CODE 5Q


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

202405977

UHID

20240206520

Pay Type

Credit(AROGYA SREE)

Age/Gender 52 Years/Male

Address

Discharge Type: Relieved

Admission Date: 06/02/2024 02:50 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CHRONIC RENAL FAILURE SECONDARY TO ADPKD

K/C/O HTN SINCE 10 YEARS

Case History and Clinical Findings

C/O LOWER LIMB SWELLING SINCE 2 MONTHS

SOB SINCE 20 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEAR AGO THEN DEVELOPED PEDAL EDEMA INSIDIOUS ONSET GRADUALLY PROGRESSIVE PITTINBG TYPE RELIEVED WITH MEDICATION SINCE 2 MONTHS NOT IMPROVED WITH MEDICATION

HIO BREATHLESSNESS SINCE 1 MONTH CLASS 3 NYHA ASSOCIATED WITH CHESTPAIN

H/O RT SIDE LOIN PAIN NON RADIATING

HIO ITCHING ALL OVER BODY

NO HIO PALPITATIONS

NO H/O DECREASED URINE OUTPUT, BURNING MICTURITION

NO HIO ORTHOPNEA, PND FEVER, COUGH, COLD

PAST HISTORY:

K/C/O HTN

N/K/C/O CAD, THYROID DISORDER, DM, TB ASTHMA, EPILEPSY

N/K/C/O/DM, HTN, CVA, THYROID TB, EPILEPSY

OFE

PT IS C/C/C

PR:86BPM

BP:140/70MHG

RR:21

SPO2:98% RA

CVS S1 S2 + NO MURMURS

RS:BAE+

FINE CREPTS PRESENT IN IAA, ISA

P/A:SOFT NON TENDER

CNS: NFND

Investigation

CBP HB TCN LEMB PLT SMEAR RFT UR CR UA CA+2 P NA+K+ CL-HIV HBSAG

HCVRBCNormocytic normochromicLight MicroscopyWBCnormal counts on smearlight MicroscopyPLATELETSAdequate in number and distributionLight MicroscopyHEMOPARASITESNO hemoparasites seenLight MicroscopyIMPRESSIONNormocytic normochromic Anemia

HBsAg-RAPID 06-02-2024 03:37 PM Negative

Anti HCV Antibodies - RAPID 06-02-2024 03:37 PM Non ReactiveABG 06-02-2024 05:23 PMPH

7.20PCO2 22.8PO2 133HCO3 8.7SLHCO3 11 1BEB-17.8BEect-17.8TCO2 19.002 Sat 97.002

Count 12.9

BLOOD UREA 08-02-2024 10:29:PM 98 mg/dISERUM CREATININE 08-02-2024 10:29 PM 4.9 mg/dl

SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 08-02-2024

10:29 PMSODIUM 141 mEq/LPOTASSIUM 4.1 mEq/LCHLORIDE 102 mEq/LCALCIUM IONIZED 0.97 mmol/LBLOOD UREA 12-02-2024 10:12 AM 98 mg/dl

SERUM CREATININE 12-02-2024 10:12 AM 3.2 mg/dISERUM ELECTROLYTES (Na, K, C I) AND

SERUM IONIZED CALCIUM 12-02-2024 10:12:AMSODIUM 145 mEq/LPOTASSIUM 2.8 mEq/LCHLORIDE 104 mEq/LCALCIUM IONIZED 1.11 mmol/L

2D ECHOMODERATE CONCENTRIC LVH, TRIVIAL MR AND AR, NO MS/AS

GOOD LV SYSTOLIC FUNCTION, GRADE I DIASTOLIC DYSFUNCTION, EF 68%

Treatment Given(Enter only Generic Name)

INJ IRON SUCROSE 100MG

INJ EPO 4000IU SC

TAB PAN 40 MG PO OD

TAB LASIX 80 MG PO BD

TAB NICARDIA 20 MG PO BD

TAB OROFER XT PO OD

TAB TELMA 80 MG OD

TAB SHELCAL PO OD

CAP BIO D3 PO/OD

FLUID RESTRICTION <1.5L/DAY

SALT RESTICTION <2GM/DAY

Advice at Discharge

INJ IRON SUCROSE 100MG

INJ EPO 4000IU SC

TAB PAN 40 MG PO OD

TAB LASIX 80 MG PO BD

TAB NICARDIA 20 MG PO BD

TAB OROFER XT PO OD

TAB TELMA 80 MG OD

TAB SHELCAL PO OD

CAP BIO D3 PO/OD

FLUID RESTRICTION <1.5L/DAY

SALT RESTICTION <2GM/DAY

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: 14/02/2024

Ward NEPHROLOGY

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