CODE 42


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

PID

202303993

UHID 20230136217

Pay Type

Credit AROGYA SREE)

Age/Gender 59 Years/Male

Address

Discharge Type: Relieved

Admission Date: 24/01/2023 06:44 PM

Name of Treating Faculty

DR. SRI RAMULU

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH THE COMPLAINTS OF SOB SINCE 2 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK THEN HE DEVELOPED SOB WHICH IS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

C/O DECREASED URINE OUTPUT SINCE 2 DAYS

BAL PEDAL EDEMA SINCE 2 DAYS TILL KNEE

PAST HIO-

K/C/O HTN SINCE 20 YRS ON MEDICATION TAB, ARKAMINE

NOT A K/C/O TB, ASTMA, EPILEPSY, THYROID DISORDERS, CAD, CVD

ON GENERAL PHYSICAL EXAMINATION

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

THERE IS NO PALLOR, ICTEURS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

EDEMA OF FEET PRESENT TILL THE KNEE

VITALS-TEMP-98.4 F

PR-78 BPM

RR-18 CPM

BP-140/80 MMHG

SPO2-98% ON RA

CVS-S1, S2 PRESENT

RS- BAE PRESENT

Investigation

CBP

HB7.8G/DL

TC-8900CELLS/CUMM

RBC-2.81MILL/CUMM

PLT-3.22 LAKHS/CUMM

SMEAR-NCNC

RFT

UR-76MG/DL

CR-6,3MG/DL

CA+8.7 MEQIL

P2.8 MEQ/L

NA+142MEQ/L

K+3.9MEQ/L

CL-101MEQ/L

SEROLOGY-NEGATIVE

TB-0.68 MG/DL

DB-0.20MG/DL

AST-36IU/L

ALT-40IU/L

ALP-383IU/L

TP-4.9G/DL

ALBUMIN -2.8G/DL

SERUM IRON-70 MG/DL

CUE-ALBUMIN++

SUGARS-NIL

USG

RT KIDNEY -5.5 X 2.4 CMS CMD LOST

LEFT KIDNEY 6.9 X 3CMS CMD LOST

IMPRESSION-B/L GRADE III RPD CHANGES

2D ECHO

MILD LVH

RA AND LA ARE DILATED

GOODSYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

EF 58%

MILD MR,AR MODERATE TR, WITH PAH

USG ABDOMEN AND PELVIS ON 24/03/23

GRADE I FATTY LIVER

BIL GRADE III RPO CHANGES

RIGHT RENAL CORTICAL CYST

MINIMAL ASCITES

Treatment Given(Enter only Generic Name)

TAB LASIX 40 MG PO BD

SALT AND FLUID RESTRICTION

TAB. NICARDIA 20 MG PO/BD

TAB. ARKAMINE 0.1 MG PO/TID

TAB SHELCAL 500 MG PO/OD

INJ. IRON SUCROSE 200 MG IN100ML NS/ IV/ONCE WEEKLY

INJ. EPO 4000 IU/SC ONCE WEEKLY

Advice at Discharge

TAB LASIX 40 MG PO TID

SALT AND FLUID RESTRICTION

TAB NICARDIA 20 MG PO/TID

TAB ARKAMINE 0.1 MG PO/ TID

TAB SHELCAL 500 MG PO/OD

INJ IRON SUCROSE 200 MG IN 100ML NS/ IV/ONCE WEEKLY

INJ. EPO 4000 IU/SC ONCE WEEKLY

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 18/02/23.

Ward: Nephrology 

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