CODE SH


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

IPID

202307564

Pay Type

Credit AROGYA SREE)

Age/Gender : 27 Years/Male

Address

Discharge Type: Rellerved

Admission Date: 16/02/2023 02:34 PM

Name of Treating Faculty

DR. SRI RAMULU (PROFFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CIO DECREASED URINE OUTPUT SINCE 1 MONTH

PEDAL EDEMA SINE 1 MONTH

COUGH ON AND OFF

C/O HEADACHE

PAST H/O:

KICIO HTN SINCE 3 YEARS

PERSONAL HISTORY

MIXED DIET

DECREASED URINE OUTPUT

NORMAL APPETITE

ADEQUATE SLEEP

BOWEL AND BLADEER HABITS REGULAR

ADDICTIONS-SMOKING

NO ALLERGIES

GENERAL EXAMINATION-

PT IS CACAC

PALLOR PRESENT

NO SIGNS OF ICTERUS CYANOSIS, CLUBBING, LYMPHEDENOPATHY

EDEMAOF FEET-PRESENT(GRADE-II)

TEMP AFEBRILE

PR- 1128PM

BP-150/100MMHG

RR-24CPM

SPO2-97% @RA

GRBS-128MG%

CVS-S1S2+, NO MURMURS

RS- BAE+, B/L CREPTS PRESENT

PIA SOFT, NONTENDER

CNS- NFND

Investigation

CBP

HB 8.1 G/DL

TC-10,300 CELLS/CUMM

RBC-304MILLION/CUMM

PLT-4.87 LAKHS/CUMM

SMEAR-NCNC

RFT

UR-86MG/DL

CR-6.4MG/DL

CA+9,6MEQAL

P582MEQM

NA+ 134MEQA

K+4.5MEQ/L

CL-98MEQ/L

SEROLOGY-NEGAT ME

TB-0.80 MG/DL

DB-0.18MG/DL

AST 10 IUAL

ALT-10 IU/AL

ALP-2921UL

TP-5.6G/DL

ALBUMIN-2.6G/DL

SERUM IRON-56 MG/DL

CUE-ALBUMIN+++

SUGARS NIL

USG

RT KIDNEY-S/P NEPHRECTOMY

LEFT KIDNEY 6.1X2.5 CMS CMD LOST

MPRESSION-LEFT GRADE III RPD CHANGES

2D ECHO

MILD LVH

LAAND LVARE DILATED

GOOD LEFT VENTRICULAR SYSTOLIC FUNCTION

GOOD LV DIASTOLIC FUNCTION

NO RUMA

MODERATEPERCAR DIAL EFFUSION

EF-68%

MILDAR MODERATETR

Treatment Given (Enter only Generic Name)

TAB LASIX 40MG/PO/BD

TAB NICARDIA 20MG PO/BD

TAB TELMA 40 MG OD

TAB SHELCAL CT 5000MG PO/OD

TAB METAPROLOL 25MG/BD

INJ ERYTHROPOITIN 4000U SAC WEEKLY ONCE

INJ IRON SUCROSE 100MG+100ML NS ONCE WEEKLY

Advice at Discharge

TAB LASIX 40MG/PO/BD

TAB NICARDIA20MG PO/BD

TAB TELMA 40 MG/OD

TAB SHELCAL CT 5000MG PO/OD

TAB METAPROLOL 25MG/BD

INJ ERYTHROPOITIN 4000U SAC WEEKLY ONCE

INJ IRON SUCROSE 100MG+100ML NS ONCE WEEKLY

Follow Up

REVIENTO NEPHROLOGY OPD AFTER 2 DAYS

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 ADMCE, DONOTMISS 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: 19/03/2023

Ward: CKD

Unit: NEPHROLOGY

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