CODE RD

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 :202356601

UHID 20231229102

Pay Type

Credit (AROGYA SREE)

Age/Gender 62 Years/Male

Address:

Discharge Type: Relieved

Admission Date: 18/12/2023 04:59 PM

Name of Treating Faculty

DR. SRI RAMULU

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O B/L PEDAL EDEMA SINCE 20 DAYS

C/O SOB SINCE 16 DAYS

HOPI-PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE 20 DAYS BACK, THEN HE DEVELOPED BILATERAL PEDAL EDEMA, SOB GRADE III PROGRESSIVE

K/C/O HTN SINCE 3 YEARS USES MEDICATION

H/O NSAID ABUSE

H/O SIMILAR COMPLAINTS IN THE PAST AND WAS ADMITTED IN THIS HOSPITAL FROM

06/12/23 ΤΟ 13/12/23

N/K/C/O DM, ASTHMA, EPILEPSY, TB, CVA

GENERAL EXAMINATION

PT IS C/C/C

BP-120/70MMHD

PR-88BPM

SPO2-97

RR-19CPM

SYSTEMIC EXAMINATION

CVS-S1S2+

RS-NVBS

CNS-NFND

P/A-SOFT,NT

Investigation

CBP HB-7.5 TC-7000 PLT-2.3

RFT UR-105 CR-5.22D ECHO

TRIVIAL MR, NO AS/MS

NO RWMA

EF 64%, GOOD LV FUNCTION

NO DIASTOLIC DYSFUNCTION

NO PE/LV CLOT

Treatment Given (Enter only Generic Name)

TAB.OROFER XT PO OD

TAB. SHELCAL PO OD

TAB LASIX 40MG PO BD

TAB MET-XL 25MG PO OD

TAB. NICARDIA RETARD 20 MG TID

TAB. TELMA 80 MG PO OD

FLUID RESTRICTION AND SALT RESTRICTION

Advice at Discharge

TAB.OROFER XT PO OD

TAB. SHELCAL PO OD

TAB. LASIX 40MG PO BD

TAB MET-XL 25MG PO OD

TAB. NICARDIA RETARD 20 MG TID

TAB TELMA 80 MG PO OD

FLUID RESTRICTION AND SALT RESTRICTION

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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