CODE 49


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 :202248290

IHID

20221130616

Pay Type

Credit AROGYA SREE

Age Gender: 39 Years/Male

Address

Discharge Type: Rallaved

Admission Date: 18/11/2022 05:39 PM

Name of Treating Faculty

DR.SRI RAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PT CAME WITH C/O B/L PEDAL EDEMA, GENERALISED WEAKNESS PUFFINESS OF FACE SINCE 5 DAYS

PT WAS APPARENTLY NORMAL 3 YEARS BACK THEN HE DEVELOPED GENERALISED WEAKNESS FOR WHICH HE WENT TO HOSPITAL AND DIAGNOSED TO BE HAVING HYPERTENSION. HE WAS FINE FOR 2 YEARS AND THEN I YEAR AGO HE DEVELOPED B/L PEDAL EDEMA, SOB GOT TREATED IN LOCAL HOSPITAL, 9 MONTHS AGO HE DEVELOPED SIMILAR COMPLAINTS AND WAS DIAGNOSED WITH CKD

K/C/O HTN SINCE 3 YEARS, NOT A KIC/O DM, TB,EPILEPSY,CAD

3 PRBC TRANSFUSIONS DONE, AV FISTULA DONE

GENERAL EXAMINATION:

PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE

VITALS:

TEMPERATURE: AFEBRILE

BP: 130/90 MMHG

HR: 80 BPM

SPO2 98% ON RA

GRBS 110 MG/DL

CVS S1,S2+

RS: CLEAR, BAE+

CNS INTACT

PIA: SOFT, NONTENDER

BS+

Investigation

CBP

HB 6.9

TC 7700

PLT 1.84

SMEAR NCNC

RFT

UR 181

CR 9.5

HIV HBSAG HCV ARE NEGATIVE

USG; B/L GARDE 3 RPD CHANGES

2D ECHI:

MILD LVH; MODERATE TR WITH PAH, NO MSIAS

EF 58%; GOOD LV FUNCTION

DILATED LA AND LV

NO LV CLOT

Treatment Given (Enter only Generic Name)

T.LASIX 80MG PO/BD

T.NICARDIA RETARD 20MG PO/QID

T.MET XL 25MG PO/OD

INJ. IRON SUCROSE 100 MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE WEEKLY

TAB. SHELCAL CT PO/OD

TAB. MVT PO/OD

Advice at Discharge

T.LASIX 80MG PO/BD

T.NICARDIA RETARD 20MG PO/QID

T.MET XL 25MG PO/OD

INJ. IRON SUCROSE 100 MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE WEEKLY

TAB. SHELCAL CT PO/OD

TAB. MVT PO/OD

Follow Up

REGULAR HEMODIAYSIS

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: 12/12/22

Unit:NEPHROLOGY

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