55 year female with fever, vomitings and shortness of breath
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UNIT 4 ADMISSION ( 07/10/21)
55 year old female Labourer by occupation came to the casuality with
c/o fever since 2 days
c/o vomitings since 2 days
c/o SOB since yesterday
c/o body pains since 2 days
Patient was apparently assymptomatic 1 yearback then she fell while working not associated with giddiness and sustained injury over lower back and was taken conservative management in private hospital during her routine investigations she was told she had kidney injection and was on conservation medication for 2 months ? unknown medication, she was apparently asymptomatic 2 days back then she had fever which was insidious on onset, associated with chills and rigors ,subsided on taking medication associated with pain abdomen tenderness in right hypochondrium ,associated with vomiting one episode non bilious and non projectile food particles as content
Complaints of shortness of breath grade 2-3
According to NYHA classification
No Orthopnea, PND , chest pain , palpitations,
she was taken to a local hospital and during her routine investigations she was told she has low platelet count and was referred to our hospital.
On examination :
Patient is conscious coherent and co operative
Temp- 97.5 F
Bp- 110/80mmhg on standing
110/90mmhg on supine
Pr- 78bpm regular normal volume
CVS - s1s2 no murmur
RS - NVBS + no crepts
P/A- soft , tenderness more in epigastrium and right hypochondrium
Bowel sounds ++
CNS - HMF INTACT
RR- 31cpm
Spo2: 99% RA
DIAGNOSIS :
Dengue NS1 POSITIVE WITH THROMBOCYTOPENIA WITH ? SEPSIS . ACUTE KIDNEY INJURY ( SEVERE METABOLIC ACIDOSIS)
Treatment :
On 07/10/21:
1.IVF 2 NS, 1RL @100ML/HR
2. NEBULIZATION WITH DUOLIN 6TH HRLY AND BUDECORT 8 TH HRLY
3. INJ. LASIX 20 MG IV BD (IF SBP >110)
4. INJ. PANTOP 40MG IV OD
5. INJ. ZOFER 4 MG IV BD
6. INJ. TRAMADOL 1 AMP IN 100ML NS IV OD
7. ONE SDP TRANSFUSION DONE
8. STRICT I/O CHARTING
9. VITALS MONITORING 4 TH HRLY
10. GRBS CHARTING 6 TH HRLY.
On 08/10/21:
1.IVF 2 NS, 1RL @100ML/HR
2. NEBULIZATION WITH DUOLIN 6TH HRLY AND BUDECORT 8 TH HRLY
3. INJ. LASIX 20 MG IV BD (IF SBP >110)
4. INJ. PANTOP 40MG IV OD
5. INJ. ZOFER 4 MG IV BD
6. INJ. TRAMADOL 1 AMP IN 100ML NS IV OD
7. ONE SDP TRANSFUSION DONE
8. STRICT I/O CHARTING
9. VITALS MONITORING 4 TH HRLY
10. GRBS CHARTING 6 TH HRLY
On 09/10/21:
ICU 2 BED
SOAP NOTES
55 YEAR OLD FEMALE
sob decreased
fever spikes present 6 am in the morning
Passed stools yesterday
One session of hemodialysis with bicarb correction 200 meq was done yesterday 2 hrs with ultra filtrate 500
O/E
Pt c/c/c
Petechiae present over hard palate
Ascitis present
TEMP-99.1
BP-120/70mmhg
PR-107 bpm,regular
RR- 31 cpm
Spo2-86 @ room air
94with 4 ltrs of O2
A
DENGUE FEVER WITH NS1 ANTIGEN POSITIVE WITH THROMBOCYTOPENIA
SEPSIS INDUCED ACUTE KIDNEY INJURY WITH METABOLIC ACIDOSIS
ABG: HCO3. 8.3-12.8
PH 7.347-7.44
PCO2. 15.6- 19.1
PO2. 101-72.4
P
HEAD END ELEVATION @30 °
IVF 1 NS ,1 RL
O2 SUPPLEMENTATION IF SPO2 LESS THAN 90%
INJ NEOMOL IF TEMP ABOVE 101.1°F
NEB WITH DUOLIN 6 HRLY
BUDECORT 12 HRLY
INJ PANTOP 40 MG /IV /OD
INJ ZOFER 4MG /IV/SOS
INJ TRAMADOL 1 AMP IN 100 ML NS /IV/SOS
TAB DOLO 650 MG /PO/BD
On 10/10/21:
ICU 2 BED
SOAP NOTES
55 YEAR OLD FEMALE
sob decreased
Passed stools yesterday
Sdp transfusion done yesterday
O/E
Pt c/c/c
Petechiae present over hard palate
Abdominal distension relieved
TEMP-99.1
BP-120/90mmhg
PR-102bpm,regular
RR- 26 cpm
Spo2-90 @ room air
A
DENGUE FEVER WITH NS1 ANTIGEN POSITIVE WITH THROMBOCYTOPENIA
SEPSIS INDUCED ACUTE KIDNEY INJURY WITH METABOLIC ACIDOSIS (resolving)
ABG: HCO3. 15.3
PH 7.44
PCO2. 22.4
PO2. 64.9
So2 91.3%
P
HEAD END ELEVATION @30 °
IVF 1 NS ,1 RL } U.O + 75ML/HR
O2 SUPPLEMENTATION IF SPO2 LESS THAN 90%
INJ NEOMOL IF TEMP ABOVE 101.1°F
NEB WITH ipravent 6 HRLY
BUDECORT 12 HRLY
INJ PANTOP 40 MG /IV /OD
INJ ZOFER 4MG /IV/SOS
INJ piptaz 2.25mg/iv/bd
Tab shelcal 500mg/po/od
Tab. Nodosis 550mg /po/od
TAB DOLO 650 MG /PO/BD
SYP. ASCORYL PO/TID
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