CODE QZ


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 202349405

UHID 20231103735

Pay Type

Credit (AROGYA SREE)

Age/Gender 52 Years/Male

Address

Discharge Type: Relieved

Admission Date: 03/11/2023 03:39 PM

Name of Treating Faculty DR.SRIRAMULU(HOD)

Diagnosis

CKD

WITH POLYCYSTIC KIDNEY DISEASE

4 SESSIONS OF HEMODIALYSIS

Case History and Clinical Findings

PATIENT IS KNOWN CASE OF CKD SINCE 5 YEARS ON CONSERVATIVE MANAGEMENT

HISTORY OF PRESENTING ILLNESS-PATIENT WAS APPERENTLY ASYMPTOMATIC SYEARS

BACK THEN HE DEVELOPED EPISODE OF VOMITIG, DECREASED APPETITE FOR WHICH HE CONSULTED LOCAL HOSPITAL AND WAS DIAGNOSED AS CKD AND WAS UT ON

CONSERVATIVE MANAGEMENT

PATIENT HAVE CHIEF COMPLAINTS OF SWELLING OF BILATERAL LOWER LIMBS SINCE 5 DAYS

SWLLING EXTENDING UPTO KNEES AND PITTING TYPE OF EDEMA AND RECLINED TO SOME EXTENT ON LYING DOWN

CHIEF COMPLAINTS SOB

CHIEF COMPLAINTS OF DECREASED URINE OUTPUT SINCE 10 DAYS

CIO DECREASED APPETITE, NAUSEA

K/C/CO HTN SINCE 10 YRS

NOT A K/C/O/ DM, EPILEPSY, TB. THYROID DISORDERS, ASTHMA

PERSONAL HISTORY

DIET MIXED

APPETITE LOST

SLEEP ADEQUATE

BOWEL REGULAR

ADDICTION HIATORY

ALCOHOL STOPPED 19 YEARS BACK

GENERAL EXAMINATION: PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

PALOR-NO

PEDAL EDEMA-NO

NO SIGNS OF CLUBBING, ICTERUS, CYANOSIS, LYMPHEDNOPATHY

VITALS:

TEMP: 98.3 F

PR: 88 BPM

BP: 140/80 MMHG

SPO2:94%

RR: 20 CPM

SYSTEMIC EXAMINATION:

CVS: S1, S2 HEARD, NO MURMURS

RS: BAE, NVBSHEARD

PA SOFT,NT, NO ORGANOMEGALY

CNS: NFAD

Investigation

CBP HB7.5 TC 5400 PLT 1.2 SMEAR NORMOCYTIC NORMOCHROMIC ANEMIA WITH MILD THROMBOCYTOPENIA HIV NEGATIVE HBSAG NEGATIVE HCV NEGATIVE

Anti HCV Antibodies - RAPID03-11-2023 10:26 AM

Non Reactive

HBsAg-RAPID03-11-2023 10:26 AM

Negative

RFT 03-11-2023 10:26:AM

UREA

62 mg/dl

CREATININE

7.2 mg/dl

URIC ACID

3.7 mg/dl

CALCIUM

9.4 mg/dl

PHOSPHOROUS

3.7 mg/dl

SODIUM

139 mEq/L

POTASSIUM

4.3 mEq/L

CHLORIDE

102 mEq/L

RFT 03-11-2023 08:36 PM

UREA

83 mg/dl

CREATININE

8.4 mg/dl

URIC ACID

4.5 mg/dl

CALCIUM

9.1 mg/dl

PHOSPHOROUS

3.7 mg/dl

SODIUM

140 mEq/L

POTASSIUM

4.4 mEq/L

CHLORIDE

105 mEq/L

RFT 05-11-2023 07:32:AM

UREA

97 mg/dl

CREATININE

9.0 mg/dl

URIC ACID

4.8 mg/dl

CALCIUM
9.0 mg/dl

PHOSPHOROUS

4.0 mg/dl

SODIUM

136 mEq/L

POTASSIUM

4.7 mEq/L

CHLORIDE

103 mEq/L

2D ECHO EF-50%,

MILD TR WITH PAH/MODERATE AR+, TRIVIAL MR+, NO RWMA. NO AS/MS, SCLEROTIC AV FAIR LV FUNCTION, CONCENTRIC LVH GRADE I DIASTOLIC DYSFUNCTION, NO PE

USG ABDOMEN

BIL POLYCYSTIC KIDNEYS WITH GRADE III RPD

Treatment Given (Enter only Generic Name)

TAB TELMA 80 MG OD

TAB LASIX 80MG PO/BD

TAB. NICARDIA 20 MG PO/TID

TAB SHELCAL 500MG POIOD

CAP BIO D3 ONCE A WEEK

TAB OROFER-XT PO OD

Advice at Discharge

TAB TELMA 80 MG OD

TAB LASIX 80MG PO/BD

TAB. NICARDIA 20 MG PO/TID

TAB SHELCAL 500MG PO/OD

CAP BIO D3 ONCE A WEEK

TAB OROFER-XT PO OD

Follow Up

REVIEW/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 Enquines 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: 10-11-23

Ward NEPHROLOGY

Comments

Post a Comment

Popular posts from this blog

Meta AI Driven Thematic Analysis NKP in 50 patients of Cardiovascular disease in ESRD on Dialysis

  Please thematically analyse the case report content below by separately addressing the four points below: Coding:  identify initial codes and labels to capture the key concepts and ideas. Categorization: group the codes into categories and subcategories to organize the data. Theme identification: identify the emerging themes and patterns in the data. Theme representation:  present the themes as learning points, highlighting the key findings and insights related to heart failure outcomes in a patient of renal failure  Dr Kranthi's patient of  40 MALE HYPERTENSIVE CHRONIC KIDNEY DISEASE ON HEMODIALYSIS WITH HFpEF July 01, 2024 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 Age Gender : 40 Years/Male Address Checharge Type: Relieved Ad...
Read more

41 M with Breathlessness ( CKD )

PRESENTING COMPLAINTS  A 41 year male clinically presented to nephrology opd with complaints of :  breathlessness of since a month Pedal edema since a month Anuria since a day. HOPI : A 41 year male clinically presented with complaints of breathlessness of grade III MMRC, insidious onset, gradually progressive,  not associated with seasonal and diurnal variation, not associated with orthopnea, postural nocturnal dyspnea and chest pain. History of grade II pedal edema since a month insidious onset and gradually progressive,  pitting type, not associated with local rise in temperature, and skin changes. History of anuria since a day. PAST ILLNESS :  History of bilateral knee Joint pains at the age of 8 years, patient sought for donsultation and started on NSAID, which he used for a year.  History of bilateral lowerlimb weakness for which he sought for consultation and was diagnosed with hypokalemia paralysis, that relieved after K+ correction.  He had co...
Read more

50 year female with loin pain

Image
This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs. PRESENTING COMPLAINTS: C/O :-  Left loin pain,  Diffuse abdominal pain,  Fever since 4 AM on 22/07/2022.  C onstipation since 3 days. HOPI:   A 55 year female presented to the casuality with c/o left loin pain radiating to the back and diffuse squeezing type of abdominal pain since 4 AM on 22/07/2022; Low grade intermittent fever associated with chills, relieved on taking medication. 2 episodes of vomiting, food as content, non bilious, non projectile at 6AM. History of Constipation since 3 days. Now admitted for further evaluation and management. PAST ILLNESS: In 2010 she had an episo...
Read more