140 SANJANA KULAKARNI
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December 16, 2021
57 YEAR FEMALE WITH DECREASED URINE OUTPUT AND SHORTNESS OF BREATH
15/12/2021
A 57 year old female patient presented to the OPD with chief complaints of decreased urine output since 3 days and shortness of breath grade II-III since one day And fever not associated with chills and rigors
HISTORY OF PRESENT ILLNESS
✓57 year old female patient resident of sirikonda,, housewife . She was apparently asymptomatic 3 years back then she had low back pain which was radiating to groin diagnosed as renal caliculi managed conservatively.... f/b diagnosed with CKD managed conservatively
✓Decreased urine output since 3days
Sob grade II-III since yesterday night
Cough with sputum yellowish in colour intermittent f/b blood tinged sputum
And fever not associated with chills and rigors
PAST HISTORY:
No similar complaints in the past
MEDICAL HISTORY:
Not a know case of diabetes, hypertension, tuberculosis, epilepsy, asthma.
FAMILY HISTORY:
No relevant family history
PERSONAL HISTORY:
-Mixed diet
---REDUCED APPETITE
-Adequate sleep
---Regular bowel movements
-micturition: Pt HAS DECREASED URINE OUTPUT.
-GENERAL PHYSICAL EXAMINATION:
PALLOR - Present
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal oedema - PRESENT (NON PITTING TYPE)
Vitals:
Temperature- afebrile
Pulse rate- 89 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 110/70 mm hg
SpO2- 90% at room air
SYSTEMIC EXAMINATION
Cardiovascular system- s1 and S2 are heard no murmurs are heard
Respiratory system:
Dyspnoea- present
Breath sounds- decreased breath sounds in right
Vesicular breath sounds are normal
Wheezing- present
Rt side Fine Crepts present
BAE- positive
Central nervous system- Patient was conscious coherent and cooperative.
Speech was normal.
No slurred speech
No meningeal irritation signs
-No abnormality detected.
-REFLEXES
Right and left biceps triceps supinator ankle and knee show grade 2 Reflex
GAIT - Normal
PROVISIONAL DIAGNOSIS
CKD with right sided pleural effusion
TREATMENT:
1.Pleural tap
2. Head and elevation up to 30°
3. O2 supplementation if SpO2 is less than 90%.
4. Fluid restriction < 1 litre per day
5. Salt restriction < 2.4 G per day
6.Inj. Augmentin 500 mg/ IV/ OD
7. Tab. Azithromycin 500 mg/ OD
8. Inj. Lasix 40 mg IV/ BD
9. Tab shelcal 500 mg audi
10.Tab orofer-xT /OD
11.Inj. Erythropoietin 4000 IU s/c weekly once
12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13.Syrup. Ascoryl 10ml /TD
14.Monitor vitals hourly
15.Strict I/O Charting,
SR LDH --255IU/DL
PLEURAL LDH--1968IU/DL
SR PROTEINS 5.4 G/DL
PL PROTEIN 3.6 G/DL
PL SUGAR 71 MG/DL
Pl ldh /sr ldh -1968/255 =7.7
Pl protein /sr protein -3.6/5.4 =0.66
Spot urine protein 53mg/dl
Spot urine creatine 106mg/dl
Ratio 0.50
Sr Electrolytes
Na+ 135 meq/l
K+ 4.0meq/l
Cl- 92meq/l
Creatine clearence 11ml/min
Day 3
57yrs old female
17/12/21
Notes amc bed 3
Yesterday in cubical no 2;
S
pt feeling better
saturation without o2 92%
O:
O/e pt c/c/c
Temp 97.5 f
Bp 100/70 mmHg
pr 115bpm
RR 22cpm
Grbbs 102 mg/dl
I/O 500/1000ml
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
WHEEZE PRESENT
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion
Egfr 9ml/min( stage 5)
EXUDATIVE >TRANSUDATIVE
? INFECTION
? MALIGNANCY
1.Pleural tap
2. Head and elevation up to 30°
3. O2 supplementation if SpO2 is less than 90%.
4. Fluid restriction < 1 litre per day
5. Salt restriction < 2.4 G per day
6.Inj. Augmentin 500 mg/ IV/ OD( D3)
7. Tab. Azithromycin 500 mg/ OD (D3)
8. Inj. Lasix 40 mg IV/ BD
9. Tab
10. Tab shelcal 500 mg audi
11. Tab orofer-xT /OD
12. Inj. Erythropoietin 4000 IU s/c weekly once
13. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
14. Syrup. Ascoryl 10ml /TD
Hemogram
HB 8.6
TLC 29000
Plt 2.57
N 96
L 1
Pcv 24.9
MCV 72.5
Mchc 34.7
57yrs old female
18/12/21
Soap notes amc bed 3
S
C/O shortness of breath
O:
O/e pt c/c/c
Temp afebrile
Bp 90/60 mmHg
pr 112bpm
Spo2 99% @ 4 lit of O2
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion
P:-
1. Head and elevation up to 30°
2.O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. Inj .pipatz 2.25gm iv bd
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9.Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
One session of dialysis done
19/12/21
57yrs old female
19/12/21
Soap notes amc bed 3
S
shortness of breath - reduced
No fever spikes
O:
O/e pt c/c/c
Temp afebrile
Bp 90/60 mmHg
pr 112bpm
Spo2 92% @ 4 RA
Cvs s1s2heard,no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
HB: 8.1, TLC: 23,000, PLT: 2.33, N - 85, L - 0.5, UREA: 137, CREAT: 4.6, NA+- 138, K- 3.8, CL- 94
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
P:-
1. Head and elevation up to 30°
2. 2.O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. inj piptaz 2.24gm iv/bd
6.Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12.Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
57yrs old female
20/12/21
Soap notes amc bed 3
S
shortness of breath - reduced
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 100/70 mmHg
pr 98bpm
Spo2 95%@RA
I/O 500/750ML
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. D3 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
15. PLAN FOR DIALYSIS
20/12/21
Rft
Urea 160 mg/dl
Creatinine 4.3mg/dl
Uric acid 6.1mg/dl
Phosphorus 3.8mg/dl
Calcium 9.1meq/l
Sodium 143meq/l
Potassium 3.8meq/dl
Chloride 96meq/dl
Serum Albumin 2.7g/dl
Serum iron 80ug/dl
57yrs old female
Shifted to CKD ward from amc bed 3
21/12/21
SOAP NOTES
shortness of breath - reduced , no fresh complaints
No fever spikes
Stools not passed
O:
O/e pt c/c/c
Temp afebrile
Bp 100/70 mmHg
pr 98bpm
Spo2 96%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4.Salt restriction < 2.4 G per day
5. D4 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14.SYP LACTULOSE 10ML PO/BD
15. UNDERGOING DIALYSIS
57yrs old female
CKD ward
22/12/21
SOAP NOTES
S
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
. O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
pr 98bpm
Spo2 96%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. D5 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
57yrs old female
CKD ward
23/12/21
SOAP NOTES
S
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 120/70 mmHg
pr 98bpm
Spo2 96%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. D6 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
57yrs old female
CKD ward
24/12/21
SOAP NOTES
S
Decreased appetite
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
pr 98bpm
Spo2 96%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3.Fluid restriction < 1 litre per day
4.Salt restriction < 2.4 G per day
5. D7 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
57yrs old female
CKD ward
25/12/21
SOAP NOTES
S
Decreased appetite
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
pr 95bpm
Spo2 97%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. Salt restriction < 2.4 G per day
5. D8 inj piptaz 2.25 gm/ IV/ BD
6. Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8.Tab shelcal 500 mg PO/OD
9.Tab orofer-xT /OD
10.Inj. Erythropoietin 4000 IU s/c weekly once
11.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12.Syrup. Ascoryl 10ml /TID
13.Neb with salbutamol thrice daily
14.SYP LACTULOSE 10ML PO/BD
57yrs old female
CKD ward
26/12/21
SOAP NOTES
S
Decreased appetite
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
pr 95bpm
Spo2 97%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4.Salt restriction < 2.4 G per day
5. D8 inj piptaz 2.25 gm/ IV/ BD
6.Inj. Lasix 40 mg IV/ BD
7. Tab. Nodosis 550mg PO/BD
8. Tab shelcal 500 mg PO/OD
9. Tab orofer-xT /OD
10. Inj. Erythropoietin 4000 IU s/c weekly once
11. Inj. Iron sucrose 1Amp in 100 ml us during dialysis
12. Syrup. Ascoryl 10ml /TID
13. Neb with salbutamol thrice daily
14. SYP LACTULOSE 10ML PO/BD
57yrs old female
CKD ward
27/12/21
SOAP NOTES
S
Decreased appetite
Pedal Edema Present
shortness of breath - reduced ,
No fever spikes
Stools passed
O:
O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 2 sessions of dialysis on 18/12/21 and 21/12/21
P:-
1. Head and elevation up to 30°
2. O2 supplementation if SpO2 is less than 90%.
3. Fluid restriction < 1 litre per day
4. 4. Salt restriction < 2.4 G per day
5. 5.D10 inj piptaz 2.25 gm/ IV/ BD
7. 7. Inj. Lasix 40 mg IV/ BD
8. 8. Tab. Nodosis 550mg PO/BD
9. 9. Tab shelcal 500 mg PO/OD
10. 10. Tab orofer-xT /OD
11. 11. Inj. Erythropoietin 4000 IU s/c weekly once
12. 12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. 13.Syrup. Ascoryl 10ml /TID
14. 14. Neb with salbutamol thrice daily
15 SYP LACTULOSE 10ML PO/BD
PLAN FOR DIALYSIS
57yrs old female
CKD ward
28/12/21
SOAP NOTES
S
C/o shortness of breath
Loose stools 3-4 episodes
No fever spikes
O:
O/e pt c/c/c
Temp afebrile
Bp 110/70 mmHg
pr 96bpm
Spo2 95%@RA
Cvs s1s2heard no murmurs
Rs :
BAE +
TRACHEA CENTRAL
VESICULAR BREATH SOUNDS HEARD
Decreased breath sounds in Right Infrascapular and suprascapular area.
Crepts present on right infrascapular area.
P/A
soft non tender
Distended
Bowel sounds heard
CNS :NAD
PROVISIONAL DIAGNOSIS
CKD with rt sided pleural effusion ( EXUDATIVE)
Underwent 3 sessions of dialysis on 18/12/21 ,,21/12/21 and 27/12/21
P:-
1. Head and elevation up to 30°
2. 2. O2 supplementation if SpO2 is less than 90%.
3. 3. Fluid restriction < 1 litre per day
4. 4. Salt restriction < 2.4 G per day
5. 5.D10 inj piptaz 2.25 gm/ IV/ BD
7. 7. Inj. Lasix 40 mg IV/ BD
8. 8. Tab. Nodosis 550mg PO/BD
9. 9. Tab shelcal 500 mg PO/OD
10. 10. Tab orofer-xT /OD
11. 11. Inj. Erythropoietin 4000 IU s/c weekly once
12. 12.Inj. Iron sucrose 1Amp in 100 ml us during dialysis
13. 13.Syrup. Ascoryl 10ml /TID
14. 14. Neb with salbutamol thrice daily
15 SYP LACTULOSE 10ML PO/BD
16 tab loperamide
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