CODE TI


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

202358028

JUHID 20231242201

Pay Type

Credit(AROGYA SREE)

Age/Gender 55 Years/Male

Address

Discharge Type: Relieved

Admission Date: 27/12/2023 08:48 PM

Name of Treating Faculty

DR. RAMULU (HOD)

Diagnosis

CKD 2 TO DIABETES

ANEMIA OF CHRONIC DISEASE

K/C/O DM 6YRS, HTN 1YR

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 4 MONTHS,

CIO DECREASED URINARY OUTPUT SINCE 4 MONTHS

HE WAS APPARENTLY ASYMPTOMATIC 4 MONTHS BACK THEN HE DEVELOPED B/L PITTING

EDEMA UPTO KNEE

NO H/O SOB, CHEST PAIN, PALPITATIONS

NO HIO NAUSE AND VOMITING

H/O HTN SINCE 1 YR ON TELMA 40MG

H/O DM SINCE 6YRS ON LINAGLIPTIN 5MG

GENERAL EXAMINATION PATIENT IS CONSCIOUS, COHERENT.COOPERATIVE, WELL ORIENTED TO TIME, PLACE AND

PERSON PALLOR,ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY EDEMA PRESENTVITALS TEMPERATURE:98.2FBP 150/100 MM HGPR 88 BPMRR:18 CPMSYSTEMIC EXAMINATION:CVS:S1,S2 HEARD NO MURMURS RS BAE NO MURMURSCNS NO FOCAL NEUROLOGICAL DEFICITS.

Investigation

CBP HB 9.4 TC 10400 PLT 4.4 SMEAR NCNC 
COMPLETE URINE EXAMINATION (CUE)

27-12-2023 12:05:PM COLOURPale

yellowAPPEARANCE ClearREACTIONAcidicSP.GRAVITY1010ALBUMIN+SUGARNIIBILE

SALTSNIBILE PIGMENTSNIIPUS CELLS3-4EPITHELIAL CELLS2-3RED BLOOD CELLSNIICRYSTALSNIICASTSNIIAMORPHOUS DEPOSITSAbsentOTHERSNilAnti HCV Antibodies

RAPID Non Reactive HBsAg-RAPIDNegative LIVER

FUNCTION TEST (LFT)  Total Bilurubin0.50 mg/dlDirect Bilurubin0.16

mg/dISGOT(AST)19 IU/LSGPT(ALT)12 IU/LALKALINE PHOSPHATE 359 IU/LTOTAL PROTEINS6.7 gm/dIALBUMIN3.4 gm/dIA/G RATIO1.02RFT 27-12-2023 12:05 PM UREA101 mg/dICREATININE6.2

mg/dIURIC ACID6.9 mg/dICALCIUM9.1 mg/dIPHOSPHOROUS3.5 mg/dISODIUM141

mEq/LPOTASSIUM3.5mEq/LCHLORIDE99 mEq/LRFT 05-01-2024 05:55:PM UREA67

mg/diCREATININE6.8 mg/dIURIC ACID5.0 mg/dICALCIUM8.4 mg/dIPHOSPHOROUS2.6 mg/dISODIUM136 mEq/LPOTASSIUM4.4 mEq/LCHLORIDE101 mEq/

2D ECHO ON 8/01/2024

EF 58%

LEFT ATRIUM 3.2CM

MILD LVH, NO RWMA

IVC COLLAPSING[1.25 CMS]

TRIVIAL MR, MILD TO MODERATE AR+, MILD TR+WITH PAH

NO RWMA, NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION PRESENT

USG ABDOMEN 27/12/23

RIGHT GRADE II AND LEFT GRADE II RPD CHANGES

B/L RENAL CORTICAL CYSTS

IRREGULAR BLADDER WALL THICKENING CYSTITIS

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION <1.5L/DAYSALT RESTRICTION <2GM/DAYTAB TELMA 40MG PO/ODTAB.

LASIX 80 MG PO/BDTAB SHELCAL PO/ODTAB NICARDIA 20 MG PO/TIDCAP BIO D3 PO/ODINJ IRON SUCROSE 100 MG IV/ ONCE IN 2 WEEKSINJ EPO 4000 IU SC ONCE IN 2 WEEK

Advice at Discharge

FLUID RESTRICTION <1.5L/DAYFLUID RESTRICTION <1.5L/DAYSALT RESTRICTION <2GM/DAYTAB TELMA 40MG PO/ODTAB. LASIX 80 MG PO/BDTAB SHELCAL PO/ODTAB NICARDIA 20 MG PO/TIDCAP BIO D3 PO/ODINJ IRON SUCROSE 100 MG IV/ ONCE IN 2 WEEKSINJ EPO 4000 IU SC ONCE IN 2 WEEK

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 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:27/1/24

Ward: CKD

Unit: NEPHROLOGY.

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