg-RAPID28-01-2024 05:24:PM

Negative

Anti HCV Antibodies - RAPID28-01-2024 05:24:PM

Non Reactive

COMPLETE URINE EXAMINATION (CUE) 28-01-2024 06:35:PM

COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++

SUGAR

trace

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

2-3

EPITHELIAL CELLS

2-3

RED BLOOD CELLS

1-2

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

LIVER FUNCTION TEST (LFT) 28-01-2024 06:35:PM

Total Bilurubin

0.56 mg/dl

Direct Bilurubin

0.17 mg/dl

SGOT(AST)

11 IU/L

SGPT(ALT)

12 IU/L

ALKALINE PHOSPHATE

110 IU/L

TOTAL PROTEINS

6.7 gm/dl

ALBUMIN

3.3.gm/dl

A/G RATIO

0.99

2D ECHO

TRIVIAL AR, TRIVIAL MR, MILD TR WITH PAH

EF 58%, GOOD LV FUNCTION

NO DIASTOLIC DYSFUNCTION

DILATED RA, DILATED LV

NO PE, NO LV CLOT

Treatment Given(Enter only Generic Name)

1.FLUID RESTRICTION <1.5 L/DAY

2.SALT RESTRICTION <2 GM/DAY

3. TAB SHELLCAL CT PO/OD

4.INJ EPO 400 IU S.C ONCE IN 2 WEEKLY

5.TAB LASIX 80 MG PO BD

6.INJ SUCROSE 200 MG IN 100 ML NS IV/ONCE IN 2 WEEKS

7.TAB NICARDIA 20 MG PO/TID

Advice at Discharge

1.FLUID RESTRICTION <1.5 L/DAY

2. SALT RESTRICTION <2 GM/DAY

3. TAB SHELLCAL CT PO IOD

4.INJ EPO 400 IU S.C ONCE IN 2 WEEKLY

5.TAB LASIX 80 MG PO BD

6.INJ SUCROSE 200 MG IN 100 ML IV JONCE IN 2 WEEKS

7 TAB NICARDIA 20 MG PO/TID

Follow Up

REVIEW AFTER 5 DAYS IN NEPHROLOGY OPD

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:3/2/24

Ward CKD

Unit:NEPHROLOGY

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