CODE 3I


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

202305300

UHID 20230202881

Pay Type

Credit(AROGYA SREE)

Age/Gender: 61 Years/Male

Address

Discharge Type: Relieved

Admission Date: 02/02/2023 04:06 PM

Name of Treating Faculty

DR.SRI RAMULU

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O DECRESED URINE OUTPUT SINCE 2 MONTHS

C/O B/L PEDAL EDEMA SINCE 1MONTH

PATIENT WAS APPARENTLY ASYMTOMATIC 2 MONTHS BACK THEN SHE HAD DECRESED URINE OUTPUT, C/O B/L PEDAL EDEMA 1 MONTH BACK, WHICH IS PITTING TYPE

PAST HISTORY:

K/C/O HTN SINCE 8 YEARS

K/C/O DM SINCE 6 YEARS

N/K/C/O ASTHMA, TB. EPILEPSY

GENERAL EXAMINATION: NO

PALLOR, ICTERUS, CYANOSIS, CLUBBING, EDEMA, LYMOHADENOPATHY

VITALS:

TEMPERATURE:98.4F

BP:140/80MMHG

PR:88 BPM

SPO2:99%ON RA

RR: 16

CVS:S1/S2

PIA:SOFT, NON TENDER

Investigation

USG: B/L SIMPLE RENAL CORTICAL CYSTS WITH RAISED ECHOGENICITY OF THE BOTH ( GRADE I RPD)

CBC

HB 7.2

TC 6000

PLT 1.90

RFT

UR 57

CR 6.1

LFT

TB 0.57

DB 0.16

AST 14

ALT 18

ALP 169

TP 4.9

ALB 1.89

2D ECHO

TRIVIAL TR, MILD MR, MILD AR, SCLEROTIC AV

MILD CONCENNTRIC LVH

EF 65%, GOOD LV FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

MINIMAL PE: NO LV CLOT

Treatment Given(Enter only Generic Name)

T.DYTOR 100MG PO BD

T.NICARDIA 20MG PO TID

T. ARKAMINE 0.1 MG PO TID

T.OROFER XT PO OD

T.SHELCAL 500MG PO OD

CAP BIO D3 PO OD

INJ EPO 4000 IU SC ONCE IN 2 WEEK

INJ IRON SUCROSE 100 MG IVIONCE IN 2 WEEKS

Advice at Discharge

T.DYTOR 100MG PO BD

T.NICARDIA 20MG PO TID

T. ARKAMINE 0.1 MG PO TID

T.OROFER XT PO OD

T.SHELCAL 500MG PO OD

CAP.BIO D3 PO OD

INJ.EPO 4000 IU SC ONCE IN 2 WEEK

INJ IRON SUCROSE 100 MG IVIONCE IN 2 WEEKS

Follow Up

REVIEW TO 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 cate, 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:2/3/23

Ward: NEPHROLOGY

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