CODE PC

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 202354917

Pay Type

Credit (AROGYA SREE)

UHID 20231213007

Age/Gender 55 Years/Male

Address

Discharge Type: Relieved

Admission Date: 08/12/2023 04:43 PM

Name of Treating Faculty

DR. RAMULU (HOD)

Diagnosis

CKD

ΑΝΕΜΙΑ 2 ΤO CKD

Case History and Clinical Findings

COMPLAINTS OF PEDAL EDEMA SINCE 15DAYS

SOB SINCE 10DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THE HE DEVELOPED SOB NOT A/W COUGH, COLD, SORE THROAT

PEDAL EEMA PITTING TYPE BELOW THE KNEE

NO HIO DECREASED URINE OUTPUT, NSAID ABUSE, HEMATURIA, PYURIA

K/C/O HTN SINCE 15YRS, CKD SINCE 15YRS

N/K/C/O DMCVA, CAD, TB, EPILEPSY

GENERAL EXAMINATION:

PT IS C/C/C

PALLOR PRESENT, OEDEMA OF FEET PRESENT

GENERAL EXAMINATION:

NO ICTERUS, CYANOSIS, KOILONYCHIA, LYMPHADENOPATHY

TEMP: 98.3 F

PR: 80 BPM

RR 21

BP 140/90

CVS S1 AND S2 HEARD
CNS NFND

GIT SOFT NON TENDER, NO ORGANOMEGALY

RS BAE +

Investigation

BLOOD UREA08-12-2023 02:57 PM178 mg/dISERUM CREATININE08-12-2023 02:57:PM12.5

mg/dISERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 08-12-2023 02:57:P SODIUM140 mEq/LPOTASSIUM4.6 mEq/LCHLORIDE 104 mEq/LCALCIUM IONIZED1.13 mmol/L.COMPLETE BLOOD PICTURE (CBP) 08-12-2023 02:57 PM HAEMOGLOBIN5.0 gm/dITOTAL COUNT5000 cells/cummNEUTROPHILS63 %LYMPHOCYTES22 %EOSINOPHILS06 %MONOCYTES09 %BASOPHILS00%PLATELET COUNT1.60SMEARNormocytic normochromic Anemia COMPLETE URINE EXAMINATION (CUE) 08-12-2023 02:57:PM COLOURPale yellowAPPEARANCE ClearREACTIONAcidicSP GRAVITY1010ALBUMIN+++SUGARTraceBILE SALTSNIBILE PIGMENTSNIPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD CELLSNIICRYSTALSNIICASTSNIIAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID08- 12-2023 09:56:PMNegative Anti HCV Antibodies - RAPID08-12-2023 09:56:PMNon Reactive RFT 08-12-2023 09:56 PM UREA 179 mg/dICREATININE 12.4 mg/dIURIC ACID6.5 mg/dICALCIUM9.1 mg/dIPHOSPHOROUS4.5 mg/dISODIUM140 mEq/LPOTASSIUM4.5 mEq/LCHLORIDE 102 mEq/LLIVER FUNCTION TEST (LFT) 08-12-2023 09:56 PM Total Bilurubin0.59 mg/dlDirect Bilurubin0.21 mg/dISGOT(AST)24 IU/LSGPT(ALT)19 IU/LALKALINE PHOSPHATE217 IUAL, TOTAL PROTEINS5.8 gm/dIALBUMIN3.51 gm/dIA/G RATIO1.53ABG 08-12-2023 11:48:PM PH7 30PCO220 4PO288.9HCO39.8SLHCO312.0BEB-15.5BEecf-15.4TCO222,602 Sat100.202 Count5.0RFT 10-12-2023 06:11 AM UREA 90 mg/dICREATININE7.1 mg/dIURIC ACID3.3 mg/dICALCIUM8.1 mg/dIPHOSPHOROUS3.4 mg/dISODIUM142 mEq/LPOTASSIUM3.8 mEq/LCHLORIDE 106 mEq/LRFT 12-12-2023 12:03:AM UREA56 mg/dICREATININE5.0 mg/dIURIC ACID2.5 mg/dICALCIUM8.7 mg/dIPHOSPHOROUS2.9 mg/dISODIUM140 mEq/LPOTASSIUM3.6 mEq/LCHLORIDE 104 mEq/LRFT 12-12-2023 11:56 PM UREA76 mg/dICREATININE5.1 mg/dIURIC ACID3.3 mg/dICALCIUM8.2 mg/dIPHOSPHOROUS3.0 mg/dISODIUM140 mEq/LPOTASSIUM3.6 mEq/LCHLORIDE98 mEq/LRFT 13-12-2023 11:21:PM UREA56 mg/dICREATININE4.5 mg/dIURIC ACID2.7 mg/dICALCIUM9.3 mg/dIPHOSPHOROUS3.2 mg/dISODIUM140 mEq/LPOTASSIUM3.8 mEq/LCHLORIDE99 mEq/L

2D ECHO

TRIVIAL MR, TRIVIAL TR WITH PAH, MILD AR

NO AS/MS

DILATE LV AND LA

MODERATE CONCENTRIC LVH,

EF 68%, GOOD LV FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

NO RWMA, NO PE/LV CLOT

Treatment Given (Enter only Generic Name)

-TAB. LASIX 80 MG PO BD

-TAB. TELMA 80 MG PO OD

-TAB. NICARDIA 20MG PO TID

TAB, OROFER XT PO OD

-TAB. SHELCAL CT PO OD

-INJ. EPO 4000U SC OD ONCE IN 2WEEKS

-INJ. IRON SUCROSE 100MG IN 100ML ONCE IN A WEEK

SALT RESTRICTION<2GM/DAY

FLUID RESTRICTION <1L/DAY

Advice at Discharge

-TAB LASIX 80 MG PO BD

-TAB. TELMA 80 MG PO OD

-TAB. NICARDIA 20MG PO TID

-TAB. OROFER XT PO OD

-TAB SHELCAL CT PO OD

- INJ. EPO 4000U SC OD ONCE IN 2WEEKS

-INJ IRON SUCROSE 100MG IN 100ML ONCE IN A WEEK

SALT RESTRICTION<2GM/DAY

FLUID RESTRICTION <1L/DAY

Follow Up

REVIEW AFTER 4 DAYS

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: 15/12/23

Ward CKD

Unit: NEPHROLOGY

CASE REPORT

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