CODE DU


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
202315423

UHID 20230409230

Pay Type

Credit AROGYA SREE)

Age/Gender 49 Years/Male

Address

Discharge Type: Relieved

Admission Date: 07/04/2023 10:19 AM

Name of Treating Faculty

DR SRI RAMULU HOD

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH C/O DECREASED URINE OUT PUT SINCE4MONTHS AND C/O BILATERAL PEDAL EDEMA SINCE 4MONTHS

HOPI

PATIENT WASAPPARENTLY ASYMPTOMATIC 4MONTHS BACK THEN HE DEVELOPED DECREASED URINE OUT PUT AND ALSO BILATERAL PEDAL EDEMA(PITTING TYPE, TILL KNEE) A/W SOB, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE GRADE II MMRC, MORE DURING NIGHT TIME

NO HIO BURNING MICTURITION FRITHY URINE, HEMATURIA.

NO HIO CHEST PAIN, PALPITATIONS, SYNCOPAL ATTACKS AND PND, ORTHOPNEA

NO H/O COLD.COUGH AND FEVER

PAST HISTORY:

K/C/O HTN SINCE 5 YRS ON TAB METXL 50MG

K/C/O DM 2 SINCE 3 YRS ON INSULIN

N/K/KC/O ASTHΜΑ, TB, EPILEPSY, CVD, CAD

PERSONAL HISTORY

DIET-MIXED

APPETITE-NORMAL

SLEEP ADEQUATE

BOWEL REGULAR

BLADDER DECREASED URINE OUT PUT

FAMILY HISTORY-INSIGNIFICANT

GENERAL EXAMINATION NO SIGNSOF PALLOR ICTERUS CYNOSIS, CLUBBING LYMPHEDENOPATHY,

B/L PEDAL EDEMA+

VITALS;

TEMP, AFEBRILE

PR:988PM

RR:20CPM

BP: 150/80MMHG

GRBS: 124MG/DL

SPO2:93 AT RA

SYSTEMICEXAMINATIOEN;

RS BAE+ NVBS HEARD

CVS, S1 S2+ NO MURMURS

P/A;SHAPE OF THE ABDOMEN OBESE, UMBILICUS CENTRE, INVERTED.

SOFT AND NON TENDER NO ORGANOMEGALY

CNS NFND.HMF+

Investigation

ECG-NORMAL

USG ABDOMEN

IMPRESSION BILATERAL GRADEIII RPD CHANGES

2D ECHO

DILATED RA, RV, LA AND LV

CONCENTRIC LVH

RWMA, ANTERIOR WALL HYPOKINESIA

MINIMAL PE

MILD MRAR, TR WITH PAH

MILD LV DYSFUNCTION

EF 49%

GRADE I DIASTOLIC DYSFUNCTION

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1.5 LIT/DAY

SALT RESTRICTION <2.5GM/DAY

TAB. LASIX 8OMG PO/BD

TAR. NICARDIA 20MG PO/TID

TAB. SHECAL CT 500MG PO/OD

TAB TELMA 80 MG PO/OD

TAB. MET XL 25 MG PO/OD

TAB ARKAMINE 0.1 MG PO/TID

INJ IRON SUCROSE 100MG IV ONE IN 2 WEEKS

INJ. EPO 4000 IU SC/ONCE IN 2 WEEKS

Advice at Discharge

FLUID RESTRICTION <1.5 LIT/DAY

SALT RESTRICTION <2.5GM/DAY

TAB. LASIX 80MG PO/BD

TAB NICARDIA 20MG PO/TID

TAB. SHECAL CT 500MG PO/OD

TAB TELMA 80 MG PO/OD

TAB. MET XL 25 MG PO/OD

TAB, ARKAMINE 0.1 MG PO/TID

INJ. IRON SUCROSE 100MG IV ONE IN 2 WEEKS

INJ. EPO 4000 IU SC/ONCE IN 2 WEEKS

Follow Up

REVIEW WITH 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



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