CODE P6


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

202325851

Pay Type

Credit AROGYA SREE)

Age/Gender 43 Years/Female

Address

Discharge Type: Relieved

Admission Date: 13/06/2023 01:23 PM

Name of Treating Faculty

DR. SRI RAMULU (HOD)

Diagnosis

CHRONIC KIDNEY DISEASE ON MHD

Case History and Clinical Findings

PATIENT CAME WITH CIO SOBSINCE 10AYS

GENERALIZED BODY SWELLING SINCE 2 MONTHS

C/O FACIAL PUFFINESS SINCE 2 MONTHS

C/O FEVER SINCE 2 MONTHS ON AND OF

PATIENT WAS APPARENTLY ASYMPTOMATIC 2YRS AGO THEN SHE HAD DEVELOPED

PEDAL EDEMA SINCE 2 MONTHS SHE HADH/O B/L PEDAL EDEMA SINCE 2 MONTHS LATER

BECAME GENERALIZED BODY EDEMA AND FACIAL PUFFINESS FEVER LOW GRADE

INTERMITTENT SINCE 2 MONTHS WITHOUT ANY DIURNAL VARIATION

SOB GRADE 4

NO HIO NAUSEA, VOMITINGS, FEVER

NO HIO CHEST PAIN PALPITATIONS SYNCOPAL ATTACKS ORTHOPΑΝΕΑ

NO HIO COLD FEVER COUGH

PAST HISTORY

K/C/O HTN SINCE 5 YRS

K/C/O DM SINCE 7 YRS

N/K/CIO ASTHMA, TB, CVD,CAD

PERSONAL HISTORY -

APPETITE-NORMAL

SLEEP-ADEQUATE

BOWEL AND BLADDER-REGULAR

ADDICTIONS-NIL

GENERAL PHYSICAL EXAMINATION:

PATIENT IS COPNSCIOUS, COHERENT AND COOPERATIVE

NO SIGNS OF PALLOR,ICTERUS, CLUBBING, LYMPHADENOPATHY, CYANOSIS.PEDAL

EDEMA

VITALS-

TEMP-97.4 F

PR-90BPM

RR18CPM

BP-170/90 MMHG

SPO2 99 AT RA

SYSTEMIC EXAMINATION:

CVS-S152 HEARD, NO MURMURS

RS-BAE PRESENT, NVBS

CNS-NAD

PA-SOFT, NON TENDER, NO ORGANOMEGALY

Investigation

HIV NEGATIVE HBSAG NON REACTIVE HCV NON REACTIVE

CBC

HB 6.2

TC 7900

PLT 2.22

RFT

CR 5.1

UR 50

LFT

TB 0.75

DB 0.15

AST 8

ALT S

ALP 122

TP 6.5

ALB 3.59

CUE

PALE YELLOW

RBC NIL

CASTS NIL

BACTERIA NIL

ALBUMIN ++

SUGAR ++

Treatment Given (Enter only Generic Name)

1) SALT RESTRICTION 2G/DAY

2)FLUIDRESTRICTION <ILT/DAY

3)INJ IRON SUCROSE 100MG IV ONCE WEEKLY

4)TAB NICARDIA 20MG PO/TID

5)TAB TELMA 40MG PO/OD

6)TAB SHELCAL CT 500MG PO/OD

7)TAB OROFER XT PO/OD

8)TAB LASIX 80MG PO/BD

9)TAB MET XL 25MG PO/OD

10) INJ EPO 4000IU/SC/TWICE WEEEKLY

Advice at Discharge

1) SALT RESTRICTION <2G/DAY

2)FLUIDRESTRICTION <1LT/DAY

3JINJ IRON SUCROSE 100MG IV ONCE WEEKLY

4)TAB NICARDIA 20MG PO/TID

5)TAB TELMA 40MG PO/OD

6)TAB SHELCAL CT 500MG PO/OD

7)TAB OROFER XT PO/OD

8)TAB LASIX 80MG PO/BD

9)TAB MET XL 25MG PO/OD

10) INJ EPO 4000IU/SC/TWICE WEEEKLY

Follow Up

RIA 3 DAYS 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 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 OF SIGNATURE OF PATIENT ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date: 12/7/23

Ward NEPHROLOGY

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