CODE NI

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 202351741

UHID 20231126910

Pay Type

Credit (AROGYA SREE)

Age/Gender 50 Years/Female

Address

Discharge Type: Relieved

Admission Date: 17/11/2023 06:29 PM

Name of Treating Faculty

DR.RAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

PATIENT CAME WITH COMPLAINTS OF GENERALISED WEAKNESS SINCE ONE MONTH BILATERAL PEDAL EDEMA INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, PITTING TYPE, NO DIURNAL VARIATION SINCE 2 WEEKS AND THEN DEVELOPED SHORTNESS OF BREATH INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, GRADE 2, MMRC, NO PND, NO CHEST PAIN

PAST HISTORY

PATIENT IS K/C/O CKD UNDERWENT 3 SESSIONS OF HEMODIALYSIS

K/C/O DM TYPE 2 SINCE 3 YEARS

K/C/O HTN

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE, WELL ORIENTED TO TIME, PLACE AND PERSON

BILATERAL PEDAL EDEMA PRESENT

NO PALLOR, ICTERUS CYANOSIS, CLUBING, LYMPHADENOPATHY

VITALS:

TEMPERATURE:98.5

BP: 140/80 MM HG

PR:78 BPM

RR:18 CPM

SYSTEMIC EXAMINATION:
CVS:S1,S2 HEARD NO MURMURS.

RS BAE + NVES

CNSINO FOCAL NEUROLOGICAL DEFICITS.

Investigation

COMPLETE BLOOD PICTURE (CBP) 17-11-2023 01:06:PMHAEMOGLOBIN9 gm/dITOTAL COUNT9900cells/cummNEUTROPHILS74 %LYMPHOCYTES18 %EOSINOPHILS02 %MONOCYTES06 %BASOPHILS00 % PLATELET COUNT

5.10COMPLETE URINE EXAMINATION (CUE) 17-11-2023 01:06:PMCOLOURPale yellowAPPEARANCEClearREACTIONAcidicSP GRAVITY 1.010ALBUMIN+++SUGAR+BILE

SALTSNIIBILE PIGMENTSNIIPUS CELLS3-4EPITHELIAL CELLS2-4RED BLOOD

CELLSNIICRYSTALSNIICASTSNIIAMORPHOUS DEPOSIT SAbsentOTHERSNILIVER FUNCTION

TEST (LFT) 17-11-2023 01:06:PMTotal Billurubin0.51 mg/dlDirect Bilurubin0.20 mg/dISGOT(AST)11

IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATE227 IU/LTOTAL PROTEINS7 gm/dIALBUMIN3.41 gm/dIA/G RATIOD.95RFT 17-11-2023 01:06:PMUREA112 mg/dICREATININES mg/dIURIC ACID7.2 mg/dICALCIUM10.1 mg/dIPHOSPHOROUS5.7 mg/dISODIUM 130 mEq/LPOTASSIUM6.1mEq/LCHLORIDE98 mEq/L

2DECHO

TRIVIAL TR PRESENT NO MRIAR

NO RWMA,NO AS/MS, SCLEROTIC AV

EF 67%, GOODLV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION, NO PAH

USG OF ABDOMEN:

B/L GRADE 2 RPD CHANGES

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION 1.5L/DAY

SALT RESTRICTION <2G/DAY

TAB.SHELCAL PO/OD

TAB OROFER XT PO/OD

TAB LASIX 80 MG PO BO

TAB TELMA 80 MG PO/OD

TAB. NICARDIA 20 MG PO/TID

Advice at Discharge

FLUID RESTRICTION 1.5L/DAY

SALT RESTRICTION-2G/DAY
TAB SHELCAL POIOD

TAB OROFER XT POOD

TAB LASIX 80 MG PO BD

TAB. TELMA 80 MG PO/OD

TAB NICARDIA 20 MG PO/TID

Follow Up

REVIEW TO NEPHRO OPD IN CASE OF SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVDID 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/Atendent 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:25/12/2023

Ward: CKD

Unit NEPHROLOGY

CASE REPORT:




Initial assessment

Hb (gm/dl) 9.1 (NCNC)

BLOOD UREA (mg/dl) 110

Sr.CREATININE (mg/dl) 5.2

eGFR (ml/min/1.72m²) 8.8

Sr.Na+ (mEq/L) 139

Sr.K+ (mEq/L) 6.5

Sr.Cl- (mEq/L) 102

Sr. Ca+2 (mEq/L) 10.0

Sr. Phosphorus (mEq/L) 5.7

TOTAL BILIRUBIN (mg/dl) 0.51

DIRECT BILIRUBIN (mg/dl) 0.20

AST/SGOT (IU/L) 11

ALT/SGPT (IU/L) 10

ALP (IU/L) 227

TOTAL PROTEINS (gm/dl) 7.0

Sr.ALBUMIN (gm/dl) 3.41

CUE Albumin+3, Sugars +1

Sr. Fe (mcg/dl) 70

Usg

RIGHT kidney 7.5 x 3.1cms, CMD PARTIALLY MAINTAINED 

LEFT kidney 7.7 x 4.4 cms, CMD PARTIALLY MAINTAINED 


IMPRESSION    

BILATERAL GRADE 2-3 RPD CHANGES



2D ECHO - 

EF 67%

Mild LVH

No Dilated chambers

Good LV systolic function

Grade 1 LV diastolic dysfunction 

No RWMA

Minimal Pericardial effusion 

 Trivial TR


Follow up assessment 

Hb (gm/dl) 8.3 (NCNC)

BLOOD UREA (mg/dl) 86

Sr.CREATININE (mg/dl) 8.7

eGFR (ml/min/1.72m²) 4.8

Sr.Na+ (mEq/L) 144

Sr.K+ (mEq/L) 3.5

Sr.Cl- (mEq/L) 106

Sr. Ca+2 (mEq/L) 9.7

Sr. Phosphorus (mEq/L) 4.7

TOTAL BILIRUBIN (mg/dl) 0.48

DIRECT BILIRUBIN (mg/dl) 0.20

AST/SGOT (IU/L) 11

ALT/SGPT (IU/L) 10

ALP (IU/L) 270

TOTAL PROTEINS (gm/dl) 5.50

Sr.ALBUMIN (gm/dl) 2.91

CUE Albumin +3, Sugars Nil

Sr. Fe (mcg/dl) 56



2D ECHO - 

EF 66%

Mild LVH

No Dilated chambers 

Good LV systolic function

Grade 1 LV diastolic dysfunction

No RWMA

Minimal Pericardial effusion 

Mild TR, Trivial TR

HFA-PEFF DIAGNOSTIC ALGORITHM FOR DIAGNOSIS OF HFpEF :

Major criteria:

1. Functional

septal e’<7 cm/s or lateral e' < 10 cm/s or Average E/e'≥ 15 or TR velocity > 2.8 m/s (PASP>35 mmHg)

2. Morphological
  LAVI > 34 ml/m² or LVMI >=149/122 g/m² (m/w) and RWT>0,42 #

3. Biomarker (SR)
NT-proBNP > 220 pg/ml or BNP > 80 pg/ml

4. Biomarkers (AF)
NT-proBNP > 660 pg/ml or BNP >240 pg/ml

Minor criteria:

1. Functional
Average E/e' 9-14 or GLS<16%

2. Morphological
LAVI 29-34 ml/m² or LVMI>115/95 g/m² (m/w) or RWT > 0,42 or LV wall thickness≥12 mm

3. Biomarker (SR)
NT-proBNP 125-220 pg/ml or BNP 35-80 pg/ml

4. Biomarkers (AF)
NT-proBNP 365-660 pg/ml or BNP 105-240 pg/ml

Each Major Criteria: 2 points

Each Minor Criteria: 1 point

≥ 5 points: HFpEF

2-4 points: Diastolic Stress Test or Invasive Haemodynamic Measurements



Criteria for HFpEF Diagnosis
Major Criteria:
Functional:
Septal e’ < 7 cm/s or lateral e' < 10 cm/s or Average E/e' ≥ 15 or TR velocity > 2.8 m/s (PASP > 35 mmHg)

Follow-up PASP: 35 mmHg (meets major criteria 2 points)

Morphological:
LAVI > 34 ml/m² or LVMI ≥ 122 g/m² (women) and RWT > 0.42

RWT: Increased in both assessments (meets major criteria 2 points)


Minor Criteria:
Functional:
Average E/e' 9-14 or GLS < 16% (grade I DD)

Morphological:
LAVI 29-34 ml/m² or LVMI > 95 g/m² (women) or RWT > 0.42 or LV wall thickness ≥ 12 mm

RWT and LV Wall Thickness: Increased and ≥ 12 mm (meets minor criteria 1 point)


Conclusion: 
Initial echo:
Major Criteria: 2 point for Morphological 
Minor Criteria: 1 point for RWT and LV wall thickness.
3 points need further testing 

Follow up echo:
Major Criteria: 2 point each for Functional and morphological criteria
Minor Criteria: 1 point for RWT and LV wall thickness.
5 points 
HFpEF.

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