A 70 year old female home maker since 10-15 years (farmer by occupation) came to causality in drowsy state.
HOPI: Patient was apparently asymptomatic 10 years back ,then patient had h/o fall for which she went to local hospital there she got diagnosed with DM and since then she is on OHA medication(glim m2).4 years back she had h/o fall and went to hospital and got diagnosed with HTN. 1 session of dialysis was done (indication/cause unknown ) .Patient wasn’t on any medication for HTN .1 month back she developed hypoglycaemia secondary to OHA’s ,then resolved later.Patient had h/o fall 4 days back ,fracture of IT femur right leg operated(? ORIF done).On POD 2, patient was drowsy ,opening eyes to deep pain .Since yesterday ,she is unable to recognise patient attenders.
PAST HISTORY:
K/C/O DM since 10 years & on medication.
K/C/O HTN since 4 years
GENERAL EXAMINATION:
O/E : Patient is responding to vocal commands
Pallor - present
Icterus absent
Cyanosis - absent
Edema of feet - present
Lymphadenopathy - absent
Clubbing - absent
VITALS:-
BP: 170/90mmhg
PR: 98 bpm
RR: 25cpm
Spo2: 95%
Grbs: 146
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM : S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM : BAE present
P/A : soft
CNS: Pt is drowsy.
tone : normal
INVESTIGATION:
12/2/22
D dimer: 6910ng/ml
BGT: B POSITIVE
ESR :. 140
RBS: 220
APTT: 30 seconds
PT : 15 seconds
INR: 1.11
USG abdomen
PROVISIONAL DIAGNOSIS:
? uraemic encephalopathy with pre renal AKI with POD 4 right femur fracture ?CRIF + PFM with DM and HTN
TREATMENT:
1. INJ. Lasix 40mg IV/BD
2. INJ. HAI SC/TID
3. INJ. CEFTRIAXON 1g/IV/BD
4. INJ. CLINDAMYCIN 600mg/ IV /TID
5.INJ. CLEXANE 20 mg SC/OD
6. INJ. OPTINEURON 1 AMP in 100 ml NS /IV/OD
7.TAB. Amlong 10mg PO /OD
8.IVF NS UO + 30 ml/hr
SOAP NOTES:-
DAY 2:
1 session of dialysis done yesterday on 13/2/22.
O:-
TEMP:- AFEBRILE
PR:- 104bpm
BP:- 140/ 80mmhg
GRBS: 123MG/DL
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- SOFT , NON TENDER
I/O: 2600/1540
A:- Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced with POD 5 right femur ? CRIF + PFN with DM &HTN
P:-
INJ. MONOCEF 1GM/IV/BD
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
INJ. CLINDAMYCIN 600mg/ IV /TID
INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO+ 30ML/HR
Day 3:
c/o 2-3 episodes of bilious vomitings .
1 session of dialysis done yesterday on 14/2/22
O:-
TEMP:- 101 F
PR:- 92bpm
BP:- 140/ 60mmhg
GRBS: 123MG/DL
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- GUARDING PRESENT
I/O: 2400/2600
Stools : not passed
A:- Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced with POD 6 right IT femur ? CRIF + PFN with DM &HTN
P:-
INJ. MONOCEF 1GM/IV/BD
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
INJ. CLINDAMYCIN 600mg/ IV /TID
INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO+ 30ML/HR
INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.
Day 4:
S:- c/o fever spike yesterday
O:-
TEMP:- 98.4 F
PR:- 96 bpm
BP:- 150/ 90mmhg
GRBS: 245MG/DL
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- GUARDING PRESENT
I/O: 2100/3200
Stools : passed
A:- Uremic encephalopathy ?pre renal AKI secondary to ?blood loss ? drug induced ?dehydration with POD 7 right IT femur ? CRIF + PFN with DM &HTN
Surgery referral done i/v/o abdominal distension and vomiting, DIAGNOSIS: ? ADYNAMIC INTESTIONAL OBSTRUCTION, suggested CT ABDOMEN .
P:- SOAP WATER ENEMA DONE
(DAY 1)INJ. PIPTAZ 4.5 GM/IV/STAT
|
PIPTAZ 2.25 GM/IV/BD
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
INJ. CLINDAMYCIN 600mg/ IV /TID
INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO + 30ML / HR
INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.
O:-
TEMP:- 100.4F
PR:- 94bpm
BP:- 180/100mmhg
GRBS: 123MG/DL
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- GUARDING PRESENT
I/O: 2400/3000
Stools : passed,enema given
A:- Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 8 right IT femur ? CRIF + PFN with DM &HTN
P:-
(DAY 2)INJ. PIPTAZ 4.5 GM/IV/STAT
|
PIPTAZ 2.25 GM/IV/BD
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
INJ. CLINDAMYCIN 600mg/ IV /TID
INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO + 30ML / HR
INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.
Day 6:
O:-
TEMP:- 98.4F
PR:- 90bpm
BP:- 140/100mmhg
GRBS: 223MG/DL @ 8am
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- GUARDING PRESENT
I/O: 1700/2100
Stools : passed
A:- Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 9 right IT femur ? CRIF + PFN with DM &HTN
P:-
(DAY 3) PIPTAZ 2.25 GM/IV/QID
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
(Day7)INJ. CLINDAMYCIN 600mg/ IV /TID
(Day7)INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO + 30ML / HR
INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.
DAY 7:
S:- c/o pain in gluteal region since yesterday ,abdominal pain decreased and right femur pain decreased.responding to commands.
O:-
TEMP:- 98.4F
PR:- 90bpm
BP:- 130/90 mm hg
GRBS: 212MG/DL @ 8am
CVS:- S1S2 heard , no murmurs
RS : BAE present
P/A:- soft
I/O: 1650/2200
Stools : passed
Grade 1 bed sore at gluteal region
A:- Uremic encephalopathy (resolving) pre renal AKI secondary to ?blood loss ? drug induced with POD 10 right IT femur ? CRIF + PFN with DM &HTN
P:-
(DAY 4) PIPTAZ 2.25 GM/IV/QID
INJ. LASIX 40 MG IV/BD
INJ. HAI SC/TID
(Day8)INJ. CLINDAMYCIN 600mg/ IV /TID
(Day8)INJ. CLEXANE 20 mg SC/OD
TAB. Amlong 10mg PO /OD
IVF NS UO + 30ML / HR
INJ ERYTHROPOIETIN 4000 IU/SC/WEEKLY ONCE.
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