CODE L2


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 202325400

LHID 20230011575

Pay Type

Credit AROGYA SREE)

Age/Gender 54 Years/Male

Address

Discharge Type: Relieved

Admission Date: 10/06/2023 11:45 AM

Name of Treating Faculty

DR KRISHNA CHAITANYA

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CIO BIL PEDAL EDEMA SINCE TWEEK ACIO DECREASED URINE OUTPUT SINCE WEEK HOPI

PATIENT WAS APPARENTLY ASYMPTOMATIC ZYRSBACK THEN HEDEVELOPED PAIN

ABDOMEN FOR WHICH HE WENT TO HOSPITAL AFOUND TO HAVEHIGH BLOOD PRESSURE HE ALSO HAD BIL PEDAL EDEMA, PITTING TYPE, EXTENDING UP TO KNEE, INSIDIOUS

ONSET A/W DRCREASEDURINE OUT PUT

NO HIO COLD, COUGH, FEVER, BURNING MICTURITION

NO HIO CHEST PAIN, PALPITATIONS, SOB, ORTHOPNEA

PAST HISTORY

KACIO HTN SINCEZYEARS

NIKICIO DMASTHMA, TB, CAD,CVD

PERSONAL HISTORY

DIET MIXED

APPETITE-NORMAL

B&S-REGULAR

SLEEP ADEQUATE

GENERAL EXAMINATION

NO PALLOR, ICTERUS CLUBBING CYANOSIS LYMPHADENOPATHY EDEMA

TEMP AFEBRILE

PR-84BPM

RR-16CPM

BP-160/80 MMHG

CVS S1S2+

RS NVBS

PA-SOFT AND NON TENDER

CNS NFND

Investigation

USG ABDOMEN

GRADE III RPD CHANGES IN LEFT KIDNEY

GRADE III RPD CHANGES IN RIIGHT KIDNEY

BIL SUBCENTRIC SIMPLE RENIAL CORTICAL CYSTS

ECG-NORMAL SINUS RHYTHM

2D ECHO

MILD CONCENTRIC LVH

NO MRITRA, NO AS/MS

EF 62%

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION

Treatment Given (Enter only Generic Name)

TAB NICARDIA 20MG PO/TID

TAB OROFER XT PO/OD

TAB SHELCAL CT PO/OD

TAB.LASIX 80MG PO/BD

TAB. TELMA 40 PO/OD

TAB. METAPROLOL 25MG POOD

TAB. ARKAMINE 0.1MG PO/TID

INJ. IRON SUCROSE 100MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

Advice at Discharge

TAB NICARDIA 20MG POTIO

TAB OROFER XT POOD

TAB SHELCAL CT PO/OD

TAB.LASIX 80MG POBD

TAB, TELMA 40 PO/OD

TAB. METAPROLOL 25MG PO/OD

TAB. ARKAMINE 0.1MG PO/TID

INJ. IRON SUCROSE 100MG IV ONCE WEEKLY

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

Follow Up

REVIEWWITH 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 Enquines 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:3/8/23

Ward: UnitNEPHROLOGY

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