CODE AO


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 : 202347391

Pay Type

Credit (AROGYA SREE)

48 Years/Male

Address

Discharge Type: Relieved

Admission Date: 21/10/2023 11:04 AM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH

C/O DECREASED OUTPUT AND BIL LEG SWELLING SINCE 1 MONTH.

C/O SOB SINCE 2 MONTHS.

PATIENT WAS APPRARENTLY ASYMPTOMATIC 2 YEARS BACK THEN HE DEVELOPED B/L PEDAL EDEMA, PITTING TYPE, ASSOCIATED WITH DECREASED U/O AND SOB GRADE 2.

K/C/O HTN, DM2.

N/KICIO TB, ASTHAMA, EPILEPSY, CVA

2D ECHO

MILD TR WITH PAH

TRIVIAL AR, TRIVIAL MR

NO AS/MS

NO PE/LV CLOT

MILD LVH, EF 56%

DILATED LA, DILATED LV

GOOD LV FUNCTION

NO DIASTOLIC DYSFUNCTION

Investigation

COMPLETE URINE EXAMINATION (CUE) 20-10-2023 02:54:PM COLOUR
Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

+++

SUGAR

++

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

34

EPITHELIAL CELLS

2-3

RED BLOOD CELLS

5-6

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

LIVER FUNCTION TEST (LFT) 20-10-2023 02:54:PM Total Bilurubin

0.54 mg/dl

Direct Bilurubin

0.20 mg/dl

SGOT(AST)

12 IU/L

SGPT(ALT)

08 IU/L

ALKALINE PHOSPHATE

293 IU/L

TOTAL PROTEINS

6.1 gmidi

ALBUMIN

3.61 gm/di

A/G RATIO

1.45

RFT 20-10-2023 02:54:PM UREA

37 mg/dl

CREATININE

4.6 mg/dl

URIC ACID

3.1 mgidi

CALCIUM

10.0 mg/dl

PHOSPHOROUS

2.3 mg/dl

SODIUM

137 mEq/L

POTASSIUM

3.9 mEq/L

CHLORIDE

98 MEQL

Treatment Given (Enter only Generic Name)

SALT RESTRICTION <2GM/DAY

FLUID RESTRICTION 1.5 LTR/DAY

TAB OROFER XT PO OD

TAB. TELMA 40 MG PO/OD

TAB LASIX 40 MG PO/BD

TAB. NICARDIA 20 MG PO/TID

INJ, IRON SUCROSE 100 MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE WEEKLY

Advice at Discharge

SALT RESTRICTION-2GM/DAY

FLUID RESTRICTION 1.5 LTR/DAY

TAB. OROFER XT PO OD

TAB. TELMA 40 MG PO/OD

TAB LASIX 40 MG PO/BD

TAB. NICARDIA 20 MG PO/TID

INJ. IRON SUCROSE 100 MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE WEEKLY

Follow Up

REVIEW 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: 05682279999 For Treatment Enquiries Patient/Altendent 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 PGINTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date:22/11/2023

Ward: NEPHROLOGY

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