CODE MO


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 :202336147

UHID 20230816342

Age/Gender

Pay Type

Credit (AROGYA SREE)

Address

51 Years/Male

Discharge Type: Relieved

Admission Date: 14/08/2023 02:03 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

K/C/O CKD ON HAEMODIALYSIS

C/O SWELLING OF FACE +

H/O SOB GRADE 2-3, SWELLING OF BOTH LEGS.

HOPI:

C/O DM SINCE 5 YEARS

SEVERE DYSPNEA UNDERGONE HAEMODIALYSIS OUTSIDE, RECENTLY 3 TIMES HAEMODIALYSIS AND AV FISTULA CONSTRUCTION

PAST HISTORY:

K/C/O DM SINCE 15 YEARS

K/C/O HTN SINCE 2 YEARS

GENERAL EXAMINATION:

PT IS C/C/C, WELL BUILT AND NOURISHED NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, BILATERAL PEDAL EDEMA

VITALS:

TEMP: AFEBRILE

PR: 86BPM

RR: 19CPM

BP: 130/80 MMHG

SYSTEMIC EXAMINATION:

CVS:S1 S2+, NO MURMURS

RS: BLAE+,NVBS

CNS: NFND

PIA: SOFT, NON TENDER

Investigation

CBP

HB-9.6

TC-7200

N-62

L-25

E-3

M-10

B-0

PLT-2.18

SMEAR-nonc

RFT

UR-209

CR-8.6

UA-11.1

CA+2-9.4

P-7.2

NA+-138

K+-3.8

CL-104

USG ABDOMEN-

GRADE 3 RPD CHANGES NOTEDIN BIL KIDNEYS

2D ECHO-

MILD AR, TRIVIAL TR/MR

NO RWMA, NOAS/MA SCLEROTIC AV

MILD CONCENTRIC LVH

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION, NO PAH/PE

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1L/DAY

SALT CONSUMPTION <2GM/DAY

TAB.TELMA 40MG PO/OD

TAB.LASIX 40MG PO/BD

TAB. METAPROLOL 25 MG PO/OD

TAB.OROFER XT PO/BD

TAB.SHELCAL PO/OD

CAP RIO D3 PO/ONCEA WEEK

INJ.ERYTHROPOIETIN 4000IU/SC/ONCE IN 2 WEEKS

INJ IRON SUCROSE 100 MG IV ALTERNATE DIALYSIS

Advice at Discharge

FLUID RESTRICTION <1L/DAY

SALT CONSUMPTION <2GM/DAY

TAB.TELMA 40MG PO/OD

TAB.LASIX 40MG PO/BD

TAB. METAPROLOL 25 MG PO/OD

TAB.OROFER XT PO/BD

TAB SHELCAL PO/OD

CAP RIO D3 PO/ONCEA WEEK

INJ.ERYTHROPOIETIN 4000IU/SC/ONCE IN 2 WEEKS

INJ IRON SUCROSE 100 MG IV ALTERNATE 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: 30/9/23

Ward:10 UnitNEPHROLOGY

Comments

Post a Comment

Popular posts from this blog

Meta AI Driven Thematic Analysis NKP in 50 patients of Cardiovascular disease in ESRD on Dialysis

  Please thematically analyse the case report content below by separately addressing the four points below: Coding:  identify initial codes and labels to capture the key concepts and ideas. Categorization: group the codes into categories and subcategories to organize the data. Theme identification: identify the emerging themes and patterns in the data. Theme representation:  present the themes as learning points, highlighting the key findings and insights related to heart failure outcomes in a patient of renal failure  Dr Kranthi's patient of  40 MALE HYPERTENSIVE CHRONIC KIDNEY DISEASE ON HEMODIALYSIS WITH HFpEF July 01, 2024 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 Age Gender : 40 Years/Male Address Checharge Type: Relieved Ad...
Read more

41 M with Breathlessness ( CKD )

PRESENTING COMPLAINTS  A 41 year male clinically presented to nephrology opd with complaints of :  breathlessness of since a month Pedal edema since a month Anuria since a day. HOPI : A 41 year male clinically presented with complaints of breathlessness of grade III MMRC, insidious onset, gradually progressive,  not associated with seasonal and diurnal variation, not associated with orthopnea, postural nocturnal dyspnea and chest pain. History of grade II pedal edema since a month insidious onset and gradually progressive,  pitting type, not associated with local rise in temperature, and skin changes. History of anuria since a day. PAST ILLNESS :  History of bilateral knee Joint pains at the age of 8 years, patient sought for donsultation and started on NSAID, which he used for a year.  History of bilateral lowerlimb weakness for which he sought for consultation and was diagnosed with hypokalemia paralysis, that relieved after K+ correction.  He had co...
Read more

50 year female with loin pain

Image
This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs. PRESENTING COMPLAINTS: C/O :-  Left loin pain,  Diffuse abdominal pain,  Fever since 4 AM on 22/07/2022.  C onstipation since 3 days. HOPI:   A 55 year female presented to the casuality with c/o left loin pain radiating to the back and diffuse squeezing type of abdominal pain since 4 AM on 22/07/2022; Low grade intermittent fever associated with chills, relieved on taking medication. 2 episodes of vomiting, food as content, non bilious, non projectile at 6AM. History of Constipation since 3 days. Now admitted for further evaluation and management. PAST ILLNESS: In 2010 she had an episo...
Read more