CODE 62

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

202402439

UHID

20240125331

Pay Type

Credit AROGYA SREE)

Age/Gender 28 Years/Male

Address

Discharge Type: Relieved

Admission Date: 16/01/2024 03:31 PM

Name of Treating Faculty DR.SRI RAMULU (HOD)

Diagnosis

CHRONIC KIDNEY DISEASE(STAGE-V)

HYPERTENSION

Case History and Clinical Findings

PRESENTING COMPLAINTS:

Nausea since 3 weeks

Decreased appetite since 15 days

Decreased Urinary output since 10 days

Abdominal pain since 5 days

Breathlessness since 5 days

Anuria since 2 days

HOPI-A 26 year male who was apparently asymptomatic 3 weeks ago, then he had complaints of nausea, followed by vomiting insidious onset, gradually progreesive, 3-4 episodes per day for 4 days; History of low grade intermittent fever not associated with chills and rigors, for which the patient sought for consultation at local hospital and treated symptomatically. Even after medicatiuon, Nausea persisted and it was associated with decreasedn intake of food and water since last 15 days. Complaints of decreased urinary output since 10 days, grdually progressed to anuria since 2 days. History of 2-3 episodes of vomiting, Non bilious, non projectile, food as content with in 30 minutes of intake of food, associated with epigastric pain. History of breathlessness since 5 days, gradually progressed to breathlessness at rest, orthopnea present, No PND/ Chest pain/ palpitations/syncopal attacks/ burning micturition/cough/cold.

PAST HISTORY:

Childhood epilepsy (GTCS) on TAB. OXCARBAMAZAPINE Intellectual disability since the age of 7 years.

NO COMORBIDITIES.

BIRTH HISTORY:

Bom to non consanguineous mamage

1st born child

Full term, LSCS done due to gestation hypertension

Prenatal checkups showed intrauterine growth reduction

Birth weight 1 kg

Poor cry after birth, Poor sucking

Kept in ICU, Not breastfeed

During development after birth, delayed milestones, Patient started walking after the 2nd child started walking,

He was diagnosed with Intellectual disability at the age of 7 yeas

GENERAL EXAMINATION-

THE PATIENT IS CONSCIOUS, COHERENT COOPERATIVE

MODERATELY BUILT AND NOURISHED

SIGNS OF PALLOR PRESENT

NO ICTERUS CYANOSIS, CLUBBING, EDEMA

VITALS

TEMP: 97.2 F

PR: 92 BPM

RR: 21 CPM

BP: 170/110 MM HG

SPO2: 91% ON 6 LIT 02

GRBS: 171 MG/DL

CVS: S1, S2 HEARS, NO MURMURS

RS: BAE+, NVBS

TRACHEA CENTRAL

NO DYSPNOEA AND WHEEZE

B/L DIFFUSE CREPTS PRESENT

ABDOMEN: SOFT,NON-TENDER, NO ORGANOMEGALY

LIVER AND SPLEEN NOT PALPABLE

BOWEL SOUNDS HEARD

CNS PATIENT IS MENTALLY CHALLENGED.

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT

SPEECH: NORMAL

NECK STIFFNESS ABSENT

KERNINGS SIGN ABSENT

CRANIAL NERVES:

MOTOR SYSTEM:

SENSORY SYSTEM

GCS:

TONE

UL IN BOTH

LL: IN BOTH

POWER

UL BOTH

LL: BOTH

REFLEXES RT LT

B++

T++

S++

K++

A++

COURSE IN THE HOSPITAL

A 28 year male presented to OP with above mentioned complaints. Upon admission necessary investigations were done, Patient was taken up for dialysis after placing the Right IJV central line, he was taken up for hemodialysis on 17th 12 am and 9 pm which were uneventful, Patients room air saturations were 84% and chest x ray was done which showed right and left lower lobe basal consolidations. Patient was kept on Nasal prongs and intermittent CPAP as the patient attendes denied for elective intubation. In suspicion of Pheochromocytoma CECT was done which showed normal study with bilated basal lobe consolidatory changes likely Infective etiology. He was taken up for another 2 sessions of hensodialysis with 1 unit of PRBC transfusion, both the sessions were uneventful.

Investigation

BLOOD UREA 16-01-2024 03:56 PM 219 mg/dl

SERUM CREATININE 16-01-2024 03:56:PM 11.0 mg/dl

SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 16-01-2024 03:56 PM

SODIUM 132 mEq/L

POTASSIUM 3.1 mEq/L

CHLORIDE 92 mEq/L

CALCIUM IONIZED 1.08 mmol/L

HBsAg-RAPID 16-01-2024 07:31:PM Negative

Anti HCV Antibodies - RAPID 16-01-2024 07:31:PM Non Reactive

LIVER FUNCTION TEST (LFT) 16-01-2024 07:31:PM

Total Bilurubin 0.90 mg/dl

Direct Bilurubin 0.16 mg/dl

SGOT(AST) 33 IU/L

SGPT(ALT) 25 IU/L

ALKALINE PHOSPHATE 177 IU/L

TOTAL PROTEINS 4.9 gm/dl

ALBUMIN 2.9 gm/dl

A/G RATIO 1.44

COMPLETE URINE EXAMINATION (CUE) 17-01-2024 01:46:AM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN

SUGAR NI

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 4-5

EPITHELIAL CELLS 2-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

RFT 17-01-2024 05:25:AM

UREA 132 mg/dl

CREATININE 6.5 mg/dl

URIC ACID 8.3 mg/dl

CALCIUM 9.6 mg/dl

PHOSPHOROUS 5.0 mg/dISODIUM 135 mEq/L

POTASSIUM 3.1 mEq/L

CHLORIDE 99 mEq/L

SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 17-01-2024 09:52 PM

SODIUM 133 mEq/L

POTASSIUM 3.0 mEq/L

CHLORIDE 98 mEq/L

CALCIUM IONIZED 1.14 mmol/L

RFT 17-01-2024 10:28:PM

UREA 102 mg/dl

CREATININE 4.7 mg/dl

URIC ACID 5.1 mg/dl

CALCIUM 10.0 mg/dl

PHOSPHOROUS 4.2 mg/di

SODIUM 136 mEq/L

POTASSIUM 3.6 mEq/L

CHLORIDE 102 mEq/L

RFT 18-01-2024 11:38:PM

UREA 67 mg/dl

CREATININE 3.7 mg/dl

URIC ACID 3.9 mg/dl

CALCIUM 9.9 mg/dl

PHOSPHOROUS 3.4 mg/dl

SODIUM 135 mEq/L

POTASSIUM 4,4 mEq/L

CHLORIDE 99 mEq/L

HEMOGRAM: (16/1/24)

HB: 7.8 GM/DL

TLC: 20,700

PLATELETS: 1.84

HEMOGRAM: (17/1/24)

HB: 7.4 GM/DL

TLC: 17,200

PLATELETS: 1.93

BGT: O +VE

SERUM IRON: 62 UG/DL

SEROLOGY: NEGATIVE

2D ECHO:(16/1/24)

EF; 60%

MODERATE TR+ WITH PAH; MILD PR+, NO RWMA. NO AS/MS, SEVERE CONCENTRIC LVH + GOOD LV SYSTOLIC FUNCTION.

DILATD RA AND RV

NO DIASTOLIC DYSFUNCTION. NO PE.

USG ABDOMEN (16/1/24):

B/L GRADE III RPD CHANGES

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION <1.5 LIT/DAY

SALT RESTRICITON <2 G/DAY

TAB. TELMA 80MG PO/OD

TAB. LASIX 80 MG PO/BD

TAB LEVIPIL 500 MG PO/OD

TAB SHELCAL-CT PO/OD

TAB. OROFER-XT PO/OD

TAB NICARDIA 20 MG PO/TID

TAB, MET XL 25 MG PO/OD

Advice at Discharge

FLUID RESTRICTION <1.5 LIT/DAY

SALT RESTRICITON <2 GIDAY

TAB, TELMA 80MG PO/OD

TAB LASIX 80 MG PO/BD

TAB. LEVIPIL 500 MG PO/OD

TAB. SHELCAL-CT PO/OD

TAB. OROFER-XT PO/OD

TAB. NICARDIA 20 MG PO ITID

TAB. MET XL 25 MG PO/OD

Follow Up

REVIEW TO NEPHROLOGY AFTER 10 DAYS

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: 22/1/24

Ward ICU

Unit: NEPHROLOGY