72 yr old female with fever, vomitings and loose stools.
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Case:-
Fever :
Low grade, intermittent, not associated with chills and rigors , associated with decreased Appetite, loose stools and vomiting.
Vomitings:-
3-4 episodes per day, non - bilious , non - projectile, food/ water as content.
Stools:-
10-12 episodes/day, green in colour associated with lower abdominal pain- diffuse, squeezing type, no aggrevating and relieving factors.
Patient was apparently asymptomatic 6 months back, from then she decreased using her left lower limb , walking with support (with wall/ stick).
She had intermittent episodes of vomiting since 6 months.
No bowel and bladder involvement.
K/c/o DM since 10 yrs.
K/c/o HTN since 10 yrs
Not a k/c/o asthma, TB, epilepsy, thyroid .
No surgical history.
O/E :-
Patient was c/c/c ,
No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy,edema.
Vitals:-
Temp: 100.2 F
Bp : 130/70 mm hg
PR: 18 BPM
Spo2 :- 99% @ RA
Grbs: 261 gm/dl
Cvs:- S1,S2 heard, no murmurs .
Rs:- BAE present,
Wheeze in left IAA present.
p/A:-
Obese, mild tenderness in lower abdomen in left hypochondrial religion.
CNS:-
Patient was conscious,
Speech - normal
No signs of meningeal signs.
Provisional diagnosis:-
Acute Gastro enteritis with acute bronchitis with DM and HTN.
Treatment:-
1. IVF NS, RL @ 150 ml/ hr.
2. Inj. Metrogyl 400 mg , iv/ tid.
3. Inj. Pantop 40 mg iv/od
4. Inj. Zofer 4 mg iv/ sos
5. Neb. Budecort and duolin 6 th hrly.
SOAP
Day 2:-
SOAP
Day 2
Subjective:-
Patient complains of fever , vomitings .
Objective-
Pt c/c/c ,
Febrile - 104.2 F
Bp : 140/60 mm hg
PR: 98bpm
RR : 22 cpm
Cvs : S1,S2 present.
Rs:-wheeze present in left IAA .
P/A:-
Soft, Mild tenderness present in right hypochondrium and epigastric reigion.
CNS :-
HMF intact.
Assessment:-
Acute GE with HTN and Dm - 2 with acute bronchitis.
Plan :-
1. IVF - RL , NS @ 150 ml/hr.
2. Inj. Metrogyl 400mg iv/od
3. Inj. Pantop 40 mg Iv/od
4. Inj. Zofer 4 mg iv/sos.
5. Tab. Sporolac - Ds po/od
6. Tab. Pcm 650 mg po/tid
7. Neb.with budecort and duolin 6 th hrly.
8. Inj. Monocef 1 gm iv/bd.
SOAP
Day 3
Subjective:-
Fever , vomitings -- resolved.
Pain abdomen present.
Objective-
Pt c/c/c ,
Febrile - 104.2 F
Bp : 140/70 mm hg
PR: 102bpm
RR : 22 cpm
Cvs : S1,S2 present.
Rs:-wheeze present in left IAA .
P/A:-
Soft, Mild tenderness present in right hypochondrium and epigastric reigion.
CNS :-
HMF intact.
Assessment:-
Acute GE ( resolved)with HTN and Dm - 2 with acute bronchitis.
Plan :-
1. IVF - RL , NS @ 150 ml/hr.
2. Inj. Metrogyl 400mg iv/od
3. Inj. Pantop 40 mg Iv/od
4. Inj. Zofer 4 mg iv/sos.
5. Tab. Sporolac - Ds po/od
6. Tab. Pcm 650 mg po/tid
7. Neb.with budecort and duolin 6 th hrly.
8. Inj. Monocef 1 gm iv/bd.
SOAP
Day 4
Subjective:-
Fever , vomitings -- resolved.
Pain abdomen present.
Shortness of breath +
Objective-
Pt c/c/c ,
Febrile - 99.7 F
Bp : 140/80 mm hg
PR: 118bpm
RR : 34 cpm
Spo2. : 100% on 4L of
Cvs : S1,S2 present.
Rs:-wheeze present in left IAA .
P/A:-
Soft, Mild tenderness present in right hypochondrium and epigastric reigion.
CNS :-
HMF intact.
Assessment:-
Sepsis secondary to ?CAP with HTN and DM -2 (uncontrolled) with acute bronchitis with paroxysmal AF.
Plan :-
1. IVF - RL , NS @ 150 ml/hr.
2. Inj. Metrogyl 400mg iv/od
3. Inj. Pantop 40 mg Iv/od
4. Inj. Zofer 4 mg iv/sos.
5. Inj. Hydrocortisone 100 mg iv/bd.
6. Tab. Pregabalin 75 mg po/od.
7. Neb.with budecort and duolin 6 th hrly.
8. Inj. Meropenam 1 gm iv/bd .
9.Inj. Lasix 40 mg iv/bd .
10. Bp, temp, and Grbs charting .
SOAP
Day 5
72year woman
She says she is feeling better
Her dyspnea has reduced but
Has been feeling feverish since morning
Patient is conscious, cooperative
PR - 100bpm
Heart rate - 72bpm
Apex pulse deficit of 28bpm
BP - 170/100mmhg
RR - 30bpm
Temp - 100.5 F
Spo2 - 90 % on RA
I/0 - 2700/1500
Stool - passed
Per abdomen - soft
Non tender
Lungs - left side inspiratory crepts in left mammary, IAA, ISA
CVS - S1,S2 +
She was started on insulin infusion on Sunday night, currently her GRBS is 172mg/dl made her infusion to 1ml/ hour as her
Abg yesterday -
PH - 7.4
Pco2 - 21.1
Po2 - 106
Hco3 - 12.9
Anion gap -21.9
Tapered her off inotropic support
A - sepsis secondary to ? CAP with HTN
With uncontrolled sugars, known case of type 2 DM
With acute bronchitis
Paroxysmal AF
P -
O2 inhalation to maintain spo2 -<94%
IVF - RL, NS @ 75ml/hour
Inj Meropenam 1gm/IV/BD day 3
Inj Metrogyl 400mg/IV/TID day 6
Inj Lasix 40mg/IV/BD
Tab Atorvas 20mg/HS
Tab Diltiazem 30mg /PO/TID
Tab Pregabalin 75mg PO HS
SOAP
Day 6
72year woman
She says has been feeling fever since last night
Patient is conscious, cooperative
PR - 125bpm
BP - 130/70mmhg
RR - 30bpm
Temp - 101 F
Spo2 - 98 % with 15L of oxygen
I/0 - 1400/1000
Per abdomen - soft
Diffuse tenderness
Lungs - left side inspiratory crepts in left mammary, IAA, ISA
CVS - S1,S2 +
GRBS - 204mg/dl
A - Sepsis secondary to ? CAP with HTN
With uncontrolled sugars, known case of type 2 DM
With acute bronchitis
Paroxysmal AF (resolved)
CHADVAS score - 2
P -
O2 inhalation to maintain spo2 -<94%
IVF - RL, NS @ 75ml/hour
Inj Insulin infusion at 2ml / hour
Inj Meropenam 1gm/IV/BD day 4
Inj Metrogyl 400mg/IV/TID day 7
Inj Unfractionated heparin 5000Units/IV/TID
Inj Lasix 40mg/IV/BD
Tab Atorvas 20mg/HS
Tab Diltiazem 30mg /PO/TID
Tab Pregabalin 75mg PO HS
Nebulization with Ipravent 2nd hourly
Budecort 6th hourly
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