CODE RX


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
202402685

UHID 20240126621

Pay Type

Credit AROGYA SREE)

Age/Gender 52 Years/Female

Address

Discharge Type: Relieved

Admission Date: 17/01/2024 06:56 PM

Name of Treating Faculty

DR SRIRAMULU(HOD)

Diagnosis

STAGE 5 CHRONIC KIDNEY DISEASE ON MAINTAINENCE HEMODIALYSIS

T2 DM+ AND HTN+

Case History and Clinical Findings

CIO FACIAL PUFFINESS SINCE 1 MONTH

C/O PEDAL EDEMA SINCE 1 MONTH

HOPI-

PT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK THEN SHE DEVELOPED FACIAL PUFFINESS AND PEDAL EDEMA, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, WITH SOB GRADE III FOR WHICH SHE USED OUTSIDE MEDICATION AND WAS PARTALLY RELIEVED, THEN SINCE 4 DAYS SYMPTOMS GOT AGGRAVATED.

SINCE 1 DAY, DECREASED URINE OUTPUT, FEVER, COUGH WITH EXPECTORATION LOW

QUANTITY

PAST HISTORY-

K/C/O DM SINCE 5 YRS

K/C/O HTN SINCE 1 YR

NOT A KICIO CVA, CAD, EPILEPSY, TB, THYROID DISORDERS

GENERAL EXAMINATION

PT IS C/C/C

NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY.

PALLOR+

PEDAL EDEMA+

VITALS-

TEMP-98.4F

PR-86BPM

BP-140/80MMHG

RR-18CPM

SP02-98% AT RA

SYSTEMIC EXAMINATION-

CVS:S1 S2 +, JVP+

RS:BAE+, B/L BASAL CREPTS+

P/A:SOFT NON TENDER

CNS: NFND

Investigation

Anti HCV Antibodies - RAPID 17-01-2024 11:07:AM Non Reactive

HBsAg-RAPID 17-01-2024 11:07:AM Negative

LIVER FUNCTION TEST (LFT) 17-01-2024 11:07:AM

Total Bilurubin 0.6 mg/dl

Direct Bilurubin 0.18 mg/dl

SGOT(AST)33 IU/L

SGPT(ALT) 37 IU/L

ALKALINE PHOSPHATASE 256 IU/L

TOTAL PROTEINS 6.0 gm/dl

ALBUMIN 3.3 gm/dl

RFT 17-01-2024 11:07:AM

UREA 158 mg/dl

CREATININE 6.6 mg/dl

URIC ACID 6.7 mg/dl

CALCIUM 9.4 mg/dl

PHOSPHOROUS 6.0 mg/dl

SODIUM 136 mEq/L

POTASSIUM 5.3 mEq/L

CHLORIDE 101 mEq/L

BLOOD UREA 18-02-2024 10:14 AM 94 mg/dl

SERUM CREATININE 18-02-2024 10:14:AM 3.2 mg/dl

SERUM ELECTROLYTES (Na, K, CI) AND SERUM IONIZED CALCIUM 18-02-2024 10:14:AM

SODIUM 146 mEq/L

POTASSIUM 3.7 mEq/L.

CHLORIDE 106 mEq/L

CALCIUM IONIZED 1.26 mmol/L

COMPLETE BLOOD PICTURE (CBP) 18-02-2024 10:14:AM

HAEMOGLOBIN 9.6 gm/di

TOTAL COUNT 9600 cells/cumm

NEUTROPHILS 76%

LYMPHOCYTES 20%

EOSINOPHILS 00%

MONOCYTES 04%

BASOPHILS 00%

PLATELET COUNT 2.04

SMEAR Normocytic normochromic anemia

USG

IMPRESSION-B/L RENAL CORTICAL CYSTS

B/L MODERATE PLEURAL EFFUSION

BIL KIDNEYS SHOW RAISED ECHOGENECITY

2D ECHO

MODERATETR+ WITH PAH, MODERATE AR+ MODERATE MR+

NO RWMA, NO AS/MS, SCLEROTIC AV

EF 62%, GOOD LV SYSTOLIC FUNCTION

DFILATED CHAMBERS

MILD CONCENTRIC LVH

MINIMAL PE, NO LV CLOT

NO DIASTOLIC DYSFUNCTION, NO LV CLOT

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION LESS THAN 1.5 LIT/DAY

SALT RESTRICTION LESS THAN 2 GM/DAY

T.NICARDIA 20 MG PO/TID

T.TELMA 40MG PO/OD

T.OROFER XT PO/OD

T. ARKAMINE 0.1 MG PO/BD

T.FUROSEMIDE 80MG PO/BD

T.SHELCAL CT PO/OD

INJ IRON SUCROSE 100MG IV/ONCE IN 2 WEEKS

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

Advice at Discharge

FLUID RESTRICTION LESS THAN 1.5 LIT/DAY

SALT RESTRICTION LESS THAN 2 GM/DAY

T.NICARDIA 20 MG PO/TID

T.TELMA 40MG PO/OD

T.OROFER XT PO/OD

T. ARKAMINE 0.1 MG PO/BD

T.FUROSEMIDE 80MG PO/BD

T.SHELCAL CT PO/OD

INJ IRON SUCROSE 100MG IV/ONCE IN 2 WEEKS

INJ. EPO 4000 IU SC ONCE IN 2 WEEKS

Follow Up

REVIEW AFTER 1 WEEK OR SOS TO NEPHROLOGY 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

SIGNATUREOF PATIENT ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date: 19/2/24

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