CODE AV


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
202400513

UHID 20240105468

Pay Type

Credit (AROGYA SREE)

Age/Gender 60 Years/Male

Address

Discharge Type: Relieved

Admission Date: 03/01/2024 03:21 PM

Name of Treating Faculty

DR SRIRAMULU

Diagnosis

STAGE V CHRONIC KIDNEY DISEASE

POLYCYSTIC KIDNEY DISEASE

ANEMIA SECONDARY TO CKD

DM+,HTN+

Case History and Clinical Findings

C/O NAUSE AND DECREASED URINARY OUTPUT SINCE 4DAYS

HOPIEPT WAS APPARENTLY ASYMPTOMATIC ALRIGHT 7 DAYS BACK THEN DEVELOPED SOB

NO HIO INVOLUNTARY FALLS

K/C/O AD PCKD

DM SINCE 4 YEARS ON GLIDAZIDE 80MG

HTN SINCE 2 YEARS

GENERAL EXAMINATION:

PT IS C/C/C

BP-140/80

PR-86BPM

SPO-99

SYSTEMIC EXAMINATION

CVS-S1S2-

RS-NVBS

CNS-NFND

P/A-SOFT NON TENDER

Investigation

RFT 03-01-2024 03:57 PMUREA252 mg/dl42-12 mg/dICREATININE 11.0 mg/dl1.3-0.9 mg/dIURIC ACID9.6 mg/d17.2-3.5 mg/dICALCIUMB.1 mg/dl10.2-8.6 mg/dIPHOSPHOROUS7.4 mg/dl4.5-2.5 mg/dISODIUM140 mEq/L145-136 mEq/L.POTASSIUM4.2 mEq/L5.1-3.5 mEq/LCHLORIDE 104 mEq/L98-107 mEq/LHBsAg RAPID03-01-2024 03:57:PMNegative Anti HCV Antibodies - RAPID03-

01-2024 03:57 PMNon Reactive COMPLETE URINE EXAMINATION (CUE) 03-01-2024

03:57 PMCOLOURPale

yellowAPPEARANCE ClearREACTIONAcidicSP GRAVITY1010ALBUMIN+SUGARNIIBILE SALTSNIIBILE PIGMENTSNIIPUS CELLS2-4EPITHELIAL CELLS2-3RED BLOOD CELLSNIICRYSTALSNIICASTSNIIAMORPHOUS DEPOSITSAbsentOTHERSNIIRFT 04-01-2024

11:42 PMUREA258 mg/dl42-12 mg/dICREATININE 11.3 mg/dl1.3-0.9 mg/dIURIC ACID8.9 mg/d17.2- 3.5 mg/dICALCIUM7.0 mg/dl10.2-8.6 mg/dIPHOSPHOROUS8.9 mg/dl4.5-2.5 mg/dlSODIUM139 mEq/L.145-136 mEq/LPOTASSIUM3.9 mEq/L5.1-3.5 mEq/LCHLORIDE106 mEq/L.98-107

mEq/LLIVER FUNCTION TEST (LFT) 05-01-2024 10:58:AMTotal Bilurubin0.68 mg/dl1-0 mg/dlDirect Bilurubin0.19 mg/d10.2-0.0 mg/dISGOT(AST) 17 IU/L35-0 IU/LSGPT(ALT)21 IU/L45-0 IU/LALKALINE PHOSPHATE274 IU/L119-56 IU/LTOTAL PROTEINS7.0 gm/d18.3-6.4 gm/dIALBUMIN4.0 gm/dl4.6-
3.2 gm/dIA/G RATIO1.53

COMPLETE URINE EXAMINATION (CUE) 05-01-202403:27:PMCOLOURPale
yellowAPPEARANCE ClearREACTIONAcidicSP GRAVITY1.010ALBUMINNIISUGARNIBILE
SALTSNIBILE PIGMENTSNIIPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD
CELLSNIICRYSTALSNICASTSNIIAMORPHOUS DEPOSITSAbsentOTHERSNIIABG RFT 05-01-2024 11:30:PMUREA122 mg/dl42-12 mg/dICREATININE 6.7mg/dl1.3-0.9 mg/dIURIC ACID4.8 mg/d17.2-3.5 mg/dICALCIUM8.9 mg/dl10.2-8.6
mg/dIPHOSPHOROUSS.5 mg/dl4.5-2.5 mg/dISODIUM139 mEq/L145-136 mEq/LPOTASSIUM3.2 mEq/L5.1-3.5 mEq/LCHLORIDE 102 mEq/L98-107 mEq/L
USG

IMPRESSION:

MULTIPLE CYSTS IN B/L LIDNEYS ALMOST COMPLETELY REPLACING RENAL PARENCHYMA

B/L POLYCYSTIC KIDNEY

2D ECHO:

MODERATE AR, MILD MR, MILD TR WITH PAH

RWMA + ANT WAL HYPOKINESIA

EF 52%

FAIR LV FUNCTION

DIASTOLIC DYSFUNCTION+

MINIMAL PE+

DILATED LA

MILD DIALATED LV

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAY

SALT RESTRICTION<2G/DAY

TAB ARKAMINE 0.1 MG PO TID

TAB. ECOSPRIN GOLD PO/HS

TAB LASIX 80 MG PO BD

TAB SHELCAL CT PO OD

TAB OROFER XT PO OD

TAB TELMA 40 MG PO OD

TAB NICARDIA 20MG PO TID

INJ IRON SUCROSE 100MG IV BD

INJ EPO 1000 IV SC STAT

Advice at Discharge

FLUID RESTRICTION 1.5L/DAY

SALT RESTRICTION-2G/DAY

TAB ARKAMINE 0.1 MG PO TID

TAB. ECOSPRIN GOLD PO/HS

TAB LASIX 50 MG PO BD

TAB SHELCAL CT PO OD

TAB OROFER XT PO OD

TAB TELMA 40 MG PO 00

TAB NICARDIA 20MG PO TID

INJ IRON SUCROSE 100MG IV BD

INJ EPO 1000 IV SC STAT

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: 12/1/2024

CKD WARD

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