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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.

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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

202410586

UHID 20240307341

Pay Type

Credit(AROGYA SREE)

Age/Gender: 66 Years/Male

Address

Discharge Type: Relieved

Admission Date: 05/03/2024 06:48 PM

Name of Treating Faculty

DR.SRI RAMULU HOD

Diagnosis

CHRONIC RENAL FAILURE

Case History and Clinical Findings

C/O BIL PEDAL EDEMA SINCE 3MONTHS

CIO LOSS OF APPETITE SINCE 1MONTH

HOPI:PT WAS APPARENTLY ASYMPTOMATIC 3MONTHS BACK THEN DEVELOPED B/L PEDAL EDEMA WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE PITTING TYPE OF EDEMA UPTO THE KNEES.

CIO LOSS OF APPETITE SINCE 1 MONTH

NO H/O FEVER, NAUSEA, VOMITING

NO H/O ABDOMINAL PAIN, BURNING MICTURITION

NO HIO INVOLUNTARY MICTURATION AND DEFECATION

NO HAO INVOLUNTARY MOVEMENTS

NO HIO SOB, ORTHOPNEA,PND

NO H/O BLEEDING MANIFESTATION

PAST HISTORY

KICIO HTN SINCE 1 YEARS (NON COMPLIANT TO DRUGS)

N/K/C/O DM,EPILEPSY, ASTHMA, CAD,CVA AND THYROID DISORDERS

GENERAL EXAMINATION

NO PALLOR, ICTERUS, CYANOSIS CLUBBING, LYMPHADENOPATHY

OEDEMA OF FEET IS PRESENT

TEMP-98.2 F

RR 20 CPM

PR-88BPM

BP-150/80 MM HG

SPO2 98% @RA

CVS-S152 HEARD, NO MURMURS

RS-BAE PRESENT

P/A-SOFT NON TENDER NO ORGANOMEGALY

CNS-NFND

IN TOTAL 4 SESSIONS OF DIALYSIS DONE UROLOGY REFERRAL DONE ON 8/3/24 I/VIO AV FISTULA

ADVISED:

B/L UPPER LIMB DOPPLER FOR AV FISTULA CREATION

-B/L UPPER LIMB STRESS BALL PHYSIOTHERAPY X 2WEEKS

-AVOID LEFT UPPER LIMB IV CANNULATION.

CENTRAL LINE WAS SECURED ON 5/3/24

Investigation

HEMOGRAM

HB-4.7

TLC-5400

N/L/E/M/B-65/22/03/10/00

PCV-14 2

MCV-82.6

MCH-27.3

MCHC-33.1

RDW-CV:18.8

RDW-SD:56.9

RBC COUNT-1.72

PLATELET COUNT-1.4

SERUM IRON-54

RBS-137MG/DL

BLOOD GROUP-B POSITIVE

BLOOD UREA 05-03-2024 03:29:PM 239 mg/dl

SERUM CREATININE 05-03-2024 03:29 PM 13.3 mg/dl

COMPLETE URINE EXAMINATION (CUE) 05-03-2024 07:21 PM

COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP GRAVITY 1.010ALBUMIN

+++SUGAR NIBILE SALTS NIIBILE PIGMENTS NIIPUS CELLS 4-5EPITHELIAL CELLS 2-3RED

BLOOD CELLS NIICRYSTALS NIICASTS NILAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 05-03-2024 07:21:PM

UREA 242 mg/dICREATININE 13.2 mg/dIURIC ACID 8.5 mg/dICALCIUM 8.7 mg/dIPHOSPHOROUS 5.9 mg/dISODIUM 137 mEq/LPOTASSIUM 5.8 mEq/LCHLORIDE 103 mEq/L

LIVER FUNCTION TEST (LFT) 05-03-2024 07:21:PM

Total Bilurubin 0.67 mg/dlDirect Bilurubin 0.19 mg/dISGOT(AST) 28 IU/LSGPT(ALT) 16

IU/LALKALINE PHOSPHATASE 455 IU/LTOTAL PROTEINS 7.3 gm/dIALBUMIN 4.4 gm/dIA/G RATIO 1.56

HBsAg-RAPID 05-03-2024 07:21 PM Negative

Anti HCV Antibodies - RAPID 05-03-2024 07:21 PM Non Reactive

RFT 06-03-2024

UREA 145 mg/dICREATININE 8.7 mg/dIURIC ACID 5.2 mg/dICALCIUM 9.2 mg/dIPHOSPHOROUS 4.4 mg/dISODIUM 143 mEq/LPOTASSIUM 4.0 mEq/LCHLORIDE 102 mEq/L

USG ABDOMEN AND PELVIS DONE ON 5/3/24

IMPRESSION:

-B/L GRADE-III RPD CHANGES

2D ECHO

TRIVIAL AR, TRIVIAL MR, TRIVIAL TR WITH PSH

EF 66%, GOOD LV FUNCTION

GRADE I DFIASTOLIC DYSFUNCTION

MILD CONCENTRIC LVH

NO RWMA, NO PE/LV CLOT

Treatment Given (Enter only Generic Name)

FLUID RESTRICTION LESS THAN 1.5 L/DAY

SALT RESTRICTION LESS THAN 2-3 GM/DAY

TAB.LASIX 80 MG PO BD

INJ.EPO 4000 IU SIC ONCE A WEEK

INJ IRON SUCROSE 100 MG IN 100 ML NS IV OD

TAB NICARDIA 20 MG PO TID

TAB TELMA 60 MG PO OD

TAB.OROFER-XT PO OD

TAB SHELCAL-CT PO OD

TAB MET XL 25MG PO/OD

Advice at Discharge

FLUID RESTRICTION LESS THAN 1.5 L/DAY

SALT RESTRICTION LESS THAN 2-3 GM/DAY

TAB LASIX 80 MG PO BD

INJ.EPO 4000 IU S/C ONCE A WEEK

INJ IRON SUCROSE 100 MG IN 100 ML NS IV OD

TAB.NICARDIA 20 MG PO TID

TAB TELMA 80 MG PO OD

TAB OROFER-XT PO OD

TAB SHELCAL-CT PO OD

TAB MET XL 25MG PO/OD

Follow Up

REVIEW NEPHROLOGY 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: 11/3/24

Ward CKD

Unit NEPHROLOGY


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