60 YR OLD MALE WITH DECREASED URINE OUTPUT


21/04/2022 ICU
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 


60yr old male farmer by occupation residing in bandapalem came with c/o 
-decreased urine output since 2 days
-generalised weakness since 2 days
-loss of appetite since yesterday
-twitching movements since morning

HOPI: Patient was apparently asymptomatic 2 days back and then c/o generalised weakness and decreased urine output,loss of appetite since 2 days.yoday morning the patient was taken to mearby hospital where fluids were infused and referred to our hospital since evening the weakness worsened,the patient developed twitching movements of the left upper limb and was brought in a dehydrated state.

PAST H/O: K/C/O  DM2 and on medication since 30 yrs.not a K/C/O asthma,TB,epilepsy.

PERSONAL H/O: Smoker(3-4 beedies /day)

GENERAL EXAMINATION
Patient is drowsy,speech is slurred.
no pallor,icterus,cyanosis,clubbing,edema,lymphadenopathy 
dehydration- present(moderate)
TEMP-Afebrile
BP-90/60mmhg
PR-104/m
RR-18/m
spO2-90%
GRBS-513 mg/dl
CVS- S1S2 +
RS-BAE +
PA-Soft,non tender
CNS-NAD

Investigations
reports on 23/04/22

reports on 24th april
reports on 25th




Diagnosis: Hyperglycemic hyperosmolar syndrome, K/C/O DM2 on medication.
Pre renal AKI

TREATMENT:
IV Fluids NS @ 200 ml/hr
Inj.HAI 1ml(40 U) + 39 ml NS-6ml/hr(according to grbs increase or decrease)
Inj.THIAMINE 1Amp in 100 ml NS IV/BD
Inj.PAN 40mg IV/OD
Inj.MONOCEF 1gm IV /BD
GRBS monitoring hourly
monitor vitals
strict I/O charting

SOAP NOTES 
23/ 04/ 2022
ICU BED 2

S - Sensorium improved

O-  Patient is conscious, speech is improved.
 No pallor, icterus, cyanosis , clubbing, edema, lymphadenopathy 

dehydration- Improved 

TEMP-Afebrile

BP-110/80mmhg

PR-90 bpm

RR-20 cpm

spO2- 95%

GRBS-145 mg/dl 8U given

CVS- S1S2 +

RS-BAE +

PA-Soft,non tender

CNS - NAD


A- Uncontrolled sugars with dehydration ? Hyperosmolar Hyperglycemic state K/C/O DM2 on medication.

P- ivf NS@ 100 ml/hr
Inj. Human atrapid insulin according to grbs 

Inj.THIAMINE 1Amp in 100 ml NS IV/OD


Inj.PAN 40mg IV /OD


SOAP NOTES 
24/ 04/ 2022
AMC

S - 5 episodes of loose stools.

O-  Patient is conscious, speech is improved.
 No pallor, icterus, cyanosis , clubbing, edema, lymphadenopathy,dehydration

TEMP-Afebrile

BP-110/80mmhg

PR-98bpm

RR-18 cpm

spO2- 98%

GRBS-175 mg/dl 10U given @8AM

CVS- S1S2 +

RS-BAE +,lungs clear

PA-Soft,non tender

CNS - NAD


A- ? Hyperosmolar Hyperglycemic syndrome K/C/O DM2 on medication.
pre renal AKI

P- ivf NS@ 100 ml/hr
Inj. Human atrapid insulin according to grbs 
-inj.MONOCEF 1gm iv BD
-inj.METROGYL 500mg iv Tid
-Inj.THIAMINE 1Amp in 100 ml NS IV/OD
-ORS socket in 1 ltr water,200 ml after every stool passed
-Inj.PAN 40mg IV /OD
-tab SPORLAC-DS 2tab PO TID
-GRBS 7 profile
-monitor vitals,grbs,i/o charting


SOAP NOTES 
25/ 04/ 2022
AMC

S - loss of appetite. loose stools relieved.

O-  Patient is conscious, speech is improved.
 No pallor, icterus, cyanosis , clubbing, edema, lymphadenopathy,dehydration

TEMP-Afebrile

BP-100/70mmhg

PR-76bpm

RR-22 cpm

spO2- 98%

GRBS-153 mg/dl 10U given

CVS- S1S2 +

RS-BAE +,lungs clear

PA-Soft,non tender

CNS - NAD


A- ? Hyperosmolar Hyperglycemic syndrome K/C/O DM2 on medication.
pre renal AKI.

P- 
Inj. Human atrapid insulin according to grbs 
-inj.MONOCEF 1gm iv BD
-inj.METROGYL 500mg iv Tid
-Inj.THIAMINE 1Amp in 100 ml NS IV/OD
-ORS socket in 1 ltr water,200 ml after every stool passed
-Inj.PAN 40mg IV /OD
-tab SPORLAC-DS 2tab PO TID
-GRBS 7 profile
-monitor vitals,grbs,i/o charting


SOAP NOTES 
26/ 04/ 2022
AMC

S - loss of appetite. 1 episode of vomiting.

O-  Patient is conscious, speech is improved.
 No pallor, icterus, cyanosis , clubbing, edema, lymphadenopathy,dehydration

TEMP-Afebrile

BP-110/70mmhg

PR-76bpm

RR-20 cpm

spO2- 98%

GRBS-153 mg/dl 10U given

CVS- S1S2 +

RS-BAE +,lungs clear

PA-Soft,non tender

CNS - NAD


A- ? Hyperosmolar Hyperglycemic syndrome K/C/O DM2 on medication.
pre renal AKI.

P- 
Inj. Human atrapid insulin according to grbs 
-inj.MONOCEF 1gm iv BD
-inj.METROGYL 500mg iv Tid
-Inj.THIAMINE 1Amp in 100 ml NS IV/OD
-ORS socket in 1 ltr water,200 ml after every stool passed
-tab.PAN 40mg IV /OD
-tab SPORLAC-DS 2tab PO TID
-tab.BUSCOPAN SOS
-GRBS 7 profile
-monitor vitals,grbs,i/o charting

Popular posts from this blog

27 YR OLD FEMALE WITH SEIZURES

Image
27 year old female patient from Nakrekal came to the OPD with the , Chief complaints : 1 episode of Generalised tonic clonic seizures  HOPI:  Patient was apparently assymptomatic 12years ago ,then she underwent RTA followed by seizures ,for that she used medication . 8years ago ,She was diagnosed with thyroiditis associated with goitre for which she used carbimazole . In 2015 - she underwent thyroid surgery ,where one lobe of thyroid is removed and continued on carbimazole  In 2021 -her 2nd lobe of thyroid removed along with parathyroid gland and started on thyronorm 100mcg -she is not on follow up since then . After thyroidectomy Surgery in 2021 ,patient complaints of parasthesias in B/l  lower limbs frequently ,for which she received multiple calcium injections but not relieved of parasthesias . Now ,since 2 to 3 days she developed parasthesias , giddiness ,generalised weakness for which ,she was taken to local hospital in Nakrekal yesterday (i.e..,31st March at evening 5
Read more

22 yr old male with vomitings and loose stools

Image
22 yr old male resident of lingotum,works in agarbathi factory came with c/o vomiting since morning 10 am,loose stools since morning 10 am. HOPI: pt was apparently asymptomatic till today morning,he had h/o packed food consumption followed by c/o loose stools assc with ?pus 4-6 episodes since today morning. c/o vomiting 3-5 episodes assc with food particles,non bilious. no c/o fever,cold,cough. c/o abdominal pain-diffuse,tenderness in epigastrium,Right hypochondrium,umbilicus. no c/o SOB,orthopnoea,PND. PAST H/O: no similar complaints in the past no h/o HTN,DM,CVA,CAD,TB,EPILEPSY. PERSONAL H/O: occasional alcoholic weekly once since 6-7 years occasional smoker. VITALS: BP-90/60mmhg PR:110/m RR:20/m TEMP:97.7 F GENERAL EXAMINATION: CVS:S1S2 + RS:BAE + CNS: NAD. DIAGNOSIS:ACUTE GASTROENTERITIS reports on 19/05/22 serology :negitive Reports on 20/05/22
Read more

1601006016 long case

Image
HALL TICKET NO.1601006016 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." I've 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 a diagnosis and treatment plan.  CASE: A 65 year old female with fever,pain abdomen and loose stools. Chief Complaints : A 65 yr old woman resident of nalgonda ,a house
Read more