CODE OF

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:

Age/Gender 66 Years/Male

Address

Discharge Type: Relleved

Admission Date: 04/11/2022 06:08 PM

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O BIL PEDAL EDEMA SINCE 1 WEEK

HOPI:

 THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK, THEN DE VELOPEDBIL PEDAL EDEMA PITTING TYPE AND ALSO DEVELOPED SOB AND DECREASED URINE OUTPUT 1 WEEK BACK

PAST HISTORY:

NOT A KICIO DM, TB, ASTHMA, EPILEPSY

GENERAL EXAMINATION,

PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE

VITALS

TEMPERATURE AFEBRILE

BP 150/70 mmHg

HR: 96 BPM

SPO2: 96% ON RA

GRBS 110 Mg/dl

CVS S1,S2

RS CLEAR, BΑΕ

CNS INTACT

PIA SOFT, NONTENDER

BS+

2D ECHO:

MILD CONCENTRIC LVH

NO RWMA

EF 63%

DILATED LA AND LV

NO PE

TRIVIAL TR, MILD MR, MILD AR

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

Investigation

CBP 

HB 8.8

TC 6500

PLT 1.67

SMEAR NORMOCYTIC NORMOCHROMIC

RFT

UR 56

CR3.2

CA+29.5

P2.5

NA+ 145

K+40

CL-105

HIV NEGATIVE

HBSAG NEGATIVE

HCV NEGATIVE

CUE YELLOW IN COLOUR

ALBUMIN++

SUGAR+

PUS CELSS 2-3

EPI CELLS 2-3

NO RBC

SR. Fe 83 

TB 0.76

DB 0.18

AST 23

ALT 17

ALP 155

TP 6.4

ALB 3.5

USG: B/L GRADE III RPD CHANGES

Treatment Given (Enter only Generic Name)

1 TAB LASIX 80 MG/BD

2T OROFER XT OD

4T SHELCAL 500 MG/OD

5 CAP BIO D3/00

6T NICARDIA 20MG/TID

7T MET XL 25 MG/OD

8 INJ EPI 400 IU/BI WEEKLY

9 INJ IRON SUCROSE 100MG/BIWEEKLY

Advice at Discharge

1 TAB LASX 80 MG/BD

2 T OROFER XT/OD

4 T SHELCAL 500 MG/OD

5 CAP BIO D3/dD

6.T NICARDIA 20MG/TID

7 T MET XL 25 MG/OD

8 INI, EPI 400 IU/BI WEEKLY

9 INU IRON SUCROSE 100MG/BI WEEKLY

Follow Up

VISIT FOR DIALYSIS THRICE WEEKLY

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT

Preventive CareAVOID SELF MEDICATION WITHOUT DOCTORS ADMCE 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 urgerit 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: 21/12/22

Ward NEPHROLOGY

CASE REPORT:

66 year male, farmer, Resident of Nalgonda who was apparently asymptomatic 30 years ago, on routine checkup diagnosed with diabetes and using OHA's; he had a alleged history of RTA causing fracture to right femur. Patient sought for consultation and was advised for surgical management and was diagnosed with Hypertensionand started on medications, he got scared and didn't visited doctor again and went for (kattu mandu) stabilization with wooden sticks and started using pain killers for the pain for 3 years. His pain gradually decreased, but not subcided. After 6 months, he started walking with stick in one hand. 5 years ago had complaints of generalized body pains for which he sought for consultation at local hospital, and on routine workup, he was diagnosed with renal failure, started on conservative management and stopped OHAs and started on Insulin therapy. After 2 years he had complaints of generalized itching, bilateral pedal edema till knees, decreased appatite, nausea, breathlessness and sought for consultation; and initated on hemodialysis. After 7 months of hemodialysis patient started having complaints of Breathlessness on exertion which was progressed to breathlessness on less than normal physical activity gradually over 4 months. He was changed the visit to dialysis from once weekly to twice weekly. After 1 1/2 year, his complaints of Breathlessness and pedal edema increased and has 3 episodes of acute pulmonary edema due to delayed visits for dialysis (overload); patient was advised for thrice weekly hemodialysis sessions. 

Laboratory parameters:

1st Assesment:

Hb (gm/dl) 8.8 (NCNC) 

BLOOD UREA (mg/dl) 56

Sr.CREATININE (mg/dl) 8

eGFR (ml/min/1.72m²) 21 (IV) 

Sr.Na+ (mEq/L) 143

Sr.K+ (mEq/L) 4.0

Sr.Cl- (mEq/L) 105

Sr. Ca+2 (mEq/L) 9.5

Sr. Phosphorus (mEq/L) 2.5

TOTAL BILIRUBIN (mg/dl) 0.76

DIRECT BILIRUBIN (mg/dl) 0.18

AST/SGOT (IU/L) 23

ALT/SGPT (IU/L) 17

ALP (IU/L) 155

TOTAL PROTEINS (gm/dl) 6.5

Sr.ALBUMIN (gm/dl) 3.5

CUE ALBUMIN +2, SUGARS +1

Sr. Fe (mcg/dl) 83

Usg

RIGHT kidney 7.2x 3.1cms ,CMD LOST

LEFT kidney 7.8 x 4.2 cms, CMD LOST 

IMPRESSION B/L GRADE 3 RPD CHANGES

2D ECHO - 

At first assessment 

EF - 63%

Mild concentric LVH (1.24cms)

Dilated LV & LA

Good LV systolic function

Grade I diastolic dysfunction 

No RWMA

No Pericardial effusion

Mild MR, Mild AR, Trivial TR

RVSP= 32mmHg

HFA-PEFF Score =3 points.

Management:

1. Fluid restriction <1.5 lit/day.

2. Salt restriction of < 2 g/day

3. TAB. FUROSEMIDE 80 MG/BD

4. TAB. NIFEDIPINE 20 mg/ TID

5. TAB. METAPROLOL 25 MG/ BD

6. TAB. OROFER XT OD

7. TAB. SHELCAL 500 MG/OD

8. CAP. BIO D3/0D

9. INJ IRON SUCROSE 100MG/BIWEEKLY

10. INJ EPI 400 IU/BI WEEKLY

Follow up assessment:

Hb (gm/dl) 8.8 (NCNC) 

BLOOD UREA (mg/dl) 67

Sr.CREATININE (mg/dl) 3.6

eGFR (ml/min/1.72m²) 10 (Stage V)

Sr.Na+ (mEq/L) 145

Sr.K+ (mEq/L) 3.6

Sr.Cl- (mEq/L) 99

Sr. Ca+2 (mEq/L) 10.1

Sr. Phosphorus (mEq/L) 3.8

TOTAL BILIRUBIN (mg/dl) 1.19

DIRECT BILIRUBIN (mg/dl) 0.24

AST/SGOT (IU/L) 22

ALT/SGPT (IU/L) 23

ALP (IU/L) 168

TOTAL PROTEINS (gm/dl) 5.7

Sr.ALBUMIN (gm/dl) 3.2

CUE ALBUMIN +2, SUGARS trace

Sr. Fe (mcg/dl) 70

2D ECHO

Follow up assesment:

EF - 52%

Mild concentric LVH

All chambers dilated

Good systolic function

Grade II diastolic dysfunction 

No RWMA

Minimal Pericardial effusion

Mild MR, mild AR, mild TR

MANAGEMENT:

1. Fluid restriction <1.5 lit/day.

2. Salt restriction of < 2 g/day

3. TAB. FUROSEMIDE 80 MG/BD

4. TAB. NIFEDIPINE 20 mg/ TID

5. TAB. METAPROLOL 25 MG/ BD

6. TAB. CLONIDINE 0.1 MG/ TID

7. TAB. SHELCAL CT 500 MG/OD

8. TAB. OROFER XT OD

9. INJ IRON SUCROSE 100MG/BIWEEKLY

10. INJ EPI 400 IU/BI WEEKLY

11. DIALYSIS ALTERNATE DAY

OUTCOMES:

INTRA-DIALYTIC HYPOTENSION: NO

POST-DIALYTIC HYPOTENSION: NO

HYPOTENSION REQUIRING IONOTROPIC SUPPORT: NO

ACUTE CARDIOGENIC PULMONARY: YES 

ISCHEMIC HEART DISEASE: NO

EMERGENCY HOSPITALIZATION: YES

MORTALITY: YES