CODE OW


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

IPID 202301999

JUHID 20230117310

Pay Type

Credit AROGYA SREE)

Age/Gender 51 Years/Female

Address

Discharge Type: Relieved

Admission Date: 13/01/2023 12:09 PM

Name of Treating Faculty

DR.SRI RAMULU

Diagnosis

CKD ON MDH

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 1 MONTH

C/O OF LOIN PAIN SINCE 1 YEAR

PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK THEN SHE C/O, OINPAIN SINCE 1 YEAR

H/O BIL PEDAL EDEMA-PITTING TYPE

LOSS OF APPETITE

NO HIO FEVER

NO HIO BURNING MICTURATION

PAST HISTORY: T2DM SINCE 15 YEARS, HYPERTENSION 15 YEARS, NSAID ABUSE

GENERAL EXAMINATION: NO

PALLOR, ICTERUS, CYANOSIS, CLUBBING, EDEMA, LYMOHADENOPATHY

VITALS

TEMPERATURE 98F

BP:160/100MMHG

PR:88 BPM

SPO2:99% ON BLO2

GRBS 112MG/DL

CVS S1/S2+

P/A SOFT NON TENDER

INVESTIGATIONS 
HEMOGRAM:

HB:6.8 GM/DL

TLC:9000

RBC-2.55MILLION/CUMM

PLT-2.99LAKHS/CUMM

SMEAR-NCNC

RFT

UR-100MG/DL

CR 6.5MG/DL

CA+8.5MEQ/L

P2.8 MEQ/L

NA+142MEQIL

K+4.7MEQ/L

CL-102MEQIL

SEROLOGY-NEGATIVE

TB-0.67 MG/DL

DB-0:20MG/DL

AST-18IU/L

ALT-201UA

ALP-270IU/L

TP-6.2G/DL

ALBUMIN-3.3G/DL

SERUM IRON-24MG/DL

CUE ALBUMIN+++

SUGARS-NIL

USG

RT KIDNEY 7.4 X 3 CMS, CMD LOST

LEFT KIDNEY -7.2X 3.6 CMS CMD LOST

IMPRESSION-B/L GRADE III RPD CHANGES

20 ECHO

MILD LVH

LA AND LV ARE DILATED

GRADE I DIASTOLIC DYSFUNCTION

NO RWMA

NO PERCARDIAL EFFUSION

EF-48%

MILD MR AR TRIVIAL TR

Treatment Given(Enter only Generic Name)

T.LASIX 80 MG PO BD

T.NICARDIA 20MG PO TID

T.METAPROLOL 25MG /OD

T.SHE CAL 500MG PO OD

INJEPO 4000 IU SC ONCE WEEKLY

INJ. IRON SUCROSE 100MG IN 100ML NS/WEEKLY ONCE

Advice at Discharge

TLASIX 80 MG PO BD

T.NICARDIA 20MG PO TID

T.METAPROLOL 25MG/OD

T.SHELCAL 500MG PO OD

INJ.EPO 4000 IU SC ONCE WEEKLY

INJ. IRON SUCROSE 100MG IN 100ML NS/WEEKLY ONCE

Follow Up

REVIEW SOS

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:2/3/23

Ward: NEPHROLOGY

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