CODE 28


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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

202409090

UHID 20240230082

Pay Type

Credit (AROGYA SREE)

Age/Gender 65 Years/Male

Address

Discharge Type: Relieved

Admission Date: 26/02/2024 07:33 AM

Name of Treating Faculty

DR.SRI RAMULU HOD

Diagnosis

CHRONIC RENAL FAILURE

ANAEMIA(NCNC) SECONDARY TO CKD

DM TYPE 2,HTN,CKD

Case History and Clinical Findings

ALTERED SENSORIUM SINCE 3 HRS HOPI

PATIENT WAS BROUGHT TO CASUALITY IN A ALTERED SENSORIUM STATE

NO HIO INVOLUNTARY MICTURATION AND DEFECATION

NO HIO INVOLUNTARY MOVEMENTS

NO HIO VOMITING, DIARRHEA

NO HIO ABDOMINAL PAIN

NO HIO SOB, ORTHOPNEA PND

NO HIO BLEEDING MANIFESTATION

PAST HISTORY

K/CIO CKD SINCE 5 YRS

KIC/O DIABETES SINCE 20 YRS ON INJ.MIXTARD 25-0-20

KICIO HTN SINCE 20 YEARS ON TELMA-40

GENERAL EXAMINATION

NO PALLOR, ICTERUS CYANOSIS, CLUBBING, LYMPHADENOPATHY OEDEMA OF FEET IS PRESENT

TEMP-98F

RR 20 CPM

BP-160/90 MM HG

SPO2 98% @RA

GRBS-45 MG% AFTER 25 D BECAME 197 MG/DL

CVS-S1S2 HEARD, NO MURMURS

RS-BAE PRESENT

PIA-SOFT NON TENDER NO ORGANOMEGALY

CNS-NFND

INITIALLY CASE WAS UNDER GENERAL MEDICINE LATER TRANSFERRED TO NEPHROLOGY

AFTER TRANSFERRING TO NEPHROLOGY HEMODIALYSIS WAS INITIATED

IN TOTAL 4 SESSIONS OF DIALYSIS DONE AND TWO UNITS OF PRBC TRANSFUSED

Investigation

HEMOGRAM 27/2/24

HB-9.0

TLC-11700

PLT-2.45

HEMOGRAM 2/3/24

HB-9

TLC-11700

PLT-1.63

HEMOGRAM 3/3/24

COMPLETE URINE EXAMINATION (CUE) 26-02-2024 09:20 AM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP GRAVITY 1.010

ALBUMIN +++

SUGAR NII

BILE SALTS N

BILE PIGMENTS NI

PUS CELLS 4-5

EPITHELIAL CELLS 2-4

RED BLOOD CELLS NII

CRYSTALS Nil

CASTS NII

AMORPHOUS DEPOSITS Absent

OTHERS Nil

SERUM CREATININE 26-02-2024 09:20 AM 6.9 mg/dl

HBsAg-RAPID 26-02-2024 09:25:AM Negative

Anti HCV Antibodies - RAPID 26-02-2024 09:25:AM Non Reactive

RFT 26-02-2024 03:45:PM

UREA 129 mg/dl

CREATININE 6.9 mg/dl

URIC ACID 6.6 mg/dl

CALCIUM 10.0 mg/dl

PHOSPHOROUS 4.4 mg/dl

SODIUM 138 mEq/L

POTASSIUM 3.4 mEq/L

CHLORIDE 103 mEq/L

LIVER FUNCTION TEST (LFT) 26-02-2024 03:45 PM

Total Bilurubin 0.53 mg/dl

Direct Bilurubin 0.18 mg/dl

SGOT(AST) 24 IU/L

SGPT(ALT) 22 IU/L

ALKALINE PHOSPHATASE 207 IU/L

TOTAL PROTEINS 6.3 gm/di

ALBUMIN 3.24 gm/dl

A/G RATIO 1.06

2D ECHO

NO RWMA CONCENTRIC LVH +

MODERATE MR + NO MS, MILD MAC+

MODERATE AR+ NO AS, SCLEROTIC AV

MODERATE TR + WITH MILD PAH

EF-60% GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION +

MINIMAL PE+

IVC SIZE-1.10 CMS COLLAPSING

DILATED LA/LV

RVSP 42+10-52 MM HG

USG-ABDOMEN AND PELVIS:

B/L GRADE 3 RPD CHANGES

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION LESS THAN 1.5 L/DAY

SALT RESTRICTION LESS THAN 2-3 GM/DAY

TAB LASIX 80 MG PO BD

TAB.NICARDIA 20 MG PO TID

TAB OROFER-XT PO OD

TAB SHELCAL-CT PO OD

INJ.EPO 4000 IU S/C ONCE 2 WEEK

INJ.IRON SUCROSE 200 MG IN 100 ML NS IV OD

Advice at Discharge

FLUID RESTRICTION LESS THAN 1.5 LIDAY

SALT RESTRICTION LESS THAN 2-3 GM/DAY

TAB LASIX 80 MG PO BD

TAB NICARDIA 20 MG PO TID

TAB OROFER-XT PO OD

TAB SHELCAL-CT PO OD

INJ EPO 4000 IU S/C ONCE 2 WEEK

INJ.IRON SUCROSE 200 MG IN 100 ML NS IV OD

Follow Up

REVIEW SOS

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: 4/2/24

Ward:AMC

Unit:NEPHRO

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