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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 202309529

UHID 20230243900

Pay Type

Credit AROGYA SREE)

Age Gender : 48 Years/Female

Address

Discharge Type: Relieved

Admission Date: 01/03/2023 01:15 PM

Name of Treating Faculty

DR. SRI RAMULU (PROFFESSOR)

Case History and Clinical Findings

CIO BREATHLESSNESS SINCE 1DAY

C/O PEDAL EDEMA SINCE 6MONTHS

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC 6MONTHS BACK, THEN SHE DEVELOPED BIL PEDAL EDEMA PITTING TYPE

CIO SOB GRADE I WHICH WAS INSIDIOUS IN ONSET GRADUALLY PROGRESSED TO GRADE 11

NO HIO FEVER, BURNING MICTURITION

PAST HISTORY:

K/C/O HTN SINCE 2YEARS

DMII SINCE 7YEARS

K/C/O CKD SINCE 2 YRS

N/K/C/O TBASTHMA EPILEPSY

PERSONAL HISTORY

MIXED DIET

NORMAL APPETITE

ADEQUATE SLEEP

BOWEL AND BLADDER REGULARNO ALLERGIESGENERAL EXAMINATION-PT. IS C/C/CB/L PEDAL EDEMA OF FEET G-HINO PALLOR, ICTERUS, CYANOSIS, CLUBBING LYMPHEDENOPATHYTEMP-AFEBRILEPR-825PMBP 140/80MMHGRR-18CPMSPO2-99% CVS-SIS2+,NO MURMURGRS-BAE+ P/A

SOFT,NTONS:NFND

Investigation

CBP

HB 8.5

TC 7600

PLT 2.17

SMEAR NCNC

RFT

UR 58

CR 5.9

CA+2 10

HIV HBSAG HCV ARE NEGATIVE

B/L GARDE 3 RPD CHANGES

2D ECHO

MILD CONCENTRIC LVH

NO AS/MS; MILD TR WITH PAH; MILA AR AND MR

EF 56%; GOOD LV SYSTOLICFUNCTION

DILATED LA AND LV

GRADE 1 DIASTOLIC DYSFUNCTION

Treatment Given (Enter only Generic Name)

TAB. TELMA 40 MG PO/OD

TAB. MET XL 25 MG PO/OD

TAB. LASIX 60MG PO/BD

TAB. NODOSIS 500MG PO/BD

TAB. SHELCAL 500MG PO/OD

TAB. OROFER-XT POIOD

Advice at Discharge

TAB. TELMA 40 MG PO/OD

TAB. MET XL 25 MG PO/OD

TAB. LASIX 60MG PO/BD

TAB. NODOSIS 500MG PO/BD

TAB. SHELCAL 500MG PO/OD

TAB. OROFER-XT PO/OD

Follow Up

REVIEW SOS TO NEPHRO 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 Treatmem 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: 07/03/2023

Ward CKD

Unit: NEPHROLOGY

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