CODE VB


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

20225 35 19

Pay Type

CreditAROGYAOREE

Age Gender

66 Years Male

Address

Chacharge Type: Relieved 

Admissiba Date: 22/12/2022 12:22 PM

Name of Treating Faculty DR.SRIRAMULU(HOD)

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O SHORTNESS OF BREATHSINCE 10 MONTHS

BA PEDAL EDEMA SINCE 10 MONTHS

DECREASED URINE OUTPUT SINCE 2 MONTHS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK, HE WAS A K/C/O CKD ON CONSERVATIVE MEMANAGEMENT

FROM 10 MONTHS HE IS ON MANTANANCE HEMODIALYSISC/O SHORTNESS OF BREATH AGGRAVATED ON EXERTION

BAL PEDAL EDEMA TILL KNEES PITTING TYPE ASSOCIATED WITH DECREASED URINE

OUTPUT

PAST HISTORY

IS K/C/O HTN SINCES YEARS IS ON NICARDIA 10 MGPOTID

NOT AK/C/O HTN, ASTHMA, EPILEPSY

GENERAL EXAMINATION:

PT IS CONSCIOUS, COHERENT AND COOPERATIVE

PALLOR PRESENT

NO ICT ERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY AND PEDAL OEDEMA

TEMP-98.6F

PR:82 BPM

RR:16 CPM

BP:120/80MMHG

SPO2:98% ON RA

GRBS:102MG/DL

CVS: S1 S2 PRESENT

RS:BAE +

CNS:NAD

PER ABDOMEN: SOFT, NON TENDER

Investigation

CBP

HB 4.6G/DL

TC-4,200CELLS/CUMM

RBC-1.61 MILLIONS/CUMM

PLT-1.20 LAKHS /CUMM

SMEAR-NCNC

RFT

UR-133MG/DL

CR-13.4MG/DL

CA+10.1MEQ/L

P 5.4MEQ/L

NA+ 141MEQ/L

K+5 MEQ/L

CL-104MEQ/L

SEROLOGY-NEGATIVE

TB-0.6 MG/DL

DB-0.21MG/DL

AST-10IU/L

ALT-10IU/L

ALP-102IU/L

TP-5.8G/DL

ALBUMIN -3.6G/DL

SERUM IRON-68MG/DL

USG
RT KIDNEY -8.1 X 3.5 CMS, CMD LOST

LEFT KIDNEY -7.5X3.3CMS CMD LOST

IMPRESSION-RT GRADE II AND LEFT GRADE III RPD CHANGES

2D ECHO

NO CONCENTRIC LVH

NO DILATED CHAMBERS

GOOD VENTRICULAR SYSTOLIC FUNCTION

GRADE ILV DIASTOLIC DYSFUNCTION

NO RWMA

NO PERCARDIAL EFFUSION

EF-68%

TRIVIAL TR AND AR

Treatment Given (Enter only Generic Name)

SALT RESTRICTION <2GM/DAYFLUID RESTRICTION <1.5LTR/DAYT.LASIX 80 MG ODT

SHELCAL 500MG ODTAB.NICARDIA 20MG/TIDINJ EPO 4000 IU SC ONCE WEKLYINJ IRON

SUCROSE 100 MG/IV/ONCE WEEKLY

Advice at Discharge

SALT RESTRICTION <2GM/DAY
FLUID RESTRICTION <1.5LTR/DAY
T LASIX 80 MG OD.
T. SHELCAL 500MG OD
TAB.NICARDIA 20MG/TID
INJ EPO 4000 IU SC ONCE WEKLY
INJ IRON SUCROSE 100 MG/IV/ONCE WEEKLY

Follow Up

REVIEW AFTER 1 WEEK OR 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: 18/1/23

Ward:NEPHROLOGY

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