CODE HV


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.

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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

IPID 202349002

Pay Type

Credit(AROGYA SREE)

Age/Gender 40 Years/Female

Address

Discharge Type: Relieved

Admission Date: 01/11/2023 01:06 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 6MONTHS, SOB SINCE 3 DAYS

HOPI

PATIENT WAS APPARANTLY ASYMPTOMATIC 6 MONTHS BACK THEN SHE DEVELOPED PEDAL EDEMA WHICH WAS PITTING TYPE, EXTENDING UPTO KNEE JOINT SINCE 3 DAYS SHE DEVELOPED SHORTNESS OF BREATH WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE PROGRESSED FROM GRADE 2 TO GRADE 4 AGGREVATED ON EXERTION ORTHOPNEA NO PND NO SEASONAL VARIATION, NO DIURNAL VARIATION DECREASED URINE OUTPUT SINCE 3 MONTHS.NO H/O FEVER COUGH, VOMITINGS, LOOSE STOOLS, PAIN ABDOMEN GIDDINESS, CHESTPΑΙΝ

PALPITAIONS, EXCESSIVE SWEATING

K/C/O CKD ON MHD SINCE 6MONTHS

K/C/O HTN SINCE 4 YRS

N/K/C/O CVA, THYROID ASTHMA, EPILEPSY

OVE

PT IS CICIC

PR:78

BP-150/80 MMHG

RR: 17

SPO2:98% ON RA

CVS S1 S2 NO MURMURS

RS BAE+ NVBS

P/A SOFT NON TENDER

CNS NFND

Investigation

NameValueNameValueLIVER FUNCTION TEST (LFT) 31-10-2023 02:38:PMTotal Bilurubin0.51 mg/dlDirect Bilurubin0.16 mg/dISGOT(AST)18 IU/LSGPT(ALT) 13 IU/LALKALINE PHOSPHATE176 IU/LTOTAL PROTEINS4.9 gm/dIALBUMIN2.3 gm/dIA/G RATIO0.92RFT 31-10-2023

02:38:PMUREA139 mg/dICREATININE7.3 mg/dIURIC ACID4.9 mg/dICALCIUMB.5 mg/dIPHOSPHOROUSS.2 mg/dISODIUM136 mEq/LPOTASSIUM4.9 mEq/LCHLORIDE106

mEq/LAnti HCV Antibodies - RAPID31-10-2023 02:38:PMNon Reactive HBsAg-RAPID31-10-2023

02:38:PMNegative COMPLETE URINE EXAMINATION (CUE) 31-10-2023 02:38 PMCOLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP GRAVITY1.010ALBUMIN++SUGAR BILE SALTSNIBILE PIGMENTSNIIPUS CELLS2-4EPITHELIAL CELLS2-3RED BLOOD CELLSNICRYSTALSNIICASTSNILAMORPHOUS DEPOSITSAbsentOTHERSNII

2D ECHO

TRIVIAL TR WITH PAH, TRIVIAL AR, NO SCLEROTIC AV, MILD MR

NO AS/MS

EF 66%, GOOD LV FUNCTION

NO DIASTOLIC DYSFUNCTION

MILD CONCENTRIC LVH

MINIMAL PE, NO LV CLOT

Treatment Given (Enter only Generic Name)

1 TAB NICARDIA 20MG PO TID

2.TAB TELMA 80 MG PO OD

3.TAB ARKAMINE 0.1 MG PO TID

4 TAB SHELCAL PO OD

STAB OROFER PO OD

6. TAB ZOFER 4MG PO TID

7. TAB LASIX 80 MG PO BD

8.EPO 4000 IU SC BD

9.INJ IRON SUCROSE 100MG IN 100ML TWICE WEEKLY

Advice at Discharge

1 TAB NICARDIA 20MG PO TID

2. TAB TELMA 80 MG PO OD

3.TAB ARKAMINE 0.1 MG PO TID

4. TAB SHELCAL PO OD

5.TAB OROFER PO OD

6.TAB ZOFER 4MG PO TID

7. TAB. LASIX 80 MG PO BD

8.EPO 4000 IU SC BD

9.INJ IRON SUCROSE 100MG IN 100ML TWICE 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

Investigations

LIVER FUNCTION TEST (LFT)

31-10-2023 02:38:PM

RFT 31-10-2023 02:38:PM

Total Billurubin

0.51 mg/dl

UREA

139 mg/dl

Direct Blurubin

0.15 mg/di

CREATININE

7.3 mg/d

SGOT(AST)

18 IU/L

URIC ACID

4.9 mmol

SGPT(ALT)

13 IU/L

CALCIUM

8.5 mg/d

ALKALINE PHOSPHATASE

176 IU/L

PHOSPHOROUS

5.2 mg/d

TOTAL PROTEINS

4.9 gm/di

SODIUM

136 mmol/L.

ALBUMIN

2.3 gm/di

POTASSIUM

4.9 mmol/L.

A/G RATIO

0.92

CHLORIDE

106 mmol/L

Anti HCV Antibodies-

Non Reactive

HBBAg-RAPID 31-10-2025 02:38 PM

Negative

RAPID 31-10-2023 02:38 PM

COMPLETE URINE EXAMINATION (CUE) 31-10-2023 02:38:PM

COMPLETE BLOOD PICTURE (CBP) 02-12-2023 05:57 AM

COLOUR

Pale yellow

HAEMOGLOBIN

9.6 gm/dl

APPEARANCE

Clear

TOTAL COUNT

8000 cells/cumm

REACTION

Aclic

NEUTROPHILS

63%

SPGRAVITY

1010

LYMPHOCYTES

27%

ALBUMIN

+

EOSINOPHILS

04%

SUGAR

+

MONOCYTES

06%

BILE SALTS

NI

BASOPHILS

00%

BILE PIGMENTS

NI

PLATELET COUNT

2.12

PUS CELLS

2-4

SMEAR

Normocytic normochromic anemia

EPITHELIAL CELLS

2-3

RED BLOOD CELLS

NII

CRYSTALS

NI

CASTS

NII

AMORPHOUS DEPOSITS

Absent

OTHERS

NII

RFT 02-12-2023 05:57 AM

UREA

54 mg/d

CREATININE

3.5 mg

URIC ACID

2.0 mmoul

CALCIUM

10.0 mg/al

PHOSPHOROUS

2.2 mg/dl

SODIUM

135 mmol/

POTASSIUM

3.4 mmol/L

CHLORIDE

95 mmol/L

Discharge Date

Date:2/12/23

Ward CKD

Unit:NEPHROLOGY

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