History :
Chief complaints :
HOPI :
Personal history :
General examination :
Systemic Examination :
Investigations :
24/09/22
25/09/22
26/09/22
Treatment :
A 50 year old male who is a farmer by occupation came to OPD on 23-09-22 with
Chief complaints :
Pedal edema since 5 days
Fever since 4 days
Weakness since 4 days
Abdominal discomfort since 3 days
HOPI :
Patient was apparently asymptomatic 2 years back, then he had fever for which he visited local hospital and was diagnosed with Diabetes mellitus and was started on OHAs. Patient was on regular treatment and was going for regular checkups, then since 6 months he has been switched to Insulin. 2 months back patient was admitted to our hospital with complaints of decreased appetite, nausea and loose stools and was treated for the same. Patient had 4 dialysis sessions in the previous admission. Presently, patient came with chief complaints of pedal edema since 5 days which is pitting type upto the level of ankle, fever since 4 days which is low grade with no diurnal variation. Patient has generalized weakness since 8 months which increased since 4 days.
Associated with loss of appetite, pain and swelling of right upper limb. Patient is complaining of abdominal pain since the previous dialysis session.
H/o weight loss +.
Past history :
Patient is a known diabetic since 2 years, was initially on OHAs, now on Insulin.
Hospital admission for 15 days due to diarrhea and loss of appetite.
Not a k/c/o Hypertension, Asthma, TB, Epilepsy, CAD.
Personal history :
Diet : Mixed
Appetite : Absent
Sleep : Adequate
Bowel : Regular
Bladder Movements : Decreased urine output, Blood in urine since 2 days after admission
Family history :
No significant family history.
General examination :
Pallor present, Edema of b/l lower limbs (pitting type) and of right upper limb is present.
Icterus, cyanosis, clubbing, lymphadenopathy are absent.
Thin Built and poorly nourished .
Vitals :
BP : 90/70 mm Hg
PR : 80 bpm
RR : 22 cpm
SpO2 : 98 % on RA
Temp. : 99.0 F
Systemic Examination :
CVS : S1, S2 heard
RS : BAE +
P/A : Soft, Non-tender
CNS : NAD
Investigations :
1. Hemogram :
23/09/22
24/09/22
26/09/22
28/09/22
29/09/22
2. RFT :
28/09/22
Blood Urea
23/09/22
24/09/22
25/09/22
26/09/22
29/09/22
30/09/22
Serum Creatinine
23/09/22
24/09/22
25/09/22
26/09/22
29/09/22
30/09/22
Serum electrolytes
23/09/22
29/09/22
30/09/22
3. ABG :
23/09/22
25/09/22
26/09/22
30/09/22
4. LFT :
23/09/22
5. APTT :
23/09/22
25/09/22
28/09/22
6. Prothrombin Time :
23/09/22
25/09/22
28/09/22
7. RBS (23/09/22)
8. CRP (23/09/22)
9. CUE
23/09/22
25/09/22
26/09/22
10. ESR (23/09/22)
11. LDH (24/09/22)
12. Reticulocyte count (24/09/22)
13. Serum Iron ( 24/09/22)
9. Blood grouping (24/09/22)
8. Culture and sensitivity
Blood - 1st subculture (26/09/22)
Blood - 2nd subculture (28/09/22)
Urine C/S (27/09/22)
9. Stool for occult blood
10. Anti HCV (23/09/22)
11. HbsAg (23/09/22)
12. HIV (23/09/22)
12. Dengue
12. X-ray
Shoulder x-ray (lateral view)
Shoulder x-ray (AP view)
15. Ultrasound report
17. ECG
18. Serum uric acid
18. Serum Osmolality
19. Serum Magnesium :
20. CECT KUB
Provisional Diagnosis :
AKI ON CKD WITH THROMBOCYTOPENIA UNDER EVALUATION WITH ANEMIA 2° TO ?RENAL FAILURE WITH AKI 2° TO GASTROENTERITIS WITH ?TCC OF BLADDER WITH DM 2 WITH HYPONATREMIA
Treatment :
1. IVF - 0.9% NS @ U.O + 30 ML/HR
2. INJ. PIPTAZ 2.25 G/IV/TID
3. INJ. PAN 40 MG/IV/OD
4. INJ. ZOFER 4G/IV/SOS
5. INJ. VIT K 1 AMP IN 100 ML/NS/IV
6. TAB. SPOROLAC 2 TAB/PO/TID
7. TAB. OROFER - XT/PO/OD
8. TAB. SHELCAL 500 MG/PO/OD
9. TAB. NODOSIS 500 MG/PO/BD
10. SYP. POTCHLOR 15 ML IN GLASS OF WATER PO/TID
SOAP NOTES :
50 yr old male, admitted on 23-09-22
Day 9 (1-19-22)
S:
Generalized weakness since 10 days
Pain in right shoulder since 10 days
Loose stools since last night
O:
Vitals
Bp: 110/60 mm Hg
PR: 60 bpm
RR: 18 cpm
Temp: 98.6 F
GRBS: 143 mg/dl
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
SEPSIS WITH MODS WITH AKI (POST RENAL) ON CKD, ANEMIA 2° TO BLOOD LOSS, ?TRANSITIONAL CARCINOMA OF BLADDER WITH DM-TYPE2
P:
1. INJ. KCL 40 MEQ IN 500 ML NS OVER 4-6 HRS
2. IV FLUIDS NS @ 75 ML/HR
3. TAB. OROFER - XT PO/OD
4. TAB. SHELCAL 500 PO/OD
5. TAB. DOLO 650 MG/PO/QID
6. TAB. ULTRACET 1/2 PO/QID
7. SYP. POTKLOR 15ML/PO/TID
8. TAB. SPOROLACB- DS
Day 9 (1-19-22)
S:
Generalized weakness since 10 days
Pain in right shoulder since 10 days
Loose stools since last night
O:
Vitals
Bp: 110/60 mm Hg
PR: 60 bpm
RR: 18 cpm
Temp: 98.6 F
GRBS: 143 mg/dl
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
SEPSIS WITH MODS WITH AKI (POST RENAL) ON CKD, ANEMIA 2° TO BLOOD LOSS, ?TRANSITIONAL CARCINOMA OF BLADDER WITH DM-TYPE2
P:
1. INJ. KCL 40 MEQ IN 500 ML NS OVER 4-6 HRS
2. IV FLUIDS NS @ 75 ML/HR
3. TAB. OROFER - XT PO/OD
4. TAB. SHELCAL 500 PO/OD
5. TAB. DOLO 650 MG/PO/QID
6. TAB. ULTRACET 1/2 PO/QID
7. SYP. POTKLOR 15ML/PO/TID
8. TAB. SPOROLACB- DS
Day 11 (3-10-22)
S:
Generalized weakness since 12 days
Pain in right shoulder since 12 days
Blood in urine since 7 days
O:
Vitals
Bp: 120/70 mm Hg
PR: 62 bpm
RR: 20 cpm
Temp: 98.3 F
GRBS: 101 mg/dl
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
AKI (POST RENAL) ON CKD, ANEMIA 2° TO BLOOD LOSS, THROMBOCYTOPENIA 2° TO MODS, HYPOKALEMIA 2° TO GI LOSSES, ?TRANSITIONAL CARCINOMA OF BLADDER WITH DM-TYPE2
P:
1. INJ. KCL 40 MEQ IN 500 ML NS OVER 4-6 HRS
2. IV FLUIDS NS @ 75 ML/HR
3. TAB. OROFER - XT PO/OD
4. TAB. SHELCAL 500 PO/OD
5. TAB. DOLO 650 MG/PO/QID
6. TAB. ULTRACET 1/2 PO/QID
7. SYP. POTKLOR 15ML/PO/TID
8. TAB. SPOROLACB- DS
S:
Generalized weakness since 12 days
Pain in right shoulder since 12 days
Blood in urine since 7 days
O:
Vitals
Bp: 120/70 mm Hg
PR: 62 bpm
RR: 20 cpm
Temp: 98.3 F
GRBS: 101 mg/dl
Cvs: S1 S2 +
RS- BAE +
P/A- soft, non tender
CNS- NAD
A:
AKI (POST RENAL) ON CKD, ANEMIA 2° TO BLOOD LOSS, THROMBOCYTOPENIA 2° TO MODS, HYPOKALEMIA 2° TO GI LOSSES, ?TRANSITIONAL CARCINOMA OF BLADDER WITH DM-TYPE2
P:
1. INJ. KCL 40 MEQ IN 500 ML NS OVER 4-6 HRS
2. IV FLUIDS NS @ 75 ML/HR
3. TAB. OROFER - XT PO/OD
4. TAB. SHELCAL 500 PO/OD
5. TAB. DOLO 650 MG/PO/QID
6. TAB. ULTRACET 1/2 PO/QID
7. SYP. POTKLOR 15ML/PO/TID
8. TAB. SPOROLACB- DS
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