CODE 77


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

202254976

UHID

20221233406

Pay Type

Credit(AROGYA SREE)

Age/Gender 61 Years/Male

Address

Discharge Type: Relieved

Admission Date: 31/12/2022 04:36 PM

Name of Treating Faculty

DR SRIRAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O DECREASED URINE OUTPUT SINCE 3 MONTHS

PEDAL EDEMA SINCE 1 MONTH

LOIN PAIN WITH PRURITIS SINCE 1 MONTH

HOPI

PATIENT WASAPPARENTLY ASYMPTOMATIC 2YRS BACK THEN CIO LOIN PAIN SINCE 1MONTH WITH PRURITIS FEVER SUBSIDED, SOB SINCE 5DAYS AND SUBSIDED, NO BURNING MICTURITION, NO URGENCY, FREQUENCY

PAST ILLNESS:

K/C/O DM SINCE 5 YRS

HTN SINCE 2 YRS

GENERAL EXAMINATION.

PATIENT IS CONSCIOUS, COHERENT, AND COOPERATIVE

PALLOR PRESENT

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

OEDEMA OF FEET PRESENT

TEMP:99F

PR:110BPM

RR 16CPM

BP: 120/80MMHG

SPO2.99%

GRBS:138MG/DL

SYSTEMIC EXAMINATION:

CVS:S1S2 +

RS: BAE+, NVBS HEARD

CNS: NFND

PA: SOFT, NONTENDER

CBP

Investigation

HB 8.1 G/DL

TC-8,800CELLS/CUMM

PLT-2.34 LAKHS/CUMM

SMEAR-NCNC

RFT

UR-121MG/DL

CR-5.3MG/DL

CA+7.0 MEQ/L

P 4.0MEQ/L

NA+135MEQ/L

K+3.6 MEQ/L

CL-98MEQ/L

SEROLOGY-NEGATIVE

TB-0.61 MG/DL

DB-0.14MG/DL

AST-20IU/L

ALT-20IU/L

ALP-273IU/L

TP-7.8G/DL

ALBUMIN-3.5G/DL

SERUM IRON-70 MG/DL

CUE-ALBUMIN++++

SUGARS+++

USG

RT KIDNEY 7 X 3.9CMS, CMD LOST

LEFT KIDNEY -7.8 X 4 CMS CMD LOST

IMPRESSION-B/L GRADE III RPD CHANGES

2D ECHO

NO LVH

NO DILATED CHAMBERS

GOOD VENTRICULAR SYSTOLIC FUNCTION

GRADE I LV DIASTOLIC DYSFUNCTION

NO RWMA

NO PERCARDIAL EFFUSION

EF-64%

TRIVIAL AR, TR

Treatment Given (Enter only Generic Name)

TAB LASIX 80MG PO BD

TAB.MET-XL 25 MG PO BD

TAB.TELMA 80 M/OD

TAB SHELCAL CT 500MG PO OD

TAB NICARDIA 20MG PO QID

INJ.EPO 4000 U SIC WEEKLY ONCE

INJ.IRON SUCROSE 100MG IV WEEKLY ONCE

TAB ALKAMINE 0.1MG/TID

Advice at Discharge

TAB LASIX 80MG PO BD

TAB.MET-XL 25 MG PO BD

TAB TELMA 80 M/OD

TAB SHELCAL CT 500MG PO OD

TAB NICARDIA 20MG PO QID

INJ. EPO 4000 U S/C WEEKLY ONCE

INJ.IRON SUCROSE 100MG IV WEEKLY ONCE

TAB ALKAMINE 0.1MG/TID

Follow Up

REVIEW TO NEPHRO OPD 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 Enquines 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:2/2/23

Ward NEPHROLOGY

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