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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

202308180

UHID

20230231623

Pay Type

Credit (AROGYA SREE)

Age/Gender

71 Years/Female

Address

Discharge Type: Relieved

Admission Date: 21/02/2023 03:10 PM

Name of Treating Faculty DR. SRI RAMULU (PROFFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O BREATHLESSNESS SINCE 1 YEAR

C/O PEDAL EDEMA SINCE 1 YEAR

C/O DECREASED URINE OUTPUT SINCE 1 YEAR

K/C/O CHRONIC KIDNEY DISEASE ON MHA SINCE 2 YEARS

HOPI

PT. WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK THEN HAD CIO BREATHLESSNESS, FACIAL PUFFINESS AND DECREASED URINE OUTPUT FOR WHICH SHE WAS DIAGNOSED WITH CKD AND WAS STARTED ON HEMODIALYSIS ON JAN 2023. TOTAL DIALYSIS 14 WITH

RIGHT AV FISTULA

PAST HISTORY-

KIC/O HTN SINCE 3YRS

NOT A K/C/O TB/ASTHMA/DM/CAD/EPILEPSY

PERSONAL HISTORY-

MIXED DIET

NORMAL APPETITE

ADEQUATE SLEEP

BOWEL AND BLADEER HABITS REGULAR

NO ADDICTIONS

NO ALLERGIES

GENERAL EXAMINATION

PT. IS C/C/C

B/L PEDAL EDEMA PRESENT TILL KNEE

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY

TEMP-AFEBRILE

PR-74BPM

BP-140/90MMHG

RR-22CPM

CVS-S1S2+ NO MURMURS

RS-BAE+NVBS

PIA-SOFT,NT

BRIEF COURSE IN HOSPITAL-

PT CAME WITH COMPLAINTS OF BREATHLESSNESS SINCE 1 YEAR

C/O PEDAL EDEMA SINCE 1 YEAR

CIO DECREASED URINE OUTPUT SINCE 1 YEAR

K/C/O CHRONIC KIDNEY DISEASE ON MHA SINCE 3 YEARS

IVIO DERANGED RENAL PARAMETERS 9 SESSIONS OF DIALYSIS WAS DONE

Investigation

CBP

HB 9.4 G/DL

TC 7500CELLS/CUMM

PLT-2.68 LAKHS/CUMM

SMEAR-NCNC

RFT

UR-31MG/DL

CR-3.5MG/DL

CA+9.0 MEQ/L

P 2.4 MEQ/L

NA+148MEQ/L

K+3.3 MEQ/L

CL-104MEQ/L

SEROLOGY-NEGATIVE

TB-0.70 MG/DL

DB-0.20MG/DL

AST-16IU/L

ALT-20IU/L

ALP-174IU/L

TP-6.8G/DL

ALBUMIN-3.4G/DL

SERUM IRON-40 MG/DL

USG

RT KIDNEY-7X3.3 CMS, CMD LOST

LEFT KIDNEY -7.7 X 3 CMS CMD LOST

IMPRESSION -B/L GRADE III RPD CHANGES

2D ECHO

MILD CONCENTRIC LVH EF-62%

NO DILATED CHAMBERS

GOOD SYSTOLIC FUNCTION

GRADE I DIASTOLIC DYSFUNCTION

MINIMAL PERCARDIAL EFFUSION

MILD AR TRIVIAL TR

Treatment Given (Enter only Generic Name)

1.TAB.DYTOR 100MG/EBD

2. TAB. SHELCAL 500MG PO/BD

3. TAB METAPROLOL 25MG/BD

4.TAB. NICARDIA 20MG PO/TID

5.INJ. EPO 4000 IV/SC/ONCE WEEKLY

6.INJ. IRON SUCROSE 100MG PO/ONCE DAILY

Advice at Discharge

1.TAB DYTOR 100MG/BD

2 TAB. SHELCAL 500MG PO/BD

3. TAB METAPROLOL 25MG/BD

4. TAB. NICARDIA 20MG PO/TID

S.INJ. EPO 4000 IV/SC/ONCE WEEKLY

6.INJ. IRON SUCROSE 100MG PO/ONCE DAILY

Follow Up

REVIEW TO 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 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: 25/03/2023

Ward CKD

Unit: NEPHROLOGY

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