CODE UH


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 202314192

UHID 20230345040

Pay Type

Credit (AROGYA SREE)

Age/Gender 48 Years/Female

Address

Discharge Type: Relieved

Admission Date: 30/03/2023 12:18 PM

Name of Treating Faculty

DR. SRI RAMULU (PROFESSOR)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

COMPLAINTS:

PATIENT CAME WITH C/O DECREASED URINE OUTPUT SINCE 1WEEK C/O PEDAL EDEMA SINCE 1 WEEK

PRESENT ILLNESS

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 WEEK BACK THEN SHE DEVELOPED DECREASED URINE OUTPUT WHICH WAS INSIDIOUS IN ONSET C/O PEDAL EDEMA BELOW KNEE

NO HIO NAUSEA, VOMITING, FEVER

PAST HISTORY

K/C/O HTN SINCE 15 YEARS

K/C/O DM SINCE 20 YEARS

N/K/C/O CAD/CVD/TB/EPILEPSY

EXAMINATION

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

BP: 140/90MMHG

PR:948PM

RR:24CPM

TEMP:AFEBRILE

CVS: S152+

RS: BAE +

CNS: NFND

Investigation

CBP

HB 8.9G/DL

TC-7400 CELLS/CUMM

RBC-3.23MILLION/CUMM

PLT-2.97LAKHS/CUMM

SMEAR-NCNC

RFT

UR-188MG/DL

CR-6.8MG/DL

CA+9.7 MEQ/L

P 5.2 MEQ/L

NA+ 137MEQ/L

K+ 4.3 MEQ/L

CL-102MEQ/L

SEROLOGY-NEGATIVE

TB-0.52 MG/DL

DB-0 12MG/DL

AST-22IU/L

ALT-24U/L

ALP-239IU/L

TP-7.1G/DL

ALBUMIN -3:2G/DL

SERUM IRON-72 MG/DL

CUE-ALBUMIN++

SUGARS-NIL

USG

RT KIDNEY-7.3 X 4 CMS, CMD PARTIALLY LOST

LEFT KIDNEY 8.8X 3.5 CMS CMD PARTIALLY LOST

IMPRESSION -BAL GRADE II RPD CHANGES

20 ECHO

MILD LVH

LA IS DILATED EF 55%

GOOD VENTRICULAR SYSTOLIC FUNCTION

GRADE ILV DIASTOLIC DYSFUNCTION

NO RWMA

NO PERCARDIAL EFFUSION, LV CLOT

TRIVIAL AR,MR, TR; NO MS/AS

Treatment Given(Enter only Generic Name)

SALT RESTRICTION DIET<2GM/DAYFLUID RESTRICTION<1LT/DAYINJ EPO 4000 IU S/C ONCE

WEEKLYINJ IRON SUCROSE 100 MG/AV/ONCE WEEKLYTAB SHELCAL 500MG PO/ODTAB TELMA BOMG/ODTAB NICARDIA 20MG/TIDEP MONITORING REGULARLYTAB LASIX 80MG /BD

Advice at Discharge

SALT RESTRICTION DIET<2GM/DAYFLUID RESTRICTION<1LT/DAYINJ.EPO 4000 IU S/C ONCE

WEEKLYINJ IRON SUCROSE 100 MG/IV/ONCE WEEKLYTAB SHELCAL SOOMG PO/ODTAB TELMA 80MG/QDTAB.NICARDIA 20MG/TIDBP MONITORING REGULARLYTAB LASIX 80MG /BD

Follow Up

REVIEW TO NEPHROLOGY OPD OR 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 Enquines 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: 13/05/23

Ward: CKD

Unit: NEPHROLOGY

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