case of 74 year old male

Patient came to the casuality with the chief complaints of

1. Generalised body pains

2. Vomitings

3. Slurring of speech

4. Not able to swallow solids or liquids 

The patient was apparantly asymptomatic 4 days back.  Then he developed generalised body pains, insidious in onset for which he took medicines from the local RMP. He had 4 episodes of vomiting, non projectile, non bilious, non foul smelling, no blood stain and had food particles as their content. Yesterday alone he had 3 episodes of vomitings, non projectile, non bilious, non foul smelling, no blood stain and had food particles as their content. Today morning he had sudden onset slurring of speech and was unable to swallow any solids or liquids.

Patient is having decreased ambulation. Has been walking with the help of a stick since 1 year. 

K/C/O DM2 (since 20years)(on inj mixtard 35u - X - 30u)

Cervical spondylitis (since 10 years)

Used TB medication for 18 months. After starting TB medicines for 5 months he developed diminished vision(regained after 2 months)

 decreased ambulatory, confined to bed

From 1 year patient is walking with stick

Personal history:

Appetite: Normal

Diet: Mixed

Bowel and bladder: Regular

Addictions: 4 years back alcohol(180ml/day), cigarette(80/day), now stopped

O/E

Patient is conscious coherent and cooperative

Vitals:

BP:130/70, Temp:98.4f, PR:100/min, RR:24/min, SpO2:92% on RA, GRBS: 557mg/dl

Cvs: S1,S2+

RS: BAE+, NVBS

CNS: 

1)Intellectual functions

 -patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory present

-appearence-well kept

-speech-normal 

2)cranial nerves

Olfactory-smell present on both sides

Optic-visual acuity -CF 6 metres

    Visual field,colour vision,reflexes -normal 

3,4,6 cranial nerves-ocular movements -present

         Nystagmus,pros is,Diplopia-absent

       Pupils are normal

Trigeminal -motor and sensory functions normal on both sides

 Facial nerve

-deviation of mouth towards left side

-frowning present

-absent nasolabial folds on right side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflexpresent on both sides

Vestibulocochlear nerve-rinnes Weber,schwabach test Negative on both sides

Vagus and glossopharyngeal -uvula midline

Spinal accessory-shrugging of shoulders present

Hypoglossal-no deviation of tongue

3)Motor system

A)attitude and position-Normal

B)bulk-no wasting

C)tone-Rt Lt

UL N N

LL N N

D)power-

UL Rt Lt

      -5/5 -5/5

LL -5/5 4/5

4)Reflexes

Superficial Rt Lt

  Corneal +2 +2

 Conjunctival +2 +2

Abdominal +2 +2        

Deep Rt Lt

Biceps Hyperreflex

Triceps Hyperreflex

Supinator Hyperreflex

Knee Hyperreflex

Ankle Hyperreflex

5)Sensory system  

Superficial -fine touch,temperature,pain -present

Deep-position,vibration,crude touch,stereognosis,2point discrimination- present 

6)Cerebellum 

Speech,nystagmus,ataxia,tremors,released reflexes absent

7)Coordination and gait

Finger nose test ,finger finger test,heel knee test-present

Gait -dragging type

 Romberg test -negative

8)signs of meningeal irritation

Nuchal rigidity,kernigs and brudzinski’s sign - absent

Neck rigidity is present due to ossified posterior longitudinal ligament(cervical spondylosis

• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard

  INVESTIGATIONS:

1. ABG- ph;7.50

           PCO2 : 30.1

           PO2 : 76.8

          HCO3 : 23.5 

2. Blood urea:72

3.Sr.creatine : 2.3

4. LFT: 

      TB: 0.97

       DB: 0.19

   SGOT: 29

   SGPT: 27

       TP: 7.2 

ALBUMIN: 3.8

     A/G: 1.15

5. Sr.Elctrolytes: 

            Na+ : 136

               K+ : 4.0

             Cl-   : 90

6. RBS: 412

7. Hemogram

         HB:12.0

        TLC:14,800

       PCV : 34.1

        MCV:71.6

        MCH:25.2

        PLT:4.42L

       RBC: 4.46

8. URINE FOR KETONES: -VE

9. BLOOD GROUPING AND TYPING: O+VE

10. CUE:

      Alb:+

    Sugar:+++

    Bile salt: nil

Pus cells: 3-4

Epithelial cells:2-4

RBC: nil

11.ECG

12. USG Abdomen

13. X-RAY chest

14. X-RAY Neck

15. CT Brain 

http://pacs.kaminenihospitals.com:99/WADO/MetaData?aet=AEKIMS&studyUID=1.2.392.200036.9116.2.6.1.3268.2051739142.1630217943.758188&sessionKey=3403b2c0-14c1-4d65-a2e0-fe8ea4b0d219&src=Vijaya

16. Phantom pillow(indicative of cervical spondylosis)

Treatment given;

Day 0:

1. Inj.HAI 39ml +1ml HAI @6ml/hr til grbs is <200mg/dl

2. Tab.Ecospirin

3.tab.clopidogrel

4. Atorvastatin/49mg/Po/Od

5. GRBS 1hrly

Day1

1.Tab.Ecospirin

2.tab.clopidogrel

3. Atorvastatin/49mg/Po/Od

4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg

5. Inj NPH/SC/BD

6.TAB.ULTRACET 1/2 TAB PO QID

7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS 

8. IVF- NS @75ml/hr

9.GRBS 1hrly

Day 2

1.Tab.Ecospirin

2.tab.clopidogrel

3. Atorvastatin/49mg/Po/Od

4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg

5. Inj NPH/SC/BD

6.TAB.ULTRACET 1/2 TAB PO QID

7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS 

8. IVF- NS @75ml/hr

9. Tab.Pregablin 75mg/po/HS

10. GRBS 1Hrly

Day3

1.Tab.Ecospirin

2.tab.clopidogrel

3. Atorvastatin/49mg/Po/Od

4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg

5. Inj NPH/SC/BD

6.TAB.ULTRACET 1/2 TAB PO QID

7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS 

8. IVF- NS @75ml/hr

9.Tab Pregablin 150mg/PO in the morning

10.Tab.Pregablin-M 75mg/po/HS

DAY 4

SUBJECTIVE:
Neck and shoulder pain

Objective:
BP:150/60mmhg
PR:97bpm
RR:21/min
GRBS:
367 --8am--15HAI,12NPH
307--1pm--20HAI
217--8pm--10HAI,20NPH

ASSESSMENT:
Rt Facial Hemiparesis Lt Facial Nerve Palsy,
Peripheral Neuropathy (?ATT Induced)
K/C/O DM-II with Uncontrolled Sugars
De-novo HTN(?post pulmo tb)

Plan:

1.Tab.Ecospirin
2.tab.clopidogrel
3. Atorvastatin/49mg/Po/Od
4. Inj. HAI/SC/TID (8am--X--8pm)inform sugars to icu pg
5. Inj NPH/SC/BD
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9.Tab Pregablin 150mg/PO in the morning
10.Tab.Pregablin-M 75mg/po/HS
11. Fentanyl 1ml+4ml NS

Opthalmic Referral done for Diabetic retinopathic changes

2D-Echo Done

 

X-ray Hip

X ray LS spine

Day 5:

A Case of 74yr old male

SUBJECTIVE:
Neck and shoulder pain

Objective:
BP:120/40mmhg
PR:92bpm
RR:21/min
GRBS:
119 --8am--10HAI
189--10am--20NPH
159--1pm--10HAI
129--8pm--10HAI,20NPH

ASSESSMENT:
Rt Facial Hemiparesis Lt Facial Nerve Palsy,
Peripheral Neuropathy (?ATT Induced)
K/C/O DM-II with Uncontrolled Sugars
De-novo HTN(?post pulmo tb)
Spondyloarthropathy with radiculopathy
Sacroileitis
Cervical OPLL(ossification of posterior longitudinal ligament)

Plan:

1.Tab.Ecospirin po/Od
2.tab.PCM 650mg/po/TID
3. Amlong 2.5mg/Po/Od
4. Inj. HAI/SC/TID (10U--10U--10U)inform sugars to icu pg
5. Inj NPH/SC/BD (20U--X--20U)
6.TAB.ULTRACET 1/2 TAB PO QID
7.INJ.TRAMADOL 1Amp in 100ml NS IV SOS
8. IVF- NS @75ml/hr
9. TAB. Benadon 40mg/po/od
10.Tab.Pregablin-M 75mg/po/HS
11. INJ. Tramadol 1amp in 100ml NS/SOS

A Case of 55yr male

A 55 year old gentleman was brought to casualty in an unconscious state by his attenders who gave the history that an hour ago the patient had developed stiffness of both upper and lower limbs with repetitive blinking of eyes for 2 minutes followed by involuntary micturition. There was no history of uprolling of eye balls, tongue bite nor frothing at mouth.

The patient didn't regain consciousness thereafter.

Similar episode occured in hospital which lasted for 2 minutes.

Another episode occured after 15 minutes following the second episode again lasting for 2 min .

The patient didn't regain consciousness inbetween the episodes.

After 1 hour the patient became irritable.

The patient also has history of shortness of breath since one year,for which he has been on medication . since 4 days Sob

has progressed from grade III to grade IV since the morning. 

There no history suggestive of orthopnea, paroxysmal nocturnal dyspnea.

The patient is a chronic alcoholic who consumes 180 ml of whiskey per day.

He was also a chronic smoker who had been smoking about 40 beedis per day for the past 20-30 yrs but has stopped smoking 3 yrs ago

He also had SOB (grade IV) 3 years ago for which he took medication for 1 month and was advised by his doctor to quit smoking and drinking. He has stopped smoking but continued drinking.

GENERAL EXAMINATION

E1V1M1——>E1V2M4

Vitals

BP 100/80

PR : 145 

RR : 23

SPO2: 98

RBS : HIGH

No pallor , icterus, cyanosis, clubbing , generalized lymphedema or pedal edema present

SYSTEMIC EXAMINATION

CNS 

                   Rt Lf 

Tone UL. Hypo. Hypo

            LL. Hypo. Hypo

Power UL. - -

            LL. - -

Reflexes B. 1+. 1+

                 T. 1+. 1+

                 S. 1+. 1+

                 K. 1+. 1+

                 A. - -

                  P. Withdrawal. Mute

No signs of meningeal irritation present

CVS

S1, S2 heard 

No murmurs or thills 

Respiratory system

Barrel shaped chest

Symmetrical expansion

Trachea central in position

BAE +, NVBS 

PER ABDOMEN

Soft , non tender

Hernial orifices intact

No organomegaly detected

INVESTIGATIONS

pH - 7.1

PCo2 - 39.2

Hco3 - 11.8

PO2 - 144

So2 - 95.3

Urinary ketone bodies - negative

HBA1C - 8.5

RBS - 731

UREA- 83

Creatinine - 1.4

Na+ 130

K+ 4.2

Cl- 95

Anion gap - 28

Serum osmolality - 190.6

Calculated serum osm. - 314.46

Osm. gap - 123.86

1) Chest X-RAY

2) ECG

TREATMENT GIVEN

DAY 1

SUBJECTIVE : 

SOB since morning

OBJECTIVE : 

Afebrile

BP 100/60

PR 86

RR 15

sPO2 98% 

 

RS BAE +, Inspiratory wheeze

P/A Soft Tender 

CNS  

Tone

             Rt.         Lt 

UL.      N.          N

LL.         N.        N

Power

UL.        5/5.     5/5

LL.          5/5.      5/5

Reflexes 

B / T /S. B/L - 1+ 

K  (B/L) - +1

Ankle (B/L) - withdrawal 

Plantar -  Flexor  (B/L)

ASSESSMENT - ?DKA

? Hyperglycemic Seizures 

PLAN - 

1. Inj METROGYL 100 ML I V. TID

2. Inj MONOCEF 1GM I.V. BD

3. INJ ACTRAPID INFUCISON TILL ACIDOSIS RESOLVES (30 ML NS + 1 ML HAI) 

4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg) 

5. IVF 5% DEXTROSE @ 50ML /HR 

(ONLY IF GRBS IS <200MG/DL TILL ACIDOSIS RESOLVES) 

6..IVF NS @ 75 ML PER HR

7. O2 INHALATION TO MAINTAIN SPO2 >92%

8. STRICT I/O CHARTING 

9. GRBS 1 HRLY

Psychiatric Referral done:

Day 2

SUBJECTIVE : 

SOB since morning

OBJECTIVE : 

Afebrile

BP 100/60

PR 86

RR 15

sPO2 98% 

 

RS BAE +, Inspiratory wheeze

P/A Soft Tender 

CNS  

Tone

             Rt. Lt 

UL. N. N

LL. N. N

Power

UL. 5/5. 5/5

LL. 5/5. 5/5

Reflexes 

B / T /S. B/L - 1+ 

K (B/L) - +1

Ankle (B/L) - withdrawal 

Plantar - Flexor (B/L)

ASSESSMENT - ?DKA

? Hyperglycemic Seizures 

PLAN - 

1. Inj METROGYL 100 ML I V. TID

2. Inj MONOCEF 1GM I.V. BD

3. INJ ACTRAPID INFUCISON TILL ACIDOSIS RESOLVES (30 ML NS + 1 ML HAI) 

4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg) 

5. IVF 5% DEXTROSE @ 50ML /HR 

(ONLY IF GRBS IS <200MG/DL TILL ACIDOSIS RESOLVES) 

6..IVF NS @ 75 ML PER HR

7. O2 INHALATION TO MAINTAIN SPO2 >92%

8. STRICT I/O CHARTING 

9. GRBS 1 HRLY

Day 3

SUBJECTIVE : 

SOB And Cough

OBJECTIVE : 

Afebrile

BP 100/60

PR 86

RR 15

sPO2 98% 

 

RS BAE +, Inspiratory wheeze

P/A Soft Tender 

CNS  

Tone

             Rt. Lt 

UL. N. N

LL. N. N

Power

UL. 5/5. 5/5

LL. 5/5. 5/5

Reflexes 

B / T /S. B/L - 1+ 

K (B/L) - +1

Ankle (B/L) - withdrawal 

Plantar - Flexor (B/L)

ASSESSMENT - 

?DKA

? Hyperglycemic Seizures 

With Rt. UL cellulitis

With Rt heart failure

PLAN - 

1. Inj METROGYL 100 ML I V. TID

2. Inj MONOCEF 1GM I.V. BD

3. INJ. HAI S/C According to sliding scale

4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg) 

5..IVF NS @ 75 ML PER HR

6. O2 INHALATION TO MAINTAIN SPO2 >92%

7. STRICT I/O CHARTING 

8. GRBS 1 HRLY

Day 4 

SUBJECTIVE : 

SOB And Cough

OBJECTIVE : 

Afebrile

BP 100/60

PR 86

RR 15

sPO2 98% 

 

RS BAE +, Inspiratory wheeze

P/A Soft Tender 

CNS  

Tone

             Rt. Lt 

UL. N. N

LL. N. N

Power

UL. 5/5. 5/5

LL. 5/5. 5/5

Reflexes 

B / T /S. B/L - 1+ 

K (B/L) - +1

Ankle (B/L) - withdrawal 

Plantar - Flexor (B/L)

ASSESSMENT - 

?DKA

? Hyperglycemic Seizures 

With Rt. UL cellulitis

With Rt heart failure

PLAN - 

1. Inj METROGYL 100 ML I V. TID

2. Inj MONOCEF 1GM I.V. BD

3. INJ. HAI S/C According to sliding scale

4. INJ. LASIX 40 MG IV. BD 8 am and 4 pm (only if SBP is >110 mm of Hg) 

5..IVF NS @ 75 ML PER HR

6. O2 INHALATION TO MAINTAIN SPO2 >92%

7. STRICT I/O CHARTING 

8. GRBS 1 HRLY

56yr old female with DKA

65/M WITH RENAL AKI SECONDARY TO UTI

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE SCENARIO

A 65 yr old male came to the opd with C/C of 

Generalized weakness and not Able to walk since 2 weeks

Fever since 1 week

Loss of appetite and nausea since 1 week

B/L pedal oedema since 1 week

Decreased urine output since 1 week

Burning micturition since 1 week

Drowsiness since 1 day

HISTORY OF PRESENT ILLNESS

       Patient was apparently alright 1 week back then he had 

Insidious onset of fever, low grade, intermittent, not associated with chills and rigors. Relived on taking medication.

Pedal edema - insidious in onset, gradually progressive from foot to knee and is pitting type.

No PND and orthopnea

Fever is associated with loss of appetite, nausea, generalised weakness and unable to walk

There is decreased in the urine output and burning micturition since 1 week

From 1day the patient is drowsy and excessively sleepy

PAST HISTORY

      Not a known case of diabetes, HTN, CAD, asthma and TB

PERSONAL HISTORY

Occupation - used to work as labour in crop fields.

Appetite - Decreased

Diet - mixed

Bowel movements - regular 

Micturution - decreased

Alcohol - Regular - takes 180ml/day since 3years

FAMILY HISTORY

       No significant family history

GENERAL EXAMINATION

No pallor 

No icterus 

No cyanosis and clubbing

No lymphadenopathy 

Edema - pedal and pitting type

Vitals

Temperature - 99.4°F

PR - 103bpm

RR - 28cpm

BP - 130/70mm Hg

SpO2 - 95%

GRBS - 86 mg%

SYSTEMIC EXAMINATION

CVS:S1 S2 HEARD, NO MURMURS.

RS: NVBS heard, BAE +, TRACHEA CENTRAL.

P/A : SOFT, NON TENDER, NON DISTENDED.

CNS: CONSCIOUS, NO SIGNS OF MENINGEAL IRRITATION.

REFLEXES.

                                      RT. LT.

                   BICEPS.       + +

                   TRICEPS.      + +

                   SUPINATOR. + +

                   KNEE              + +

                   ANKL            + +

                   PLANTAR: FLEXOR.

PROVISIONAL DIAGNOSIS

    UTI WITH AKI WITH HYPONATREMIA

INVESTIGATIONS 

1) ECG 

2) Ultrasound

3) Chest X - ray

4) ABG

5) RFT

6) Serology 

7) Haemogram

8) 2D ECHO

TREATMENT

• FOSFOMYCIN sachet - 3mg in 1glass of water/ stat

• Tab DOLO 650mg PO/ TID

• Tab NODOSIS PO/BD

• Strict I/O charting

• Condome Catheterization

• Inj LASIX 40mg IV/BD if SBP > or = 110mmHg

• IVF 20NS @75ml/hr

• Temperature charting 4th hourly

• GRBS charting 8th hourly

• BP / PR / RR / Spo2 charting 2nd hourly

DAY 2 

 SUBJECTIVE:

Altere sensorium

OBJECTIVE

Temperature-97 F

Bp-120/60 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 90 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

1) Central line placed with consent taken

    Complication: Hemothorax

    --- X ray

     

ICD placed 

Xray post icd 

 Day3

SUBJECTIVE:

Fever spike

Stools not passed

Drowsy but arousable

OBJECTIVE

Temperature-101 F

Bp-130/80 mmhg

PR- 90bpm

RR -11 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Dialysis done(along with Blood Transfusion)(1 unit)

Urine culture on mc conkey agar 

       1) lactose fermenting colonies formed(pink)

       2) Indole(+ve), citrate(-ve), urease(+ve), 

       3) Triple sugar iron -- A/A WITH GAS

       4) Gram Stain -- Gram -ve bacilli

F/S/O:- E-coli

Day 4

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13. 2nd dialysis done (Along with Blood Transfusion)(1 unit)

Day 5

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

Day 6

SUBJECTIVE:

PAIN AT DRAIN SITE

OBJECTIVE

Temperature-101 F

Bp-150/80 mmhg

PR- 86bpm

RR -16 cpm

GRBS - 101 gm/dl

ASSESSMENT-

RENAL AKI WITH UREMIC ENCEPHALOPATHY

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

PLAN OF CARE- 

1. High flow O2 @15lit/min

2. IVF- NS@ 100ml/hr, RL@75ml/hr

3. Inj. Piptaz 2.25 gm/IV/TID

4. Tab. Nodosis 500mg/PO/BD

5. RT feeds 200ml milk protein powder (2nd hourly, 100ml water/2nd hourly)

6. Inj.Metrogyl 100ml/IV/TID

7. Inj. Pantop 40mg/IV/OD

8. Tab. Shelcal 500 mg/PO/BD

9. TAB. Dolo 650 PO/SOS

10. TAB. Lasix 40mg/PO/BD

11. NEB WITH DUOLIN/IN/TID, BUDECORT/IN/BD

12. Syp. LACTULOSE 10ml/RT/HS

13.3rd dialysis done (along with 1 unit of blood transfusion)

Day 7-

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Subjective : 

 Pt complaints of burning micturition 

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1) ORAL FEEDS 

2. inj PIPTAZ 2.25gm /iv /tid 

3. Inj METROGYL 100ml / iv/tid 

4. Inj PAN 40mg /iv / od 

5. TAB LASIX 40mg /po/ od 

6. Tab NODOSIS 500 mg /po /od 

7. Tab DOLO 650mg /po/sos 

8. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

9. SYP LACTULISE 10ml /po/ HIS

Day 8

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

 

Foley's removed and planned for ICD removal

Day 9

SOAP NOTES 

 A 65 yr old man with AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid. BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 10

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 11

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS

Day 12

SOAP NOTES 

 A 65 yr old man with  AKI SECONDARY TO UTI 

Iatrogenic Hemothorax

Anemia secondary to chronic disease and blood loss

Subjective : 

 Pt complaints of burning micturition

Objective :

 Temp:98

 PR:94 

 RR: 22

 BP: 120/70mmhg 

 Grbs :100 

Assessment-

RENAL AKI SECONDARY TO UTI (ECOLI sps) 

WITH IATROGENIC HEMOTHORAX (SECONDARY TO CENTRAL LINE INSERTION) 

WITH ANEMIA SECONDARY TO BLOOD LOSS 

Plan of treatment - 

1.ORAL FEEDS

2. Inj PAN 40mg /iv / od 

3. TAB LASIX 40mg /po/ od 

4. Tab NODOSIS 500 mg /po /od 

5. Tab DOLO 650mg /po/sos 

6. NEBULISATION WITH DUOLIN /tid.                   BUDECORT /bd 

7. SYP LACTULISE 10ml /po/ HIS