CODE 8I


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

202242592

Pay Type

Credit AROGYA SREE)

Age/Gender :49 Years/Male

Address

Discharge Type: Relieved

Admission Date: 11/10/2022 01:25 PM

Name of Treating Faculty

DR. SRI RAMULU PROF

Diagnosis

CKD ON MHD

Case History and Clinical Findings

DECREASED URINE OUTPUT SINCE 10 DAYS.

SHORTNESS OF BREATH

PEDAL EDEMA

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK, THEN HE DEVELOPED DECREASED URINEOUTPUT SINCE THEN ASSOCIATED WITH PEDAL EDEMA

CKD ON MHD SINCE 3 YEARS

K/C/OHYPERTENSION SINCE 8 YEARS, DM SINCE 10 YEARS

NOT AK/C/O DM, THYROID, EPILEPSY.

ON EXAMINATION

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

BP-130/90

PR-88

RR16CPM

TEMPERATURE-AFEBRILE.

CVS-S1S2+

RS-BAE+

P/A-SOFT NONTENDER

CNS-NFLD

Investigation

CBP

HB 10.1

TC 6900

PLT1.60

SMEAR NCNC

RFT

UR 53

CR 5

10.1

CA+2

P2.9

HIV HBSAG HCV NEGATIVE

2D ECH:

MILD CONCENTRIC LVH;

MILD TR, MILD MR AND AR

LV DILATED

EF 64%; GOOD LV FUNCTION

Treatment Given(Enter only Generic Name)

1. SALTRESTRICTION-2.4 G/DAY 2.FLUID RESTRICTION 1 L/DAY3.TAB LASIX 60MG PO/BD4.TAB NICARDIA 20MG PO/TID5.TAB TELMA 80MG PO/OD.6.T SHELCAL 500MG PO/OD7.TAB OROFER ΧΤΡΟ/OD8.TAB BIO D3 WEEKLY ONCE 9.TAB MET XL 25 MG PO/OD 10. TAB. ARKAMINE 0.1 MG PO/TID

Advice at Discharge

1. SALTRESTRICTION-2.4 G/DAY 2.FLUID RESTRICTION 1 L/DAY3.TAB LASIX 60MG PO/BD4.TAB NICARDIA 20MG PO/TIDS.TAB TELMA 80MG PO/OD 6.T SHELCAL 500MG PO/OD7.TAB OROFER ΧΤΡO/OD8 TAB BIO D3 WEEKLY ONCE 9.TAB MET XL 25 MG PO/OD10.

TAB. ARKAMINE 0.1 MG POITID

Follow Up

REVIEW TO NEPHROLOGY 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 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: 14/11/22

Ward: CKD WARD

Unit:NEPHROLOGY

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