65 year old female with Fever since 10 days, sob since 5 days

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CHIEF COMPLAINTS:-

65 year old female came with complaints of

Shortness of breath since 5 days

HISTORY OF PRESENT ILLNESS:-

Patient was apparently normal 2 years back,she then developed shortness of breath which was insidious in onset ,gradually progressive.Now it gradually progressed to Grade-3,she is having shortness of breath with rest since 5 days.

She has a fever episode,15 days back which is continuous ,low grade not associated with chills and rigors.

She also had 5 episodes of loose stools, watery type and 3 episodes of vomitings,non projectile,non bilious for 2 days and got treated with iv fluids.

PAST HISTORY:-

K/C/O HTN since 13 years and on medication (unkown) 

H/O usage of pain killers for 15 years everyday, as she has bilateral knee pain

H/O blood transfusion 40 years back

N/k/c/o DM,Thyroid, Asthma, CAD, CVA, Epilepsy

FAMILY HISTORY:-

Insignificant

PERSONAL HISTORY:-

Occupation:- She used to work at hotel (cleans the hotel and washes utensils) and stopped working 15 yrs back as she developed ankle pain and knee pain.

Diet:- Mixed

Bowel and Bladder:- Regular

Appetite :- Normal

No known allergies

Addictions:- addicted to beedi since 40 yrs(takes 1 beedi daily) 

GENERAL EXAMINATION:-

Patient is conscious,coherent & co-operative

Well built and well nourished.

No signs of pallor, icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals @ admission 

Temp - 98F

RR -28CPM

PR - 90 BPM

BP - 150/90mmHg

Spo2 - 98% on RA

GRBS:-174mg%

I/0- 2300/1600

SYSTEMIC EXAMINATION:-

Respiratory system:-

Bilateral air entry present 

NVBS heard

Cardiovascular system:-

S1, S2 heard

CNS:-

NFND

Abdomen:-

Soft, Non tender

Clinical Images:-

INVESTIGATIONS:-

Hemogram

Cue

RBS

LFT

RFT

28/5/23

29/5/23

30/5/23

31/5/23

LDH

UPCR

Urinary Electrolytes

ECG

2D Echo

PROVISIONAL DIAGNOSIS:-

AKI on CKD secondary to NSAID abuse with acute gastroenteritis.

TREATMENT:-

On 26/5/23:-

Nephrology refferal done on 26/5/23 and advised for hemodialysis. 

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

On 27/5/23:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring hrly

On 28/5/23:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

On 29/5/23:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

On 30/5/23:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

On 31/5/23:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

Soap notes:-

On 27/5/23:-

S:-Decreased shortness of breath

O:-

Patient is c/c/c

Temp:- 98

PR- 90bpm

RR - 28cpm

BP-  150/90mmHg

GRBS- 174mg%

I/0- 2300/1600

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-

AKI on CKD

P:-

1)IV fluids NS, RL @ 75ml/hr

2) Inj. LASIX 40 mg IV BD 

3) Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5) Neb with Salbutamol 2nd hrly

6)Temp monitoring 2nd hrly

7) Vitals monitoring  hrly

On 28/5/23:-

S:-Decreased shortness of breath

O:-

Patient is c/c/c

Temp:- 98

PR- 98bpm

RR - 28cpm

BP- 120/80mmHg

GRBS-93mg%

I/0- 1800/1600

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-

AKI on CKD

Hemodialysis done on 27/5/23

P:-

1)IV fluids NS, RL @ 75ml/hr

2)Inj. LASIX 40 mg IV BD 

3)Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5)Temp monitoring 2nd hrly

6)Vitals monitoring  hrly

On 29/5/23:-

S:-Decreased shortness of breath

O:-

Patient is c/c/c

Temp:- 98

PR- 98bpm

RR - 30cpm

BP- 160/90mmHg

GRBS-147mg%

I/0- 2500/2300

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-

AKI on CKD

P:-

1)IV fluids NS, RL @ 75ml/hr

2)Inj. LASIX 40 mg IV BD 

3)Tab.NODOSIS 500mg PO/TID

4)Tab. NICARDIA 10 mgPO/TID

5)Temp monitoring 2nd hrly

6)Vitals monitoring hrly

On 30/5/23:-

S:-Decreased shortness of breath

One fever spike in the night 

stools passed

O:-

Patient is c/c/c

Temp:- 98

PR- 92bpm

RR - 20cpm

BP-  150/80mmHg

GRBS- 153mg/dl

I/0- 1900/2000

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-

AKI on CKD 2°to gastroenteritis

2° to analgesic abuse

With k/c/o htn since 3 yrs

Hemodialysis done on 29/5/23

P:-

1)IV fluids NS, RL @ 55ml/hr

2)Inj. LASIX 40 mg IV BD 

3)Tab.NODOSIS 500mg PO/TID

4)Tab Nicardia 10 mg /po/TID

5)Tab.nephrosave po/od

6)Tab.dolo 650mg po/sos

7)Temp monitoring 2nd hrly

8)Vitals monitoring 2nd  hrly

On 31/5/23:-

S:-Decreased shortness of breath

stools passed

O:-

Patient is c/c/c

Temp:- 98

PR- 92bpm

RR - 20cpm

BP- 150/80mmHg

GRBS- 153mg/dl

I/0- 1900/2000

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-

AKI on CKD 2°to gastroenteritis

2° to analgesic abuse

With k/c/o htn since 3 yrs

Hemodialysis done on 30/5/23

P:-

1)IV fluids NS, RL @ 55ml/hr

2)Inj. LASIX 40 mg IV BD 

3)Tab.NODOSIS 500mg PO/TID

4)Tab Nicardia 10 mg /po/TID

5)Tab.nephrosave po/od

6)Tab.dolo 650mg po/sos

7)Temp monitoring 2nd hrly

8)Vitals monitoring 2nd hrly