CODE 3V


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

IPID 202349607

UHID 20231105625

Pay Type

Credit (AROGYA SREE)

Age/Gender 45 Years/Male

Address

Discharge Type: Relieved

Admission Date: 04/11/2023 05:24 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH

C/O SOB SINCE 3 DAYS

C/O GENERALIZED BODY SWELLING SINE 20 DAYS

PT WAS APPARENTLY ASYMPTOMATIC 30 DAYS AGO,

C/O GENERALISED BODY SWELLING TILL KNEES INITIALLY, THEN GRADUALLY PROGRESSED TO THE WHOLE BODY SINCE 20 DAYS

CIO SOB MORE ON EXERTION SINCE 3 DAYS

KICIO DM TYPE-2 SINCE 10 YEARS

KICIO HTN SINCE 5 MONTHS ON TAB. NICARDIA 20MG/OD

NOT A KIC/O THYROID, ASTHMA, EPILEPSY, CAD.TB

Investigation

LIVER FUNCTION TEST (LFT) 04-11-2023 10:43 AM Total Bilurubin0.59 mg/dlDirect Bilurubin0.21 mg/dISGOT(AST)20 IU/LSGPT(ALT)17 IU/LALKALINE PHOSPHATE 151 IU/LTOTAL PROTEINS6.2 gm/dIALBUMIN2.8 gm/diA/G RATIO0.83

RFT 05-11-2023 07:34 AM UREA80 mg/dICREATININE6.2 mg/dIURIC ACID6.4 mg/dICALCIUM 10.0 mg/dIPHOSPHOROUS3.8 mg/dISODIUM132 mEq/LPOTASSIUM4.4 mEq/LCHLORIDE101 mEq/L
COMPLETE URINE EXAMINATION (CUE) 08-11-2023 12:22 PM

COLOURReddishAPPEARANCE ClearREACTIONAcidic SP GRAVITY 1.010ALBUMIN+SUGAR+BILE

SALTSNIBILE PIGMENTSNIIPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD

CELLSNIICRYSTALSNIICASTSNIIAMORPHOUS DEPOSITSAbsentOTHERSNil

RFT 08-11-2023 04:09:PM UREA88 mg/dICREATININE5.3 mg/dIURIC ACID5.6 mg/dICALCIUM10.1 mg/dIPHOSPHOROUS3.9 mg/dISODIUM131 mEq/L.POTASSIUM3.9 mEq/LCHLORIDE99 mEq/L

RFT 09-11-2023 07:10:AM UREA79 mg/dICREATININES.3 mg/dIURIC ACID5.7 mg/dICALCIUM10.1 mg/dIPHOSPHOROUS4.2 mg/dISODIUM132 mEq/LPOTASSIUM4.7 mEq/LCHLORIDE97 mEq/L.

HBsAg-RAPID04-11-2023 10:43:AMNegative

Anti HCV Antibodies - RAPID04-11-2023 10:43:AM Non Reactive

2D ECHO

MILD AR, MODERATE MR, TRIVIAL AR

MODERATE CONCENTRIC LVH

DILATED LA AND LV

EF 43%, MODERATE LV DYSFUNCTION

RWMA+, LAD RCA AND LCXHYPOKINESIA

GRADE I DIASTOLIC DYSFUNCTION

NO PE, NO LV CLOT

Treatment Given (Enter only Generic Name)

SALT RESTRICTION <2GM/DAY

FLUID RESTRICTION <1.5 LTR/DAY

TAB OROFER XT PO OD

TAB NICARDIA 20MG PO TID

TAB TELMA 80 MG PO/OD

TAB LASIX 80 MG PO BD

TAB MET XL 25 MG PO BD

INJ EPO 4000 IU SC 1 X WEEKLY

INJ IRON SUCROSE IN 100ML NS IV ONCE WEEKLY

Advice at Discharge

SALT RESTRICTION <2GM/DAY

FLUID RESTRICTION <1.5 LTR/DAY

TAB OROFER XT PO OD
TAB NICARDIA 20MG PO TID

TAB TELMA 80 MG PO/OD

TAB LASIX 80 MG PO BD

TAB MET XL 25 MG PO BD

INJ EPO 4000 IU SC 1 X WEEKLY

INJ IRON SUCROSE IN 100ML NS IV ONCE WEEKLY

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 16/12/23

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