A 63 YR OLD FEMALE WITH ABDOMINAL TIGHTNESS, SOB, BURNING MICTURITION
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Case presentation:
A 63 year old female who is a retired judicial superintendent came to casualty on 5/1/2021 at 6pm with
℅ Sob , abdominal tightness , burning micturition since 1 month
Vomitings,Right upper quadrant pain, since 3 days
Patient was apparently asymptomatic 1month back then she developed abdominal tightness ,
sob intially grade 3 and now progressed to grade 4
And burning micturition not associated with increased frequency and hesitancy
Since 3 days back she had
H/o Vomitings 5-6 episodes , non projectile , non foul smelling
with right upper quadrant pain
Patient went to local outside hospital with these complaints on Sunday basic investigations were done , fluids given , found out creatinine (2--3.9---4.5) on raising trend referred to KIMS for further treatment
Patient is known case of Diabetes and Hypertension since 12 years
She was started on insulin Mixtard
HTN-Telma 80mg(morning),Metoprolol & Amlodipine
Later on her husband has renal failure landed on the dialysis after which he died due to heart stroke(history given by his son)
Later patient had emotional disturbances underwent PTCA(2017 december)
Followed up for six months and stopped taking medications
Later had history of UTI in 2019 december and recieved antibiotics 10 days and got resolved
History of gallstones since three years and on conservative management
Personal history:
Diet : mixed diet
appetite: decreased
bowel : regular
Bladder : decreased urine output with burning micturition
Sleep: adequate.
addictions: none
GENERAL EXAMINATION
PT is conscious , coherent , cooperative
Bilateral pedal edema+ which is of pitting type
No signs of pallor, icterus, cyanosis, clubbing,
lymphadenopathy
Vitals:
Temperature: Afebrile
Pulse: 102bpm
Blood pressure: 160/70mm of hg
Respiratory rate: 28 cpm
SpO2: 98 %at room air
Grbs: 392mg/dl
CVS EXAMINATION
S1S2 heard
No murmurs
RESPIRATORY SYSTEM
Bilateral air entry present, NVBS
Bilateral crepts + in right infraaxillay , inframammary and infrascapular region
PER ABDOMEN
Abdomen is distended
bowel sounds +
CNS
No abnormality detected
PROVISIOAL DIAGNOSIS
AKI ON CKD SECONDARY TO UROSEPSIS WITH UNCONTROLLED SUGARS
? CHOLELITHIASIS, DYSELECTROLEMIA (HYPERKALEMIA), HYPOALBUMINEMIA
POST PTCA(2017), K/C/O HTN and TYPE2DM
INVESTIGATIONS
ON ADMISSION OUTSIDE REPORTS
DAY 1
HAEMOGRAM
RBS
ABG
LFT
RFT
CUE
URINE FOR KETONE BODIES
SPOT URINE PROTEIN/ CREATININE RATIO
URINE ELECTROLYTES
PT,INR
CT, BT
APTT
SERUM AMYLASE
SERUM LIPASE
HIV 1/2 RAPID TEST
HBsAG- RAPID
ANTI HCV ANTIBODIES- RAPID
CHEST X RAY
X RAY ERECT ABDOMEN
ECG
Shows tall twaves with narrow base
USG ABDOMEN
ABG AT 11PM
UROLOGY REFERAL
GYNAECOLOGY REFERAL
OPHTHALMOLOGY REFERAL
BLOOD GROUPING AND TYPING
DAY 3
PLBS
ECG at 3:30pm
DAY 4
HAEMOGRAM
RFT
ABG
BLOOD CULTURE
URINE CULTURE
CHEST X RAY
ABG at 10pm
CUE
DAY 7
ECG
ABG at 5am
ABG at 9am
CHEST X RAY
ABG at 12:40pm
BT, CT
APTT
PT, INR
LFT
ABG at 6pm
2D ECHO
TREATMENT
DAY 1
INJ PIPTAZ 2.25mg IV TID
INJ ZOFER 4mg IV TID
INJ LASIX 40mg BD ( IF SBP >= 110mmhg)
IVF NS URINE OUTPUT + 30 ml/hr
NEBULIZATION WITH SALBUTAMOL 4amp 4hrly
INJ CALCIUM CARBONATE 1amp IV STAT OVER 10 mins
INJ HAI 8 units /SC GIVEN
INJ INSULIN HAI 40 units in 39 ml NS/ IV @ 6ml/hr infusion was kept
DAY 2
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD ( IF SBP >= 110mmhg)
IVF NS URINE OUTPUT + 30 ml/hr
INJ HAI S/C AFTER INFORMING GRBS
DAY 3
Patient has been taken for hemodialysis (2hrs) early morning in view of oliguria
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD ( IF SBP >= 110mmhg)
IVF NS URINE OUTPUT + 30 ml/hr
INJ HAI S/C AFTER INFORMING GRBS
TAB NODISIS 500mg TID
CAP CINDOP -10 BD
CAP BIO D3 BD
IV ERYTHROPOIETIN 4000 UNITS ( WEEKLY TWICE)
IV IRON IN 50 ML NS ( WEEKLY TWICE)
Patient had fever with chills during iron sucrose injection and was stopped.
DAY 4
Fever spike +
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
TAB NODISIS 500mg TID
CAP CINDOP -10 BD
CAP BIO D3 BD
DAY 5
Bleeding manifestation seen on left arm
Patient had c/o abdomen distension then taken for dialysis at 3:30pm with blood transfusion
At night patient had fever spike , tachycardia , tachypnea
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
TAB NODISIS 500mg TID
TAB CILNIDIPINE 10mg PO OD
NEBULIZATION BUDECORT 12TH HRLY
TAB METOLAZONE 2.5 mg BD
SYP LACTULOSE 5ml PO H/S
DAY 6
Fever spike+
Patient had C/O SOB and abdominal distension kept on oxygen inhalation and intermittent CPAP
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
TAB NODISIS 500mg TID
TAB CILNIDIPINE 10mg PO OD
NEBULIZATION BUDECORT 12TH HRLY
TAB METOLAZONE 2.5 mg BD
DAY 7
Suspected of TRALI
Taken to dialysis - morning ( 10am)
INJ PIPTAZ 2.25mg IV TID
INJ PAN 40 mg IV OD
INJ LASIX 40mg BD
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
TAB NODISIS 500mg TID
TAB CILNIDIPINE 10mg PO OD
NEBULIZATION BUDECORT 12TH HRLY
TAB METOLAZONE 2.5 mg BD
INJ VIT K 10 mg IV OD
INJ HYDROCORT 100mg IV STAT
INJ SODABICA 10meq in 5cc NS IV STAT
DAY 8
ABG at 2 am
HAEMOGRAM
ABG
RFT
CHEST X RAY
D- DIMER
SARS COV-2 QUALITATIVE PCR
ABG at 5:30 pm
BLOOD CULTURE
URINE CULTURE
TREATMENT
Patient had complaints of SOB
Orthopnea+, fever spike+( early morning)
RT Feeds milk + protein - 100ml , free water 4th hourly
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX 40mg IV TID
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
INJ HYDROCORTISONE 100mg IV TID
INJ VIT K 10 mg IV OD
TAB NODISIS 500mg PO TID
TAB CILNIDIPINE 10mg PO OD
NEBULIZATION BUDECORT 4TH HRLY
IPRAVENT 4TH HRLY
TAB METOLAZONE 2.5 mg BD
OXYGEN INHALATION TO MAINTAIN SPO2 >90% AT 10lit
DAY 9
HAEMOGRAM
LFT
RFT
ABG at 8 am
CHEST X RAY
TREATMENT
Patient had complaints of SOB, Abdominal distension +, stool not passed and fever spike+
Patient is taken for dialysis at 10 am
RT Feeds milk + protein - 100ml , free water 4th hourly
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX 40mg IV TID
INJ HUMAN MIXTARD S/C ( 10 UNITS------X-------5UNITS)
INJ HYDROCORTISONE 100mg IV TID
INJ VIT K 10 mg IV OD
TAB NODISIS 500mg PO TID
TAB CILNIDIPINE 10mg PO OD
NEBULIZATION BUDECORT 4TH HRLY
IPRAVENT 4TH HRLY
TAB METOLAZONE 2.5 mg BD
TAB RAMIPRIL 5mg PO OD
SYP LACTULOSE 10ml RT TID
OXYGEN INHALATION TO MAINTAIN SPO2> 90% AT 8lit
DAY 10
ABG at 8 am
HAEMOGRAM
RFT
PT , INR
APTT
CHEST X RAY
ABG at 9 am
TREATMENT
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
INTERMITTENT CPAP ( 2HRS) 2-3 TIMES / DAY
RT FEEDS 100 ml MILK + PROTEIN AND 50ml FREE WATER - 3HRLY ( 8 am- 10pm) (900ml)
SYP LACTULOSE 15ml / RT/ 4TH HRLY
INJ HAI /SC/ TID
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX 80mg IV TID
INJ HYDROCORTISONE 100mg IV TID
TAB NODISIS 500mg /RT/ TID
NEBULIZATION BUDECORT 4TH HRLY
IPRAVENT 4TH HRLY
TAB METOLAZONE 2.5 mg / RT/ BD
TAB RAMIPRIL 5mg / RT/ OD
INJ VIT K 10mg / IV/ OD
TAB UDILIV 300mg / RT/ OD
THROMOPHOBE OINTMENT FOR LA
3% Nacl LOOSE GAUZE DRESSING FOR LT ARM REGION
INJ ZOFER 4mg IV TID
AIR BED OR WATER BED
TRANSFUSION OF 2FFPs done ( 1 in morning and 1 in evening) ( Transfusion uneventful)
DAY 11
HAEMOGRAM
ABG at 7 am
PT, INR
APTT
RFT
CHEST X RAY
ECG at 2am
PULMONOLOGY REFERAL
TREATMENT
Patient complains of palpitations
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
INTERMITTENT CPAP ( 2HRS) 2-3 TIMES / DAY
RT FEEDS 100 ml MILK + PROTEIN AND 50ml FREE WATER - 3HRLY ( 8 am- 10pm) (900ml)
SYP LACTULOSE 15ml / RT/ 6TH HRLY
INJ HAI /SC/ TID ( 12u-------12u-------10u)
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX IV TID (80mg------80mg-------40mg)
INJ HYDROCORTISONE 100mg IV TID
TAB NODISIS 500mg /RT/ TID
NEBULIZATION BUDECORT 4TH HRLY
TAB METOLAZONE 2.5 mg / RT/ BD
TAB RAMIPRIL 5mg / RT/ OD
INJ VIT K 10mg / IV/ OD
TAB UDILIV 300mg / RT/ OD
THROMOPHOBE OINTMENT FOR LA
3% Nacl LOOSE GAUZE DRESSING FOR LT ARM REGION
INJ ZOFER 4mg IV TID
GLYCERINE + MgSO4 DRESSING FOR LEFT ARM WITH LEFT ARM COMPLETE ELEVATION
DAY 12
HAEMOGRAM
ABG at 7am
RFT
LFT
PT, INR
APTT
CHEST X RAY
SERUM IRON
SERUM LDH
RETICULOCYTE COUNT
PERIPHERAL SMEAR
TREATMENT
Patient complains of burning micturition - Foley's removed
Patient is taken for dialysis at 10am
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
INTERMITTENT CPAP ONCE / DAY FOR 2HRS
RT FEEDS 100 ml MILK + PROTEIN AND 50ml FREE WATER - 3HRLY ( 8 am- 10pm) (900ml)
SYP LACTULOSE 15ml / RT/ 8TH HRLY
INJ HAI /SC/ TID
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX IV TID (80mg------80mg-------40mg)
INJ HYDROCORTISONE 100mg IV TID
INJ ZOFER 4mg IV SOS
TAB NODISIS 500mg /RT/ TID
NEBULIZATION BUDECORT 4TH HRLY
TAB METOLAZONE 2.5 mg / RT/ BD
TAB RAMIPRIL 5mg / RT/ OD
INJ VIT K 10mg / IV/ OD
TAB UDILIV 300mg / RT/ OD
THROMOPHOBE OINTMENT FOR LA
3% Nacl LOOSE GAUZE DRESSING FOR LT ARM REGION
GLYCERINE + MgSO4 DRESSING FOR LEFT ARM WITH LEFT ARM COMPLETE ELEVATION
DAY 13
HAEMOGRAM
RFT
ABG at 7 am
CHEST X RAY
TREATMENT
Patient complains of pain in the left side of the body, Abdominal discomfort while sitting
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
INTERMITTENT CPAP OR SOS
ORAL FEEDS 100 ml MILK + PROTEIN AND 50ml FREE WATER - 3HRLY ( 8 am- 10pm) (900ml)
SYP LACTULOSE 15ml / 12TH HRLY
INJ HAI /SC/ TID
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX IV TID (80mg------80mg-------40mg)
INJ HYDROCORTISONE 100mg IV TID
INJ ZOFER 4mg IV SOS
TAB NODISIS 500mg /PO / TID
NEBULIZATION WITH BUDECORT 4TH HRLY
TAB METOLAZONE 2.5 mg / PO / BD
TAB RAMIPRIL 5mg / PO/ OD
INJ VIT K 10mg / IV/ OD
TAB UDILIV 300mg / OD
TAB OROFER XT /OD
THROMOPHOBE OINTMENT FOR LA
GLYCERINE + MgSO4 DRESSING FOR LEFT ARM WITH LEFT ARM COMPLETE ELEVATION
DAY 14
HAEMOGRAM
ABG at 7 am
RFT
CHEST X RAY
TREATMENT
Patient complains of fatigue and sleeplessness
Patient is taken for dialysis at 10:30 am
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
INTERMITTENT CPAP OR SOS
ORAL FEEDS 100 ml MILK + PROTEIN AND 50ml FREE WATER - 3HRLY ( 8 am- 10pm) (900ml)
SYP LACTULOSE 15ml / 12TH HRLY
INJ HAI /SC/ TID
INJ MEROPENAUM 500mg IV BD
INJ PAN 40mg IV OD
INJ LASIX IV TID (80mg------80mg-------40mg)
INJ HYDROCORTISONE 100mg IV BD
INJ ZOFER 4mg IV SOS
TAB NODISIS 500mg /PO / TID
NEBULIZATION WITH BUDECORT 6TH HRLY
TAB METOLAZONE 2.5 mg / PO / BD
TAB RAMIPRIL 5mg / PO/ OD
INJ VIT K 10mg / IV/ OD
TAB UDILIV 300mg /PO/ OD
TAB OROFER XT /OD
SYP CITRALKA QID
THROMOPHOBE OINTMENT FOR LA
GLYCERINE + MgSO4 DRESSING FOR LEFT ARM
DAY 15
CBP
ABG at 6 am
RFT
CHEST X RAY
TREATMENT
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
ENCOURAGE ORAL INTAKE OF FLUIDS( UPTO 1.5L) AND SOFT DIET
SALT RESTRICTED DIET ( < 2.4 g/day)
STRICT DIABETIC DIET
INJ MEROPENUM 500mg IV BD
INJ HYDROCORTISONE 100mg IV H/S
INJ HAI S/C TID
TAB LASIX 40 mg PO TID
TAB METALAZONE 2.5mg PO BD
TAB RAMIPRIL 10mg PO BD
TAB NODOSIS 500mg PO TID
NEBULIZATION WITH BUDECORT 8TH HRLY
SYP LACTULOSE 5ML PO H/S
SYP CITRALKA PO QID
TAB OROFER XT PO OD
GLYCERINE + MGSO4 DRESSING FOR LEFT ARM
THROMOPHOBE OINTMENT FOR LEFT ARM
DAY 16
HAEMOGRAM
RFT
ABG at 7 am
SOAP NOTES
S-
Pt is subjectively feeling well
No fresh complaints
O-
Pt is conscious,coherent
Bp-130/60mm of hg
PR-94/min
RR-24cycles/min
Spo2-98% in room air
Cvs-s1 s2 +
Rs-B/LAE+ inspiratory crept’s in Rt infrascapular area
Cns-No focal deficit
P/A- soft,non tender
A-
Hb 8.2—>7.6-->7.8—>7.3-->6.6–>6.4–>6.3→ 6.6---->6.0---->6.4
Tlc 42000——>34000-->33,000–>25,000 ->20000–>18600–>17,800-->16100---->15,800---->25,800
Plt 2.0—->2.09--->2.4–>2.06 - > 1.93 —->2.32–>1.63→ 1.96--->2.00---->2.25
Abg
PH-7.2–>7.35--->7.39——>7.38 -- > 7.36—>7.40–>7.41→ 7.46--->7.454--->7.44
Pco2-28.9—->26.8---->24.8—->31.8-> 38.9—>39.0–>41.3→ 33.5---->34.7----->24.1
Hco3 - 13.3—->14.4---->14.8—->19.8-- > 21.6—>24.3–>26.0→ 23.5---->24---->16.3
Rft
Urea-105—>70--->124—->98→ 127–>177—>96→ 146---->147---->186
Creat-3.7—->2.2---->5—->2.4→ 3.5–>4.7–>3.2→ 4.2---->4.8--->6.5
Lft
TB-7.1--->8.31—->0.78
DB-0.64---->0.58——>0.20
Ast-13---->11——>7
Alt-12----->10——->17
Alp-260----->261——>180
Tp-5.3------>4.9——>4.7
Albumin-2.4------>2.2——>2.6
A/G-0.85--------0.78——->1.21
PT 20—>19—>17
INR.1.4—>1.4—>1.25
APTT -39–>39—>34
P-Conservative
TREATMENT
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
ENCOURAGE ORAL INTAKE OF FLUIDS( UPTO 1.5L) AND SOFT DIET
INJ MEROPENUM 500mg IV BD
INJ HYDROCORTISONE 100mg IV H/S
INJ HAI S/C TID
TAB LASIX PO TID (8 am 80 mg----12pm 40mg----4pm 40mg)
TAB METALAZONE 2.5mg PO BD
TAB RAMIPRIL 5mg PO BD
TAB NODOSIS 500mg PO TID
NEBULIZATION WITH BUDECORT 8TH HRLY
SYP LACTULOSE 5ML PO H/S
SYP CITRALKA PO QID
TAB OROFER XT PO OD
TAB LINAGIPTIN 5mg PO OD
Patient was taken for dialysis at 4 pm
DAY 17
HAEMOGRAM
RFT
SOAP NOTES
S-
Pt is subjectively feeling well
No fresh complaints
O-
Pt is conscious,coherent
Bp-130/60mm of hg
PR-94/min
RR-24cycles/min
Spo2-98% in room air
Cvs-s1 s2 +
Rs-B/LAE+ inspiratory crept’s in Rt infrascapular area
Cns-No focal deficit
P/A- soft,non tender
A-
Hb 8.2—>7.6-->7.8—>7.3-->6.6–>6.4–>6.3→ 6.6---->6.0---->6.4----->6.2
Tlc 42000——>34000-->33,000–>25,000 ->20000–>18600–>17,800-->16100---->15,800---->25,800---> 3300
Plt 2.0—->2.09--->2.4–>2.06 - > 1.93 —->2.32–>1.63→ 1.96--->2.00---->2.25--->1.77
Abg
PH-7.2–>7.35--->7.39——>7.38 -- > 7.36—>7.40–>7.41→ 7.46--->7.454--->7.44
Pco2-28.9—->26.8---->24.8—->31.8-> 38.9—>39.0–>41.3→ 33.5---->34.7----->24.1
Hco3 - 13.3—->14.4---->14.8—->19.8-- > 21.6—>24.3–>26.0→ 23.5---->24---->16.3
Rft
Urea-105—>70--->124—->98→ 127–>177—>96→ 146---->147---->186---> 99
Creat-3.7—->2.2---->5—->2.4→ 3.5–>4.7–>3.2→ 4.2---->4.8--->6.5----> 3.9
Lft
TB-7.1--->8.31—->0.78
DB-0.64---->0.58——>0.20
Ast-13---->11——>7
Alt-12----->10——->17
Alp-260----->261——>180
Tp-5.3------>4.9——>4.7
Albumin-2.4------>2.2——>2.6
A/G-0.85--------0.78——->1.21
PT 20—>19—>17
INR.1.4—>1.4—>1.25
APTT -39–>39—>34
P-Conservative
TREATMENT
HEAD END ELEVATION UPTO 30 DEGREES
OXYGEN INHALATION WITH NASAL PRONGS TO MAINTAIN SPO2>92%
ENCOURAGE ORAL SOFT DIET WITH FLUIDS
INJ MEROPENUM 500mg PO BD
INJ HYDROCORTISONE 100mg IV OD
INJ HAI S/C TID
INJ LASIX IV TID
TAB METALAZONE 2.5mg PO BD
TAB RAMIPRIL 5mg PO BD
TAB NODOSIS 500mg PO TID
NEBULIZATION WITH BUDECORT 8TH HRLY
SYP LACTULOSE 5ML PO H/S
TAB OROFER XT PO OD
TAB LINAGLIPTIN 5mg PO OD
TAB MET XL 12.5 mg PO OD
GLYCERINE + MgSO4 DRESSING OF BILATERAL HANDS WITH ELEVATION OF UPPER LIMB
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