A 68 YEAR OLD FEMALE CAME TO OPD WITH COMPLAINTS OF PAIN ABDOMEN SINCE 4 DAYS FEVER WITH CHILLS SINCE 4 DAYS VOMITINGS AND ABDOMINAL DISTENSION SINCE 3 DAYS CONSTIPATION SINCE 2 DAYS
PATIENT
WAS APARANTLY ASYMPTIMATIC 1 WEEK BACK THEN SHE HAD COMPLAINTS OF LOOSE
STOOLS 3-4 EPISODES WATERY,NOT ASSOCIATED WITH BLOOD AND MUCOUS, LARGE
VOLUME,BLACK COLOURED LASTED FOR 2 DAYS,THEN SHE HAD COMPLAINTS OF PAIN
ABDOMEN,DIFFUSE,SQUEEZING TYPE ASSOCIATED WITH COMPLAINTS OF FEVER
WITH CHILLS,INTERMITTENT,NO EVENING RAISE OF TEMPERATURE ,WITH
VOMITINGS,BILIOUS,NONPROJECTILE FOR 4 DAYS AND ALSO COMPLAINTS OF
OBSTIPATION SINCE 2 DAYS
CLINICAL CASE OF DIABETES MELLITUS SINCE 10 NYEARS ON MEDICATION.
NOT A CLINICAL CASE OF HYPERTENSION,TB,ASTHMA,CAD,EPILEPSY,CVA
PERSONSAL HISTORY
MIXED DIET
APPETITE:LOST SINCE 1 WEEK
SLEEP: ADEQUATE
CONSTIPATION SINCE 2 DAYS
BURNING MICTURITION SINCE 10 DAYS
ADDICTIONS NONE
GENERAL EXAMINATION
PATIENT IS CONSCIOUS ,COHERENT,COOPERATIVE
NO PALLOR,ICTERUS, CYANOSIS, CLUBBING,LYMPHADENOPATHY ,EDEMA
TEMPERATURE:98.7F
PR:110 BPM
BP:130/70 MMHG
RR:24CPM
GRBS:91MG/DL
CVS:S1S2+ NO MURMURS
RS:BAE+
P/A:SOFT ' TENDER IN HYPOGASTRIUM
CNS:NFND HMF+
18/05/2023: GYNAECOLOGY REFERRAL IN VIEW OF LOWER PAIN ABDOMEN AND
ADVISED FOR MRI TO RULEOUT TORSION AND ALSO CA-125,USG DOPPLER.
IMPRESSION: UTI WITH LEFT OVARIAN CYST
HEMOGRAM:
15/5/23
HB:8.8
TLC:16800
PLT:1.14L
17/5/23
HB:10.6
TLC:13,400
PLT:1.56L
24/5/23
HB:8.6
TLC:10600
PLT:4.8L
19/05/2023:
BACTERIAL C/S FOR STOOL: NORMAL FLORA GROWN
USG ABDOMEN ON 22/05/2023:
LEFT OVARIAN CYST (MEASURING 07 X 5.4 CMS)
ALTERED ECHOTEXTURE OF LEFT KIDNEY,
INVESTIGATIONS:
COURSE AT THE HOSPITAL WITH TREATMENT
DAY 2
Soap notes
68 year old female came with c/o loose stools since 1 week , pain abdomen and fever with chills since 4 days, vomitings and abdominal distension since 3 days, constipation since 2 days.
S:
C/o pain abdomen but decreased relatively,
Fever spikes present( 2 spikes yesterday night)
Stools passed.
O/E:
Temp- 97.8 F
Bp-110/70 mm hg
Pr- 92bpm
Rr-22cpm
Spo2- 97% on RA
GRBS:@ 245mg/dl hai 8u given
I/o:1900/800ml
General examination:
Pt is c/c/c
No pallor icterus cyanosis clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact
Per abdomen : soft, non tender.
A:
A 68F with pyrexia with thrombocytopenia(resolved)
With pain abdomen under evaluation, AKI secondary to ?sepsis
P:
Iv fluids 2units ns,1 unit RL @ 75ml/hr
Inj.PAN 40mg iv/od
Inj.ZOFER 4mg/iv/bd
Inj.NEOMOL 1gm/iv/sos if temp. is >101F
Inj.BUSCOPAN im/sos
Tab.DOLO 650mg/po/sos
Inj.HAI sc/tid/premeal a/c to RBS.
S:
Pain abdomen decreased
Fever spikes present( 2 spikes yesterday night)
Stools passed.
C/o Lower back ache.
O/E:
Temp- 98.7 F
Bp-120/80mm hg
Pr- 78bpm
Rr-22cpm
Spo2- 97% on RA
GRBS:@ 231mg/dl hai 8u given
I/o:2200/1700
General examination:
Pt is c/c/c
No pallor icterus cyanosis clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact
Per abdomen : soft, non tender.
A:
A 68F with pyrexia with thrombocytopenia(resolved)
With pain abdomen under evaluation, AKI secondary to ?sepsis
P:
Iv fluids 2units ns,1 @ 50ml/hr
Inj.PAN 40mg iv/od
Inj.ZOFER 4mg/iv/bd
Inj.NEOMOL 1gm/iv/sos if temp. is >101F
Inj.BUSCOPAN im/sos
Tab.DOLO 650mg/po/sos
Inj.HAI sc/tid/premeal a/c to RBS.
Inj.LASIX 20mg iv/od
Soap notes
68 year old female came with c/o loose stools since 1 week , pain abdomen and fever with chills since 4 days, vomitings and abdominal distension since 3 days, constipation since 2 days.
S:
Pain abdomen decreased
Fever spikes present( 2 spikes yesterday night)
Stools passed.
C/o Lower back ache stabbing type,cannot sleep due to pain
O/E:
Temp- 98.7 F
Bp-1300/80mm hg
Pr- 94bpm
Rr-28cpm
Spo2- 97% on RA
GRBS:@ 235mg/dl hai 10u given
I/o:2750/730ml
General examination:
Pt is c/c/c
pallor+, icterus cyanosis clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact
Per abdomen : tender in hypogastrium region
A:
A 68F with pyrexia with thrombocytopenia(resolved)
With pain abdomen under evaluation, AKI secondary to ?sepsis
P:
Iv fluids 2units ns,1 @ 50ml/hr
Inj.PAN 40mg iv/od
Inj.ZOFER 4mg/iv/bd
Inj.NEOMOL 1gm/iv/sos if temp. is 100.1 degree F
Inj.BUSCOPAN im/sos
Tab.DOLO 650mg/po/sos
Inj.HAI sc/tid/premeal a/c to RBS.
Inj.LASIX 20mg iv/od
S:
Pain abdomen decreased
Fever spikes present( 1 spikes yesterday night)
Stools passed.
appetite
C/o Lower back ache decreased
O/E:
Temp- 98.9F
Bp-100/60mm hg
Pr- 94bpm
Rr-28cpm
Spo2- 97% on RA
Grbs- 257 10 units hai given
General examination:
Pt is c/c/c
pallor+, icterus cyanosis clubbing lymphadenopathy, edema
Systemic Examination:
Cardiovascular System : S1, S2 heard, no
murmurs
Respiratory System : Bilateral air entry present.Normal vesicular breath sounds heard.
Central Nervous System : Higher mental functions intact
Per abdomen : tender in hypogastrium region,left iliac fossa
A:
A 68F with pyrexia with thrombocytopenia(resolved)
With pain abdomen under evaluation, AKI secondary to ?sepsis
P:
Iv fluids 2units ns,1 @ 50ml/hr
Inj.PAN 40mg iv/od
Inj.ZOFER 4mg/iv/bd
Inj.NEOMOL 1gm/iv/sos if temp. is 100.1 degree F
Inj.BUSCOPAN im/sos
Tab.DOLO 650mg/po/sos
Inj.HAI sc/tid/premeal a/c to RBS.
Inj.LASIX 20mg iv/od.
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