CODE OX


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 :202250102

UHID

20221148018

Pay Type

Credit AROGYA SREE)

Age/Gender

52 Years/Male

Address

Discharge Type: Relieved

Admission Date: 30/11/2022 12:23 PM

Name of Treating Faculty

DR SRIRAMULU (HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O SOB SINCE 2 TO 3 MONTHS

BIL PEDAL EDEMA

DECREASED URINE OUTPUT

HOPI

PT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS BACK THEN HE DEVELOPED PEDAL EDEMA FOLLOWED BY DECREASED URINE OUTPUT AND SOB

PAST HISTORY

KIC/O HTN FROM 3 YEARS AND ON MEDICATION (TAB CINOD 10 MG)

GENERAL EXAMINATION

PT IS CONSCIOUS, COHERANT AND COOPEARTIVE

NO PALLOER, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY AND EDEMA OF FEET

TEMP 98 F

PR 84 BPM

RR 24 CPM

BP 130/80MMHG

SPO2: 99%

CVS: S1 S2 PRESENT

RS. BAE+

PER ABDOMEN SOFT AND NON TENDER

CNS:NAD

Investigation

CBP

HB 11.8G/DL

TC-6,800 CELLS/CUMM

RBC-4.15MILLIONS /CUMM

PLT-2.62LAKHS/CUMM

SMEAR-NCNC

RFT

UR-130MG/DL

CR-49MG/DL

CA+10 SMEQIL

P55MEQA

NA+ 139MEQ/L

K+4.1 MEQ/L

CL-102MEQ/L

SEROLOGY-NEGATIVE

TB-1.38 MG/DL

DB-0.31MG/DL

AST-121U/L

ALT-15IU/L

ALP-1981UL

TP-6.7G/DL

ALBUMIN 3.83G/DL

SERUM IRON-60 MG/DL

CUE-ALBUMIN +

SUGARS-NIL

USG

RT KIDNEY-6.5X3 CMS CMD LOST

LEFT KIDNEY-68 X 5,2 CMS CMO LOST

MPRESSION-B/L GRADE III RPD CHANGES

2D ECHO

MILD LVH

GOOD LV SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

NO RUMA, PE

EF-68%

TRIMAL MR TRIMTH PAH

Treatment Given Enter only Generic Name)

SALT RESTRICTION <24 GM/DAY

FLUID RESTRICTION <15 LT/DAY

TAB LASIX 80MG PO BD

TAB NICARDIA 20MG/TID

TAB SHELCAL 500MG OD

INJ EPO 4000 IU/SC ONCE WEEKLY

INJ IRON SUCROSE 100 MG/M/ONCE WEEKLY

Advice at Discharge

SALT RESTRICTION <24 GM/DAY

FLUID RESTRICTION 15 LT/DAY

TAB LASDX 80MG PO BD

TAB. NICARDIA 20MG/TID

TAB SHELCAL 500MG OD

INJ EPO 4000 IU/SC ONCE WEEKLY

INJ IRON SUCROSE 100 MG/M/ONCE WEEKLY

Follow Up

REVIEW AFTER ONE WEEK OR REVIEW SOS

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY MMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT

Preveritive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADICE, DONOTMISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact 08682279999 For Treatment Enquiries Patient/Artendent Declaration The medicines prescribed and the adwoe 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 19/1/23

Vard NEPHROOGY

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