CODE QS

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

: 202249216

UHID

: 20221133355

Pay Type

: Paying

Age Gender: 49 Years/Female

Address

Discharge Type: Relleved

Admission Date: 24/11/2022 05:53 PM

Name of Treating Faculty

DR SRI RAMULU (PROFESSOR)

Diagnosis

CHRONIC RENAL FAILURE

Case History and Clinical Findings

PT CAME WITH COMPLAINTS OF BIL PEDAL EDEMA SINCE 1 YEAR

PUFFINESS OF FACE SINCE 2 MONTHS

PT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK THEN SHE DEVELOPED BILATERAL PEDAL EDEMA EXTENDING UPTO KNEE, PITTING TYPE AND PUFFINESS OF FACE SINCE 2 MONTHS REDUCED AFTER TAKING MEDICATIONS AND STARTED AGAIN FROM 1 WEEK.

K/C/O HTN SINCE 2 YEARS (ON REGULAR MEDICATION TAB. NICARDIA 20 MG PO BD)

NOT A K/C/O DM,TB,ASTHMA EPILEPSY, ON EXAMINATION

PT IS C/C/C

BP 150/90

PR 99BPM

RR 20 CPM

SPO2 100%

TEMP 98.9

CVS 51 52+

RS BILAE PRESENT

CNS NFND

Investigation

CBP

HB 7.7 GM/DL TC9200 2.06 SMEAR NORMOCYTIC NORMOCHROMIC

USG

B/L GRADE 3 RPD CHANGES

2D ECHO

NO LVH, EF 64%; NO AS/MS/ SCLEROTIC AV

DILATED LV: MILD MR. NO TR, PAH

GOOD LV FUNCTION

Treatment Given (Enter only Generic Name)

1) TAB NICARDIA 20 MG PO TID

2) TAB MET XL 25MG PO OD

3) TAB LASIX 40 MG PO BD

4) TAB OROFER XT PO/BD

5) TAB SHELCAL PO BO

6) TAB IRON SUROSE 100 MG IV ONCE WEEKLY

7) INJ ERYTHROPOETIN 4000 IU

SIC WEEKLY ONCE

8)TAB DOLO 650 MG PO QID

9) VITALS MONITORING 4TH HRLY

Advice at Discharge

1) TAB NICARDIA 20 MG PO TID

2) TAB MET XL 25MG PO OD

3) TAB LASIX 40 MG PO BD

4) TAB OROFER XT PO/BD

5) TAB SHELCAL PO BD

6) TAB IRON SUROSE 100 MG IV ONCE WEEKLY

7) INJ ERYTHROPOETIN 4000 IU

SIC WEEKLY ONCE

Follow Up

REVIEW AFTER 1 WEEK OR 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:1/12/22

Ward NEPHRO WARD