CODE 8B


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

202405995

UHID 20240207407

Pay Type

Credit AROGYA SREE)

Age/Gender 75 Years/Male

Address

Discharge Type: Relieved

Admission Date: 06/02/2024 03:42 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O GENERALISED SWELLING SINCE 1 WEEK

HOPI

PATIENT WAS APPARENTLY ALRIGHT 1 WEEK BACK, THEN HE DEVELOPED GENERALISED SWELLING OF LOWER LIMBS UPPER LIMBS, ABDOMEN INSIDIOUS ONSET GRADUALLY PROGRESSIVE, PITTING TYPE

H/O DECREASED URINE OUTPUT SINCE 10 DAYS

H/O BREATHLESSNES CLASS III NYHA INSIDIOUS ONSET

HIO ITCHING ALL OVER BODY, COUGH-PRODUCTIVE (MUCOID NON BLOOD STAINED, NON FOUL SMELLING)

H/O BURNING MICTURATION

NO HIO CHEST PAIN, VOMITING, FEVER, LOOSE STOOLS, PALPITATIONS

PAST HISTORY

K/C/O CKD UNDERWENT 1 SESSIONSOF HEMODIALYSIS 5 YEARS BACK

KICIO HTN SINCE 5 YEAR

NOT K/C/O DM, EPILEPSY, THYROID DISORDERS,CVA, ASTHAMA

GENERAL EXAMINATION

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE

NO PALLOR, NO ICTERUS, NO CLUBBING, NO CYANOSIS, NO LYMPHADENOPATHY, OEDEMA IS PRESENT

TEMPERATURE-97.2F

PULSE RATE-84BPM

RR-19CPM

BP-140/100

SPO2-95%

SYSTEMIC EXAMINATION

CVS-S1 S2 HEARD NO MURMURS

RS-BAE+

PA-SOFT, NT

CNS NO FND

Investigation

NameValueNameValueBLOOD UREA05-02-2024 02:29:PM121 mg/dISERUM CREATININE05-02- 2024 02:29:PM8.6 mg/dISERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM

05-02-2024 02:29 PM SODIUM140 mEq/LPOTASSIUM3.8 mEq/LCHLORIDE 105 mEq/LCALCIUM IONIZED1.16 mmol/LHBsAg-RAPID06-02-2024 05:11:PMNegative Anti HCV Antibodies - RAPID06-

02-2024 05:11:PMNon Reactive ABG 06-02-2024 05:11 PM

PH7 29PC0227.0PO2125HCO312.9St.HCO314.9BEB-12 1BEect-12.3TC0227 702 Sat97.002 Count12.2BLOOD UREA08-02-2024 10:20 PM140 mg/dISERIUM CREATININE08-02-2024

10:20 PM6.9 mg/dISERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 08-02-

2024 10:20 PM SODIUM145 mEq/LPOTASSIUM3.5 mEq/LCHLORIDE 104 mEq/LCALCIUM

IONIZED 1.24 mmol/LBLOOD UREA12-02-2024 10:13:AM128 mg/dISERUM CREATININE12-02- 2024 10:13:AM5.4 mg/dISERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM

12-02-2024 10:13:AM SODIUM143 mEq/LPOTASSIUM3.7 mEq/LCHLORIDE105 mEq/LCALCIUM IONIZED1.22 mmol/L

USG

B/L GRADE II TO III RPD CHANGES

LEFT RENAL CORTICAL CYSTS

2D ECHO

EF: 63

MODERATE MR/AR/TR WITH PAH

NO RWMA NO AS/MS SCLEROTIC AV

DILATED RA AND RV

SEVERE CONCENTRIC LVH

GOOD LV SYSTOLIC FUNCTIONS

GRADE I DIASTOLIC DYSFUNCTION

MINIMAL PE, NO LV CLOT

Treatment Given(Enter only Generic Name)

1.TAB PAN 40 MG PO OD

2.TAB LASIX 80MG PO BD

3.TAB MET XL 25 MG PO OD

4.TAB OROFER XT PO OD

5.TAB SHELCAL PO OD

6.TAB. TELMA 80 MG PO/OD

7.TAB NICARDIA 20 MG PO TID

8.INJ EPO 4000IU SC

Advice at Discharge

1.TAB PAN 40 MG PO OD

2. TAB LASIX 80MG PO BD

3.TAB MET XL 25 MG PO OD

4. TAB OROFER XT PO OD

5.TAB SHELCAL PO OD

6.TAB. TELMA 60 MG PO/OD

7.TAB NICARDIA 20 MG PO TID

8. INJ EPO 4000IJ SC

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: 14/2/24

Ward DIALYSIS

Unit: NEPHROLOGY

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