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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

202309343

UHID

20230243002

Pay Type

Credit (AROGYA SREE)

Age/Gender : 51 Years/Female

Address

Discharge Type: Relieved

Admission Date: 28/02/2023 03:27 PM

Name of Treating Faculty

DR. SRI RAMULU (PROFFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 8 MONTHS

C/O BREATHLESSNESS SINCE 8 MONTHS DECREASED URINE OUTPUT SINCE 8MONTHS

HOPI

PT WAS APPARENTLY ASYMPTOMATIC 8MONTHS BACK, THEN SHE DEVELOPED BIL PEDAL

EDEMA PITTING TYPE

C/O SOB WHICH WAS INSIDIOUS IN PNSET GRADUALLY PROGRESSIVE

C/O DECREASED URINE OUTPUT SINCE 1MONTH

NO HIO FEVER, BURNING MICTURITION

PAST HISTORY

K/C/O HTN SINCE 8 MONTHS ON T.NICARDIA 10MG

DMII SINCE 15MONTHS ON INSULIN

N/K/C/O TB,ASTHMA 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-JINO PALLOR,

ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHYTEMP-AFEBRILEPR-84BPMBP-

140/80MMHGRR-18CPMSPO2-97%CVS-S1S2+ NO MURMURSELEVATED JVPRS-BAE+

CREPTS IN BIL IAA REGIONP/A-SOFT NTCNS NFNDCVS-S152+, NO MURMURSRS-BAE+P/A-

SOFT,NTCNS NFND

Investigation

CBP

HB 16.6G/DL

TC-6,700CELLS/CUMM

PLT-2.6 LAKHS /CUMM

SMEAR-NCNC

RFT

UR-36MG/DL

CR 4.7MG/DL

CA+10.2 MEQIL

P3.DMEQ/L

NA 137MEQAL

K+4.2 MEQIL

CL-99MEQ/L

SEROLOGY-NEGATIVE

TB-0.6 MG/DL

DB-0.19MG/DL

AST-26IU/L

ALT-4IU/L

ALP-237IU/L

TP-7.3G/DL

ALBUMIN -4.4G/DL

SERUM IRON-70 MG/DL

CUE ALBUMIN++

SUGARS

USG

RT KIDNEY -6X 2.6 CMS, CMD PARTIALLY LOST

LEFT KIDNEY -7.1 X 2.6 CMS CMD PARTIALLY MAINTAINED

IMPRESSION-B/L GRADE II RPD CHANGES

2D ECHO

MILD CONCENTRIC LVH

RA AND LA ARE DILATED EF -60%

GOOD SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

MILD PERCARDIAL EFFUSION, NO LV CLOT

MILD MR AR MODERATE TR, WITH PAH

Treatment Given (Enter only Generic Name)

1.TAB.DYTOR 100MG/BD

2. TAB SHELCAL 500 MG PO/OD

3. INJ EPO 4000 IU/SC ONCE WEEKLY

4 TAB TELMA 80MG/OD

5. INJ IRON SUCROSE 100 MG/IV/ONCE WEEKLY

6.TA NICARDIA 20MG/TID

Advice at Discharge

1.TAB.DYTOR 100MG/BD

2. TAB SHELCAL 500 MG POIOD

3. INJ EPO 4000 IU/SC ONCE WEEKLY

4 TAB TELMA 80MG/OD

5. INJ IRON SUCROSE 100 MG/IV/ONCE WEEKLY

6.TA NICARDIA 20MG /TID

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 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: 31/03/2023

Ward CKD

Unit: NEPHROLOGY

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