CODE JM


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

202335894

UHIO 20230816041

Pay Type

Credit AROGYA SREE)

Age/Gender: 42 Years/Male

Address

Discharge Type: Ralleved

Admission Date: 12/08/2023 12:10 PM

Name of Treating Faculty DR.SRIRAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 4 MONTHS AND DECREASED APPETIE SINCE 15 DAYS

HOPI-PT. WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK THEN HE DEVELOPED PEDAL EDEMA, PITTING TYPE BELOW KNEE, DECREASED APPETITE, SOB +GRADE 2 WITH DECREASED URINE OUTPUT 15 DAYS BACK THEN HE DEVELOPED DECRESED APPETITE H/O SOB GRADE 2. H/O DECREASED URINEOUTPUT

NO H/O HEMATURIA, FEVER. COUGH

PAST H/O-PT. IS K/C/O HTN SINCE YEARS AND ON IRREGULAR MEDICATION NO HIO DM ASTHAMA, EPILEPSY TB, CVD

GENERAL EXAMINATION:

THE PATIENT IS CONSCIOUS, COHERENT, COOPERTIVE

MODERATELY BUITL AND NOURISHED

OEDEMA OF FEET PRESENT

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS

TEMP AFEBRILE

PR: 89 BPM

RR: 20 CPM

BP: 110/70 MM HG

SPO2: 98% RA

GRBS. 92 MG/DL

CVS: S1,S2 HEARD, NO MURMURS

RS: NVBS

PA: SOFT AND NON TENDER

CNS: NFND

Investigation

CBP

HB: 7.6 GM/DL.

TC: 1700 CELLS CUMM

NLEM: 86/08/02/04/00

PL: 2.24 LAKHS CUMM

RFT

UR: 129 MG/DL

CR: 5.9 MG/DL

UA: 9.6 MG/DL

CA+2: 9.6 MMOL/L

P: 3.4 MG/DL

NA+:138 MEQL

K+: 4.4 MEQL

CL-: 101 MEQL

HIV: NEGATIVE

HBSAG: NEGATIVE

HCV: NEGATIVE

RBS-96MG/DL

SERUM IRON-65MICRO GRAM/DL

BG RH TYPING-O POSITIVE

ULTRASOUND IMPRESION-

B/L GRADE 3 RPD CHANGES

2D ECHO-TRIVIAL AR TRIVIAL TR WITH PAH

NO RWMA

MILD CONCENTRIC LVH

EF 64%,GOOD LV FUNTION

NO DIASTOLIC DYSFUNTION.NO LV CLOT/PE

Treatment Given(Enter only Generic Name)

1.FLUID RESTRICTION <1L/DAY

2. SALT RESTRICTION <2G/DAY

3.T.TELMA 40MG PO/OD

4. T.LASEX 80 MG PO/TID

5.T. OROFER PO/OD

6.T SHELCAL PO/OD

7.CAP BIO D3 PO/ONCE A WEEK

B.T.NICARDIA 20MG PO/TID

9.T. MET XL 25 MG PO/OD

10. INJ. IRON SUCROSE 100 MG IVI ONCE IN 2 WEEKS

11. INJ. EPO 4000 IU SC/ONCE IN 2 WEEKS

Advice at Discharge

1.FLUID RESTRICTION <1L/DAY

2. SALT RESTRICTION <2G/DAY

3.T.TELMA 40MG PO/OD

4.T. LASIX 80 MG PO/TID

5.T. OROFER PO/OD

6.T SHELCAL PO/DD

7.CAP BIO D3 PO/ONCE A WEEK

8.T NICARDIA 20MG PO/TID

9.T. MET XL 25 MG PO/OD

10. INJ. IRON SUCROSE 100 MG IV/ ONCE IN 2 WEEKS

11 INJ. EPO 4000 IU SC/ONCE IN 2 WEEKS

When to Obtain Urgent Caro

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:3-10-23

Ward NEPHROLOGY WARD

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