CODE FC


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

:202236047

UHID : 20220843260

Pay Type

Credit AROGYA SREE)

Age/Gender 55 Years/Male

Address

:

Discharge Type: Relieved

Admission Date: 28/08/2022 12:37 PM

Name of Treating Faculty DR.SRI RAMULU(PROFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

THIS IS A CASE OF 54 YEAR FEMALE WITH CHIEF COMPLAINTS OF

DECREASED URINE OUTPUT SINCE 1 MONTH

B/L PEDAL EDEMA PITTING TYPE WITH SOB (GRADE 2 TO 3)

HOPI: PATIENT WAS APPARENTLY ASSYMPTOMATIC 1 MONTH BACK THEN DEVELOPED

DECREASED URINE OUTPUT AND BIL PEDAL EDEMA AND SOB (GRADE 2 TO 3)

K/C/O HTN

KICIO CKD ON MHD (ON HEMODIALYSIS) SINCE 4 YRS.

PALLOR-NO,ICTERUS-NO, CYANOSIS-NO, CLUBBING-NO.LYMPHADENOPSTHY-NO, EDEMA-NO TEMPERATURE-98.5, PULSE RATE-99BPM, RR-18 CPM,GRBS-115

Investigation

CBP

HB 9.8 G/DL

TC 5000 CELLS/MM3

PLT 1.50

SMEAR NORMOCYTIC NORMOCHROMIC AΝΕΜΙΑ

RFT

UR 130 MG/DL

CR 9.6 MG/DL

CA+2 10

P 3.5

NA+ 141

K+3.7

CL-101

HIV NEGATIVE

HBSAG NEGATIVE

HCV NEGATIVE

USG: B/L GRADE 3 RPD CHANGES

2D ECHO

SEVERE LVH; EF 48%;

MILD MR, MILD AR, NO AS/MS; TRIVIAL TR WITH PAH

GRADE 1 DIASTOLIC DYSFUNCTION

MILD SYSTOLIC DYSFUNCTION

Treatment Given (Enter only Generic Name)

1) FLUID RESTRICTION <1 LIT/DAY

2)SALT RESTRICTION, 1.4 G/DAY

3)TAB NICARDIA 20MG PO/TID

4)TAB SHELCAL 500 MG PO/OD

5)TAB OROFER XT PO/OD

6)TAB LASIX 40 MG PO/TID

7)INJ ERYTHROPOIETIN 4000 IU (AFTER DIALYSIS)

8)TAB METAPROLOL 25 MG PO/OD

Advice at Discharge

1)FLUID RESTRICTION <1 LIT/DAY

2)SALT RESTRICTION, 1.4 GIDAY

3)TAB NICARDIA 20MG PO/TID

4) TAB SHELCAL 500 MG PO/OD

5)TAB OROFER XT PO/OD

6)TAB LASIX 40 MG PO/TID

7) ТАВ МЕТАPROLOL 25 MG PO/OD

8)INJ ERYTHROPOIETIN 4000 IU (AFTER DIALYSIS)

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 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:6/10/2022

Ward:NEPHROLOGY

Unit:NEPHROLOGY

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