CODE Y3


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

202349224

UHID 20231100000

Pay Type

Credit(AROGYA SREE)

Age/Gender :55 Years/Male

Address

Discharge Type: Relieved

Admission Date: 02/11/2023 05:08 PM

Name of Treating Faculty

DR.SRIRAMULU

Diagnosis

CKD ON MHD

POLYCYSTIC KIDNEY DISEASE K/C/CO HTN,DM

Case History and Clinical Findings

PT WAS BROUGHT TO HOSPITAL WITH C/O FEVER SINCE 15 DAYS, GENERALIZED WEAKNESS SINCE 10 DAYS, BURNING MICTURITION SINCE 10 DAYS, COUGH SINCE 10 DAYS, MULTIPLE JOINT PAINS SINCE 1 WEEK

OCCASIONAL IRRITABILITY PRESENT, FLUCTUATING SENSORIUM SINCE 10 DAYS

HOPI-PT WAS APPARENTLY ASYMPTOMATIC 15 DAYS BACK THEN HE DEVELOPED FEVER WHICH IS HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, CONTINUOUS, RELIEVED WITH MEDICATION, NO DIURNAL VARIATION

GENERALISED WEAKNESS SINCE 10 DAYS

BURNING MICTURITION SINCE 10 DAYS

COUGH SINCE 10 DAYS, PRODUCTIVE COUGH, SCANTY, NON-FOUL SMELLING, NOT BLOOD

STAINED

MULTIPLE JOINT PAINS SINCE 1 WEEK, OCCASIONAL IRRITABILITY +

FLUCTUATING SENSORIUM SINCE 10 DAYS, NOT ABLE TO IDENTIFY ATTENDERS SOMETIMES, IRRELEVANT TALK PRESENT

H/O VOMITINGS SINCE 1 WEEK, NON-BILIOUS, NON PROJECTILE, NON BLOOD TINGED

HJO HYPOGLYCEMIC EPISODES PRESENT, 3 EPISODES 3 MONTHS AGO

PAST HISTORY - KICIO TYPE 2 DM SINCE 20 YRS ON UNKNOWN MEDICATION, STOPPED MEDICATION SINCE 3 MONTHS

HTN SINCE 15 YRS

N/KICIO, TB, ASTHMA, CAD, CVA, EPILEPSY

PERSONAL HISTORY -

DIET-MIXED

APPETITE-NORMAL

SLEEP ADEQUATE

BOWEL REGULAR

ADDICTIONS-CONSUMED ALCOHOL REGULARLY DAILY 2-3 QUARTERS STOPPED 4

MOTNHS AGO

TOBACCO SNUFF SINCE 30 YRS ABOUT 10-12 CIGARETTES PER DAY

BETEL LEAF CONSUMPTION SINCE 20 YRS

GENERAL PHYSICAL EXAMINATION -

PATIENT IS CONCIOUS, COHERENT, COOPERATIVE

VITALS.

PR-98 BPM

BP-160/100 MM HG

RR-18 CPM

TEMP-AFEBRILE

GRBS-105 MG/DL

SPO2-98@ RA

SYSTEMIC EXAMINATION-

CVS S1 S2+

RS BAE TRACHEA CENTRAL NVBS HEARD

PIA SOFT, NON TENDER

CNS-NFND

Investigation

CBP HB TCN LEMB PLT SMEAR RFT UR CRUA CA-2P NA+ K+ CL- HIV HBSAG

HCVNameValueName Value

HBsAg-RAPID01-11-2023 03:42:PM

Negative LIVER FUNCTION TEST (LFT) 01-11-2023 03:42:PM Total Bilurubin

0.59 mg/dl

Direct Bilurubin

0.16 mg/dlSGOT(AST)

18 IU/L

SGPT(ALT)

17 IU/LALKALINE PHOSPHATE

323 IU/L

TOTAL PROTEINS

6.4 gm/dl

ALBUMIN

3.4 gm/dl

2D ECHO

TRIVIAL AR, MILD TR

NON AS/MS

EF 62%, GOOD LV FUNCTION

NON DIASTOLIC DYSFUNCTION

MILD CONCENTRIC LVH

NO PE/NO RWMA/ NO LV CLOT

Treatment Given(Enter only Generic Name)

1.TAB NICARDIA 20 MG PO TID2 FLUID RESTRICTION LESS THA 1.5 L/DAY3.TAB PAN 40 MG PO OD4. TAB LASIX 80 MG PO/BD5.TAB OROFER XT PO/OD6. SALT RESTRICTION LESS THAN 2G/DAY7.EPO 4000 IU SC ONCE WEEKLY

Advice at Discharge

1.TAB NICARDIA 20 MG PO TID2. FLUID RESTRICTION LESS THA 1.5 L/DAY3. TAB PAN 40 MG PO OD4.TAB LASIX 80 MG PO/BD5.TAB OROFER XT PO/OD6. SALT RESTRICTION LESS THAN 2G/DAY7 EPO 4000 IU SC ONCE WEEKLY

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:06/12/2023

Ward NEPHROLOGY

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