CODE AQ


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

PID 202243463

JUHID : 20221023236

Pay Type

Credit (AROGYA SREE)

Age/Gender: 66 Years/Male

Address

Discharge Type: Relieved

Admission Date: 17/10/2022 11:02 AM

Name of Treating Faculty

DR.SRI RAMULU

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O DECAREASED URINE OUTPUT SINCE 3 DAYS

SOB SINCE 3DAYS

PT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED C/O DECREASED URINE OUTPUT SINCE 3 DAYS ASSOCIATED WITH SOB SINCE 3 DAYS WHICH IS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE TO MMRC GRADE 4

NO CIO BURNING MICTURITION AND PEDAL EDEMA, FEVER

PERSONAL HISTORY: HTN, DM +

DIET MIXED

APPETITE:NORMAL

BOWEL HABITS REGULAR

DECREASED URINE OUTPUT

ADDICTIONS: NONE

FAMILY HISTORY INSIGNIFICANT

GENERAL EXAMINATION:

PT IS C/CIC

WELL ORIENTED TO TIME, PLACE AND PERSON

VITALS:

TEMP. 98

BP:140/80 MMHG

PR: 78 BPM

SPO2: 98%

SYSTEMIC EXAMINATION:

CVS: S1, S2 HEARD

RS: BAE+

CNS: NFND

PIA: SOFT, NT, BS+

Investigation

CBP

HB 10.4

TC 7400

PLT 1.50

SMEAR NONC

RFT

UR 79

CR 4.4

HIV NEGATIVE

HBSAG NEGATIVE

HCV NEGATIVE

USG

B/L GRADE 3 RPD CHANGES

2D ECHO

DILATED RA

DILATEDE LA

EF 56%, GOOD LV FUNCTON

GRADE I DIASTOLIC DYSFUNCTION

MODERATE AR, MILD TR, MILD MR. NO AS/MS

NO PE/ LV CLOT

Treatment Given(Enter only Generic Name)

1)SALT RESTRICTION LESS THAN 2.4 GM/DAY

2) FLUID RESTRICTION LESS THAN ILTRIDAY

3)TAB TELMA 80 PO/OD

4)TAB SHELCAL PO/BD

5)TAB OROFER XT PO/OD

6)TAB LASIX40 MG/PO/BD

7)INJ ERYTHROPOIETIN 4000 IU S/C AFTER EACH DIALYSIS

8)TAB BIOP3 WEEKLY ONCE

9)TAB NICARDIA 20 MG PO/TID

10)TAB ARKAMINE 0.1 MG PO/TID

11) INJ. IRON SUCROSE 100 MG ONCE WEEKLY

Advice at Discharge

1)SALT RESTRICTION LESS THAN 2.4 GM/DAY

2)FLUID RESTRICTION LESS THAN 1 LTR/DAY

3)TAB TELMA 80 PO/OD

4)TAB SHELCAL PO/BD

SITAS OROFER XT PO/OD

6)TAB LASIX40 MG/PO/BD

7)INJ ERYTHROPOIETIN 4000 IU S/C AFTER EACH DIALYSIS

8)TAS BIOP3 WEEKLY ONCE

9)TAB NICARDIA 20 MG PO/TID

10)TAB ARKAMINE 0.1 MG PO/TID

11) INJ. IRON SUCROSE 100 MG ONCE WEEKLY

Follow Up

REVIEW TO NEPHRO OP AFTER 1 WEEK

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/Attendent Declaration: The medicines prescribed and the advice regarding preventive aspects of care when and now to oblain 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:23-11-22

Ward: CKD WARD

Unit: NEPHROLOGY

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