CODE FM


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 202315825

UHID 20230413317

Pay Type

Credit (AROGYA SREE)

Age/Gender

42 Years/Female

Address

Discharge Type: Relleved

Admission Date: 10/04/2023 10:43 AM

Name of Treating Faculty

DR SRI RAMULU HOD

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH CIO DECREASED URINE OUT PUT SINCE 2WEEKS AND C/O DECREASED APPETITE SINCE 2WEEKS

HOPI:

PATIENT WASAPPARENTLY ASYMPTOMATIC 2WEEKS BACK THEN HE DEVELOPED DECREASED URINE OUT PUT AND ALSO DECREASED APPETITE

NO HIO BURNING MICTURITION FRITHY URINE HEMATURIA

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

NO HIO PEDAL EDEMA, FACIAL PUFFINESS

NO HIO PAIN ABDOMEN, NAUSEA AND VOMITINGS

NO HAO COLD, COUGH AND FEVER,

PAST HISTORY:

KICIO HTN SINCE SYRS ON TAB TELMA 40MG

PERSONAL HISTORY:

NIKIKC/O DM ASTHMA, TB, EPILEPSY, CVO, CAD

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, PEDAL EDEMA

VITALS:

TEMP; AFEBRILE

PR:82BPM

RR:18CPM

BP:130/80MMHG

GRBS: 104MG/DL

SPO2;98AT RA

SYSTEMICEXAMINATIOEN

RS BAE+ NVBS HEARD

CVS; S1 S2+, NO MURMURS

P/A SHAPE OFTHE ABDOMEN OBESE, UMBILICUS CENTRE, INVERTED, SOFT AND NON TENDER NO ORGANOMEGALY.

CNS NFND,HMF+

Investigation

USG ABDOMEN- IMPRESSION-BILATERAL GRADE III RPD CHANGES

2D ECHO

MILD TR+TRIVIAL AR+/MR+

NO RWMA, NO AS/MS, EF 61% GOOD LV SYSTOLIC FUNCTION

NO DIASTOLICDYSFUNCTION, NOPAH/PE

ECG-NORMAL

Treatment Given (Enter only Generic Name)

SALT RESTRICTION DIET 2GM/DAY

FLUID RESTRICTION 1.5 LIT/DAY

TAB. NICARDIA 20MG PO/TID

TAB. TELMA 40MG PO/OD

TAB. LASIX 80MG PO/BD

TAB SHELCAL 500MG PO/OD

INJ. IRON SUCROSE 100 MG IV ONCE IN 3 WEEKS

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

Advice at Discharge

SALT RESTRICTION DIET <2GM/DAY

FLUID RESTRICTION <1.5 LIT/DAY

TAB. NICARDIA 20MG PO/TID

TAB. TELMA 40MG PO/OD

TAB. LASIX 80MG PO/BD

TAB SHELCAL 500MG POIOD

INJ. IRON SUCROSE 100 MG IV ONCE IN 3 WEEKS

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

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 now 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:4/5/23

Ward: UnitNEPHROLOGY

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