60 YR OLD MALE WITH DECREASED URINE OUTPUT


21/04/2022 ICU
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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

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