CODE 8P


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

202348163

UHID 20231038752

Pay Type

Credit (AROGYA SREE)

Age/Gender: 67 Years/Female

Address

Discharge Type: Relieved

Admission Date: 27/10/2023 12:21 PM

Name of Treating Faculty

DR.SRIRAMULU

Diagnosis

CKD STAGE V

Case History and Clinical Findings

CIO PEDAL EDEMA SINCE 30 DAYS

CIO FACIAL PUFFINESS SINCE 15 DAYS

HOPI-PT WAS APPARANTLY ASSYMPTOMATIC 30 DAYS BACK THEN SHE DEVELOPED

PEDAL EDEMA WHICH IS PITTING TYPE, EXTENDING UPTO KNEE JOINT

EXTERNAL SOB, PROGRESSEDFROM GRADE I TO GRADE III

N/H/O DECREASED URINE OUTPUT

PAST H/O-

K/C/O CKD SINCE 1 YEAR

K/C/O HTN SINCE 1 YEAR

N/H/O COUGH, VOMITING, LOOSE STOOLS, PAIN ABDOMEN

N/K/C/O/ DM, BRONCHAL ASTHMA, TB, EPILEPSY, CAD, CVA

PAST SURGICAL H/O- TUBECTOMY 40 YEARS BACK

PERSONAL HISTORY

DIET MIXED

APPETITE GOOD

SLEEP ADEQUATE

BOWEL REGULAR

ALCOHOL STOPPED 2 YEARS AGO (TEETOTALER

GENERAL EXAMINATION PATIENT IS CONSCIOUS COHERENT, COOPERATIVE

PALLOR-PRESENT

PEDAL EDEMA-GRDAE 2 TO 3

NO SIGNS OF CLUBBING, ICTERUS, CYANOSIS, LYMPHEDNOPATHY,

VITALS:

TEMP: 96.8 F

PR: 84 BPM

BP: 170/110 MMHG

GRBS: 148 MG/DL

SPO2:97%

RR: 28 CPM

SYSTEMIC EXAMINATION:

CVS S1, S2 HEARD, NO MURMURS

RS. BAE+, NVBSHEARD

PASOFT,NT, NO ORGANOMEGALY

Investigation

NameValueNameValueBLOOD UREA26-10-2023 12:24:PM175 mg/dISERUM CREATININE26-10- 2023 12:24:PM

10.2 MG/DL

COMPLETE URINE EXAMINATION (CUE) 26-10-2023 12:24 PM COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP GRAVITY

1.010

ALBUMIN

+++

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

3-4

EPITHELIAL CELLS

2-4

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

LIVER FUNCTION TEST (LFT) 26-10-2023 12:25:PM Total Bilurubin

0:62 mg/dl

Direct Bilurubin

0.19 mg/dl

SGOT(AST)

20 IU/L

SGPT(ALT)

18 IU/L

ALKALINE PHOSPHATE

239 IU/L

TOTAL PROTEINS

6.0 gm/dl

ALBUMIN

3.2 gm/dl

A/G RATIO

1.2

SERUM CHLORIDES26-10-2023 12.25 PM101 mmol/LSERUM ELECTROLYTES (Na, K, CI) AND

SERUM IONIZED CALCIUM 27-10-2023 11:47:PM SODIUM

130 mEq/L

POTASSIUM

4.9 mEq/L

USG ABDOMEN PELVIS-

B/L SIMPLE RENAL CORTICAL CYSTS

B/L GRADEII RPD

GRADE I FATTY LIVER

2 D ECHO-

MILD AR PRESENT

TRIVIAL TR PRESENT WITH PAH

NO RWMA, NO AS MS, SCLEROTIC AV

EF 68%, GOOD LV SYSTOLICFUNCTION

MILD CONCENTRIC LVH

GRADE I DIASTOLIC DYSFUNCTION

NO PE

Treatment Given (Enter only Generic Name)

INJ LASIX 40 MG PO/TID

INJ IRON SUCROSE 100 MG IN 100ML NS IV/OD

TAB NICARDIA 20 MG PO/TIOD

TAB TELMA 80 MG PO/OD

TAB OROFER XT PO/OD

TAB SHELCAL-LT 500 MG PO/BD

TAB VIT D3 60 K ONCE WEELY FOR 8 WEEKS

Advice at Discharge

INJ LASIX 40 MG PO/TID

INJ IRON SUCROSE 100 MG IN 100ML NS IV/ONCE IN 2 WEEKS

TAB NICARDIA 20 MG PO/TID

TAB TELMA 80 MG PO/OD

TAB OROFER XT PO/OD

TAB SHELCAL-LT 500 MG PO/BD

TAB VIT D3 60 K ONCE WEELY FOR 8 WEEKS

Follow Up

REVIEW AFTER 1 WEEK OR IN 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:04/11/2023

WARD-NEPHROLOGY


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