CODE NT
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
202410882
UHID
20240308286
Pay Type
Credit(AROGYA SREE)
Age/Gender 54 Years/Male
Address
Discharge Type: Relieved
Admission Date: 07/03/2024 11:50 AM
Name of Treating Faculty
DR SRIRAMULU (HOD)
Diagnosis
CKD ON MHD WITH DM SINCE 10 YEARS AND HTN SINCE 15 YEARS
Case History and Clinical Findings
C/O B/L PEDAL EDEMA SINCE 2MONTHS
C/O DECREASED APPETITE SINCE 2 MONTHS
HOPI-
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK AND DEVELOPED BIL PEDAL EDEMA UPTO KNEES PITTING TYPE ASSOCIATED WITH DECREASED URINE OUTPUT. CIO
DECREASEDAPPETITE SINCE 2 MONTHS
NO C/O FEVER COUGH COLD
PAST HISTORY-
K/C/O DM SINCE 10 YEARS
K/C/O HTN SINCE 15 YEARS
KICO CKD SINCE 5 YEARS
N/K/C/O TB EPILEPSY CVA THYROID
ON EXAMINATION
GENERAL EXAMINATION
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
PITTING TYPE OF PEDAL EDEMA
TEMP- AFEBRILE
RR 16 CPM
BP-150/90 MM HG
PR 71 BPM
SPO2 98% @RA
CVS-S1S2 HEARD, NO MURMURS
RS-BAE PRESENT
PIA-SOFT NON TENDER NO ORGANOMEGALY
CNS-NFND
Investigation
COMPLETE URINE EXAMINATION (CUE) 06-03-2024 11:38:AMCOLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP GRAVITY 1.010ALBUMIN ++++SUGAR +++BILE
SALTS NIIBILE PIGMENTS NIIPUS CELLS 3-4EPITHELIAL CELLS 3-4RED BLOOD CELLS
NIICRYSTALS NIICASTS NILAMORPHOUS DEPOSITS AbsentOTHERS Nil
BLOOD UREA-77 mg/dISERUM CREATININE 7.1 mg/dl
SERUM ELECTROLYTES (Na, K, C I) SODIUM 132 mmol/LPOTASSIUM 4.0 mmol/LCHLORIDE
101 mmol/LHBsAg-RAPID Negative
CALCIUM IONIZED 9.4 MMOL/L
HAEMOGLOBIN 8.2gm/dITOTAL COUNT 8,200 cells/cummNEUTROPHILS 61% LYMPHOCYTES 26% EOSINOPHILS 03% MONOCYTES 10% BASOPHILS 00%PCV 23.9 vol % MCV 82.7 IMC
H28.4 pgM CH C 34.3% RDW-CV 12.4% RDW-SD 37.9 11 RBC COUNT 2.89 millions/cumm PLATELET COUNT 4.4 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC With in normal limitsPLATELETS Adeqaute HEMOPARASITES No hemoparasites seenIMPRESSION Normocytic normochromic blood
BLOOD GROUP: ABRH TYPING: POSITIVE (+VE) RBS 109 MG/DL,
USG IMPRESSIONS: RIGHT GRADE II RPD CHANGES
LEFT GRADE II RPD CHANGES
2D ECHO
MILD CONCENTRIC LVH
GOOD LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION
NO RWMA
NO PE, EF 68%
MILD AR, MILD MR, MODERATE TR WITH MILD PAH
NO LV CLOT
Treatment Given(Enter only Generic Name)
SALT RESTRICTION <2G/DAY
FLUID RESTRICTION <1.5L/DAY
INJ EPO 4000 IV S/C ONCE IN 2 WEEKS
TAB MVT PO/OD X 5 DAYS
TAB TELMA 80MG PO/OD X 5 DAYS
TAB NICARDIA 20MG PO/TID X 5 DAYS
TAB LASIX 80MG PO/BD X 5 DAYS
TAB MET XL 25 MG PO/OD X 5 DAYS
TAB SHELCAL CT PO/OD X 5 DAYS
INJU IRON SUCROSE 100MG IV/ ONCE IN 2 WEEK
Advice at Discharge
SALT RESTRICTION <2G/DAY
FLUID RESTRICTION <1.5L/DAY
INJ EPO 4000 IV S/C ONCE IN 2 WEEKS
TAB MVT PO/OD X 5 DAYS
TAB TELMA 80MG PO/OD X 5 DAYS
TAB NICARDIA 20MG PO/TID X 5 DAYS
TAB LASIX 80MG PO/BD X 5 DAYS
TAB MET XL 25 MG PO/OD X 5 DAYS
TAB SHELCAL CT POIOD X 5 DAYS
INJU IRON SUCROSE 100MG IV/ ONCE IN 2 WEEK
Follow Up
REVIEW SOS TO NEPHROLOGY OPD
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:06/04/24
Ward:NEPHROLOGY
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