CODE BY


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 202246131

UHID 20221107100

Pay Type

Credit(AROGYA SREE)

Age/Gender: 66 Years/Male

Address

Discharge Type: Relieved

Admission Date: 04/11/2022 08:08 PM

Name of Treating Faculty

DR SRIRAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O B/L PEDAL EDEMA SINCE 1 WEEK

HOPI: THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK, THEN DEVELOPEDB/L PEDAL EDEMA PITTING TYPE AND ALSO DEVELOPED SOB AND DECREASED URINEOUT

PUT 1 WEEK BACK

PAST HISTORY:

K/C/O DM,HTN

GENERAL EXAMINATION;

PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE

VITALS:

TEMPERATURE: AFEBRILE

BP: 150/70 MMHG

HR: 98 BPM

SPO2: 96% ON RA

GRBS: 110 MG/DL

CVS: S1,S2+

RS: CLEAR, BAE +

CNS INTACT

P/A SOFT, NONTENDER

BS +

2D ECHO:

MILD CONCENTRIC LVH

NO RWMA

EF 63%

DILATED LA AND LV

NO PE, NO LV CLOT

TRIVIAL TR, MILD MR, MILD AR

GOOD SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

Investigation

CBP HB 8.8

TC 6500

PLT 1.67

SMEAR NORMOCYTIC NORMOCHROMIC

RFT

UR 56

CR 8.0

CA+29.5

P 2.5

NA+ 145

K+4.0

CL-105

HIV NEGATIVE

HBSAG NEGATIVE

HCV NEGATIVE

CUE: YELLOW IN COLOUR

ALBUMIN ++

SUGAR+

PUS CELSS 2-3

EPI CELLS 2-3

NO RBC

SR. Fe 83 mcg/dl

TB 0.76

DB 0.18

AST 23

ALT 17

ALP 155

TP 6.4

ALB 3.5

USG: B/L GRADE III RPD CHANGES

Treatment Given (Enter only Generic Name)

1 TAB LASIX 80 MG/BD

2 T OROFER XT /OD

4 T SHELCAL 500 MG/OD

5 CAP BIO D3 /OD

6 T NICARDIA 20MG/TID

7T MET XL 25 MG/OD

8 INJ. EPI 400 IU/ONCE IN 2 WEEK

9 INJ IRON SUCROSE 100MG/ONCE IN 2 WEEKS

Advice at Discharge

1 TAB LASIX 80 MG/BD

2 TOROFER XT /OD

4T SHELCAL 500 MG/OD

5 CAP BIO D3/OD

6 T NICARDIA 20MG/TID

7 T MET XL 25 MG/OD

8 INJ. EPI 400 IU/ONCE IN 2 WEEKS

9 INJ IRON SUCROSE 100MG/ONCE IN 2 WEEKS

Follow Up

VISIT FOR DIALYSIS THRICE WEEKLY

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: 21/12/22

Ward: NEPHROLOGY

Comments

Post a Comment

Popular posts from this blog

Meta AI Driven Thematic Analysis NKP in 50 patients of Cardiovascular disease in ESRD on Dialysis

  Please thematically analyse the case report content below by separately addressing the four points below: Coding:  identify initial codes and labels to capture the key concepts and ideas. Categorization: group the codes into categories and subcategories to organize the data. Theme identification: identify the emerging themes and patterns in the data. Theme representation:  present the themes as learning points, highlighting the key findings and insights related to heart failure outcomes in a patient of renal failure  Dr Kranthi's patient of  40 MALE HYPERTENSIVE CHRONIC KIDNEY DISEASE ON HEMODIALYSIS WITH HFpEF July 01, 2024 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 Age Gender : 40 Years/Male Address Checharge Type: Relieved Ad...
Read more

41 M with Breathlessness ( CKD )

PRESENTING COMPLAINTS  A 41 year male clinically presented to nephrology opd with complaints of :  breathlessness of since a month Pedal edema since a month Anuria since a day. HOPI : A 41 year male clinically presented with complaints of breathlessness of grade III MMRC, insidious onset, gradually progressive,  not associated with seasonal and diurnal variation, not associated with orthopnea, postural nocturnal dyspnea and chest pain. History of grade II pedal edema since a month insidious onset and gradually progressive,  pitting type, not associated with local rise in temperature, and skin changes. History of anuria since a day. PAST ILLNESS :  History of bilateral knee Joint pains at the age of 8 years, patient sought for donsultation and started on NSAID, which he used for a year.  History of bilateral lowerlimb weakness for which he sought for consultation and was diagnosed with hypokalemia paralysis, that relieved after K+ correction.  He had co...
Read more

50 year female with loin pain

Image
This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs. PRESENTING COMPLAINTS: C/O :-  Left loin pain,  Diffuse abdominal pain,  Fever since 4 AM on 22/07/2022.  C onstipation since 3 days. HOPI:   A 55 year female presented to the casuality with c/o left loin pain radiating to the back and diffuse squeezing type of abdominal pain since 4 AM on 22/07/2022; Low grade intermittent fever associated with chills, relieved on taking medication. 2 episodes of vomiting, food as content, non bilious, non projectile at 6AM. History of Constipation since 3 days. Now admitted for further evaluation and management. PAST ILLNESS: In 2010 she had an episo...
Read more