CODE RC


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

202357813

LIHID

20231240902

+

X

Pay Type

Credit (AROGYA SREE)

295

Age/Gender 54 Years/Male

Address

Discharge Type: Relieved

Admission Date: 26/12/2023 05:19 PM

Name of Treating Faculty

Diagnosis

DR. SRI RAMULU

CKD ON MHD

Case History and Clinical Findings

C/O B/L PEDAL EDEMA SINCE 2 MONTHS

C/O SOB GRADE III

HOPI:- PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 10 DAYS. THEN HE DEVELOPED BILATERAL SWELLINGS OF LOWER LIMBS.

C/O SOB GRADE III PROGRESSIVE

PAST HISTORY.

K/C/O CKD

K/C/O HTN SINCE 10 YEARS USES MEDICATION

K/C/O DM SINCE 5 YEARS (ON MEDICATION)

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

GENERAL EXAMINATION

PT IS CIC/C

BP-160/80MMHD

PR-1068PM

SPO2-82

RR-23CPM

GRBS-132MG/DL

SYSTEMIC EXAMINATION

CVS-S1S2+

RS-NVBS

CNS-NFND

PIA-SOFT,NT

Investigation

CBP HB-7.4 TC-8000 PLT-2.0

RFT UR-129 CR-8.9 NA 140 K 3.6 CL 101 CA 10 PO44

LFT TB 0.77 DB 0.17 AST 16 ALT 10 ALP 176 TP 6.8 ALB 2.8

CUE

COLOUR YELLOW

ALBUMIN+++++

SUGAR +

RBC NIL

CASTS NIL

SERUM IRON 48

USG

B/L GRADE 2 RIPD CHANGES

2D ECHO

TRIVIAL TR, NO AS/MS, SCLEROTIC AV

EF 66%, GOOD LV FUNCTION

GRADE 1 DIASTOLIC DYSFUNCTION

NO PE/LV CLOT

Treatment Given (Enter only Generic Name)

TAB. LASIX 80MG PO BD

TAB NICARDIA 20 MG/TID

TAB.OROFER XT PO OD

TAB.TELMA 80 MG/OD

TAB. SHELCAL CT 500MG PO OD

FLUID RESTRICTION AND SALT RESTRICTION

INJ IRON SUCROSE 100 MG/ONCE IN 2 WEEKS

INJ.EPO 4000 IU/ONCE IN 2WEEKS

Advice at Discharge

TAB. LASIX 8OMG PO BD

TAB. NICARDIA 20 MG/TID

TAB.OROFER XT PO OD

TAB TELMA 80 MG/OD

TAB, SHELCAL CT 500MG PO OD

FLUID RESTRICTION AND SALT RESTRICTION

INJIRON SUCROSE 100 MG/ONCE IN 2 WEEKS

INJ.EPO 4000 IU/ONCE IN 2WEEKS

Follow Up

COME FOR DIALYSIS 2 TIMES/WEEKS AND 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: 17/01/24

Ward: NEPHROLOGY



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