45 years old P3L3 female, agricultural labourer by occupation, came to the casuality with C/O generalised weakness since 2 days
45 years old P3L3 female, agricultural labourer by occupation, came to the casuality with C/O generalised weakness since 2 days.
H/O vomitings and loose stools 2 days back.
HOPI:
Patient was apparently asymptomatic 1 year back and then had H/O Neck pain and backache - dragging type of pain, not associated with any numbness, tingling sensation of upper and lower limbs.
Patient started taking NSAID daily once for pain for 1 month, then she visited orthopaedician and advised her to get MRI: L-Spine and after that she was advised for surgery.
Patient had difficulty in passing stools (constipation) since 1 month for which the patient went to the nearby doctor 2 days back.
She was put on Syp. Lactulose and after 1 day, the patient had 5 episodes of watery stools for 1 day, 2 episodes of vomitings for 1 day which subsided now.
Generalised weakness present since 2 days.
PAST HISTORY:
Not a K/C/O DM/HTN/BA/TB/Epilepsy/Thyroid disorders/CAD/CVA
Patient underwent ECSL for Right Renal stones (ECSL) 6 years back, Hysterectomy 20 yrs back and Left Cataract Surgery 6 yrs back.
PERSONAL HISTORY:
Diet- mixed
Appetite- Normal
Sleep- Adequate
Bowel and bladder movements- Regular
No known allergies
No addictions
Family history: not significant
GENERAL EXAMINATION:
Patient is Conscious, coherent, cooperative.
No Pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
Vitals:
Temp.- Afebrile
BP- 110/70 mmHg
PR- 100 bpm
RR- 12 cpm
SpO2- 98%
GRBS- 138 mg/dL
SYSTEMIC EXAMINATION:
CVS- S1 S2 heard, no murmurs
RS- BAE+ NVBS+
P/A- Soft, Non-tender
CNS-
Patient is Lethargic
GCS- 15/15
Sensory and motor systems - Intact
Cranial nerves- intact
Reflexes- Intact
INVESTIGATIONS:
USG ABDOMEN:
CHEST X-RAY PA VIEW:
RFT on18/01/2022:
MRI:
PROVISIONAL DIAGNOSIS:
AKI on CKD secondary to ?anagesic neuropathy
Pyrexia under evaluation
TREATMENT GIVEN:
1. IV Fluids NS and RL @ UO+50 ml/h
2. Inj. Optineuron 1 amp in 100 ml NS
3. Inj. PANTOP 40 mg IV OD
4. Inj. Lasix 20 mg IV BD (if sBP>110 mmHg)
5. Inj. Neomol 100 ml IV SOS (if temp>101 F)
6. Tab. PCM 500 mg PO SOS
7. GRBS - 6th hrly
8. I/O Charting
9. Monitor vitals 4th hrly
Orthopedics referral:
Nephrology Referral:
SOAP NOTES:
Day 2 (14/01/2022)
S:
Generalised weakness present
No fresh complaints
O:
Temp.- Afebrile
BP- 120/70 mmHg
PR- 98 bpm
RR- 18 cpm
SpO2- 97% at RA
GRBS- 103 mg/dL
A:
Viral Pyrexia with Thrombocytopenia
AKI secondary to ?Sepsis
P:
1. IVF - NS,RL,DNS @ UO+100 ml/h
2. Inj. PANTOP 40 mg IV OD
3. Inj. Zofer 4 mg IV SOS
4. Inj. Lasix 40 mg IV BD (if sBP>110 mmHg)
5. Inj. Neomol 100 ml IV SOS (if temp>101 F)
6. Tab. PCM 500 mg PO/SOS
7. Tab. Doxycycline 100 mg PO/BD
8. Monitor vitals 4th hrly
9. I/O and Temp. Charting
Day 3 (15/01/2022)
S:
C/o burning micturition, nausea (+), decreased appetite,
No h/o fever, vomitings
O:
Pt is C/C/C
Temp- afebrile
Bp- 120/70 mmhg
PR- 74bpm
RR- 16cpm
SPO2- 99%
CVS- S1 S2 heard
Rs- BAE+
CNS- NFND
P/A- Soft, Non-tender
A:
Viral pyrexia with thrombocytopenia
AKI secondary to ?GE
With UTI secondary with R renal calculi
P:
1. IVF- NS RL DNS UO+ 50ml/hr
2. Inj. Optineuron 1amp in 100ml NS IV/OD
3. Inj. Pantop 40mg IV OD
4. Inj. Zofer 4mg IV OD
5. Inj. Neomol 1amp in 100ml NS IV if temp >101F
6. T. PCM 500mg PO/SOS
7. Temperature and I/O charting
8. Vitals monitoring
Day 4 (16/01/2022)
S:
C/o burning micturition, nausea (+) decreased appetite,
No h/o fever, vomitings
O:
Pt is C/C/C
Temp- afebrile
Bp- 110/70 mmhg
PR- 72 bpm
RR- 17 cpm
SPO2- 98%
CVS- S1 S2 heard
RS- BAE+
CNS- NFND
P/A- Soft, Non-tender
A:
Viral pyrexia with thrombocytopenia
AKI secondary to ?GE
With UTI secondary with R renal calculi
P:
1. IVF- NS RL DNS UO+ 50ml/hr
2. Inj. Optineuron 1amp in 100ml NS IV/OD
3. Inj. Pantop 40mg IV OD
4. Inj. Zofer 4mg IV OD
5. Inj. Neomol 1amp in 100ml NS IV if temp >101F
6. T. PCM 500mg PO/SOS
7. Temperature and I/O charting
8. Vitals monitoring
Day 5 (17/01/2022)
S:
C/O decreased appetite and nausea+
No fever spikes
O:
Pt is C/C/C
Temp- Afebrile
Bp- 110/80 mmhg
PR- 82 bpm
RR- 18 cpm
SPO2- 99%
CVS- S1 S2 heard
RS - BAE+
CNS- NFND
P/A- Soft, Non-tender
A:
Viral pyrexia with thrombocytopenia
AKI secondary to ?GE
With UTI secondary with R renal calculi
P:
1. IVF- NS RL DNS UO+ 50ml/hr
2. Inj. Optineuron 1amp in 100ml NS IV/OD
3. Inj. Pantop 40mg IV OD
4. Inj. Zofer 4mg IV OD
5. Inj. Neomol 1amp in 100ml NS IV if temp >101F
6. Inj. Lasix 40 mg IV BD if sBP>110 mmHg
7. T. PCM 500mg PO/SOS
8. T. Doxycycline 100 mg PO/BD
9. Syp. Lactulose 15 ml PO/HS
10. Syp. Aristroxyme 15 ml PO/TID
11. Syp.
12. Temperature and I/O charting
13. Vitals monitoring
14. GRBS monitoring 12 th hrly
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