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

202246131

UHID

20221107169

Pay Type

Credit AROGYA SREE)

Age/Gender 66 Years/Male

Address

Discharge Type: Relieved

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

Name of Treating Faculty

DR SRIRAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O B/L PEDAL EDEMA SINCE 1 WEEK

HOPI: THE PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK, THEN DEVELOPEDB/L PEDAL EDEMA PITTING TYPE AND ALSO DEVELOPED SOB AND DECREASED URINEOUT

PUT 1 WEEK BACK

PAST HISTORY:

K/C/O DM,HTN

GENERAL EXAMINATION:

PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE

VITALS:

TEMPERATURE: AFEBRILE

BP: 150/70 MMHG

HR: 98 BPM

SPO2: 96% ON RA

GRBS: 110 MG/DL

CVS S1,S2 +

RS CLEAR, BAE+

CNS INTACT

P/A: SOFT, NONTENDER

BS +

2D ECHO

MILD CONCENTRIC LVH

NO RWMA

EF 63%

DILATED LA AND LV

NO PE, NO LV CLOT

TRIVIAL TR MILD MR, MILD AR

GOOD SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

Investigation

CBP HB 8.8

TC 6500

PLT 1.67

SMEAR NORMOCYTIC NORMOCHROMIC

RFT

UR 56

CR 8.0

CA+29.5

P 2.5

NA+ 145

K+4.0

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 mcg/dl

TB 0.76

DB 0.18

AST 23

ALT 17

ALP 155

TP 6.4

ALB 3.5

USG BAL GRADE III RPO 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/OD

6 T NICARDIA 20MG/TID

7T MET XL 25 MG/OD

8 INJ. EPI 400 IU/ONCE IN 2 WEEK

9 INJ IRON SUCROSE 100MG/ONCE IN 2 WEEKS

Advice at Discharge

1. TAB LASIX 80 MG/BD

2 T OROFER XT/OD

4 T SHELCAL 500 MG /OD

5 CAP BIO D3/OD

6 T NICARDIA 20MG/TID

7 T MET XL 25 MG/OD

8 INJ. EPI 400 IU/ONCE IN 2 WEEKS

9 INJ IRON SUCROSE 100MG/ONCE IN 2 WEEKS

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 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: 21/12/22

Ward: NEPHROLOGY

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