AMC BED 6

1/11/21
AMC admission bed 4

65 yr old female , house wife came to casualty with cheif complaints of
1. FEVER SINCE 1WEEK
2. FACIAL PUFFINESS SINCE 1DAY
3. PAIN ABDOMEN SINCE 1DAY
4. SOB SINCE 1DAY.

HOPI:.
patient was apparently asymptomatic 1week back, then she developed
fever ,high grade , subsided with medication.
not associated with cough, loose stools, vomitings.
Now developed SOB and facial puffiness since 1day.

CREATININE= 6.0 mg/dl, on that day.

NOT A K/C/O DM,HTN, ASTHMA, TB, EPILEPSY.
No significant family history
No significant drug history.

PERSONAL HISTORY:
takes mixed diet
Appetite-normal
Regular bowel and bladder movements
No known allergies.
No addictions.

O/E:
pt is c/c/c
PALLOR+
No icterus,cyanosis,clubbing, lymphadenopathy, edema.

VITALS:
Afebrile temperature
PR: 90BPM
BP:110/70MMHG
RR:20CPM
SPO2:98%
CVS: S1S2+

RS:
Dyspnoea+
No wheeze
Normal vesicular breath sounds
CREPTS+ IN  B/L IAA

P/A: NAD
CNS:NAD.

INVESTIGATIONS:

HEMOGRAM:
HB:8.0
TC:6700
PLT:1.50

RBS:93 MG/DL

SERUM UREA: 37

CUE:
ALB: 2+
PUS CELLS: 3-4
EPI CELLS: 2-3

LFT:
TB:0.79
DB:0.20
SGOT:20
SGPT:10
ALP:264
TP:6.2
A/G: 0.53

SERUM CREATININE: 10.1 MG/DL

URIC ACID: 6.8

SEROLOGY: NEGATIVE

SERUM ELECTROLYTES:
Na: 134
K: 4.4
Cl: 98


PROVISIONAL DIAGNOSIS:

AKI ON CKD SECONDARY TO VIRAL INFECTION.

PLAN OF CARE:
1. IVF 1 NS @30ML/HR
2.TAB . AUGMENTIN 625MG OD @10AM
3. TAB. DOXYCYCLINE 100MG PO/BD
4. INJ.LASIX 20mg IV /BD
5.TAB.PAN 40MG PO/OD
6.SYP.AMBROXOL 10ML PO/TID
7.NEB. DUOLIN 1RSP TID
             BUDECORT 1RSP BD


2/11/21
AMC BED 6

SOAP NOTES DAY 1

S:
C/O 1 Episode of vomiting yesterday night 
cough increased
No fever spikes
SOB +

O:
Pt is C/C/C
BP: 100/60MMHG
PR:82BPM
RR:22CPM
SPO2:99% @room air.
GRBS:113MG/DL
CVS: S1S2+
RS: BAE +, B/L CREPTS IN IAA
P/A: SOFT,NON TENDER
CNS: NAD

A:
AKI ON ?CKD SECONDARY TO ?VIRAL.

P:
1.IVF 1 O NS @ 30ML/HR
2.Inj. LASIX 20MG /IV/BD
3. TAB. AUGMENTIN 625MG /OD.  DAY 1
4.TAB.DOXYCYCLIN 100MG PO/BD DAY 1
5.TAB.PAN 40MG /PO/OD
6.NEB. DUOLIN 1RESP P/N TID
7. NEB . BUDECORT 1RESP P/N BD
8.SYP. AMBROXOL 10ML PO/TID.




3/11/21



SOAP NOTES DAY 2

AMC BED 4

SHIFTING TO NEPHRO FOR DIALYSIS

S:

No fever spikes

SOB decreased.

Cough associated with sputum since yesterday.

DECREASED URINE OUTPUT

O:

PT IS C/C/C
PR: 62BPM
BP:90/60MMHG
CVS: S1S2+
RS:
BAE+
CREPTS+ B/L IAA,IMA (R>L)
P/A: SOFT 
CNS: NAD 

Egfr : 2ml/min/1.73m2

I/O: 1200/100

STOOLS+

A:

CKD STAGE 5
AKI SECONDARY TO ?VIRAL

P:

1. Fluid restriction < 1.5L/day
2. Salt restriction <2.4gm/day
3.INJ.LASIX 20MG IV /BD (IF BP>110MMHG)
   8AM - 4PM
4.TAB.AUGMENTIN 625MG /PO/OD
5.TAB.DOXYCYCLINE 100MG /PO/OD
6.TAB.PANTOP 40MG PO/OD
7.TAB.NODOSIS 55MG PO/TID
8.MONITOR VITALS 4TH HRLY
9. STRICT I/0 CHARTING.
 



            





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