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           CASE E-LOG                      

                                                CASE SHEET

           A 70 year old female came with c/o SOB since 7 days  

Chief complaints:    

  • shortness of breath with cough
History of presenting illness:
  • Patient was apparently asymptomatic 2 years back. The patient then had an episode of SOB . Now, the patient again has an episode of SOB  associated with cough with expectoration , scanty sputum present .No h/o pedal edema , decreased urine output, hematuria, frothy urine.

History of past illness:
  • 2 years back patient had similar complaint of shortness of breath and treated in a local hospital.
Family history :
  • No relevant family history.
Personal history 
  • Diet :                              Mixed
  • Appetite :                      decreased
  • Bowel movements :      Regular
  • Bladder movements :     Regular
General examination:

         Patient is conscious, coherent and cooperative
         Malnutrition+ ,mild dehydration
  • Pallor: - Not seen
  • Icterus: - Not seen
  • Cyanosis: - Not seen
  • Clubbing: - Not seen
  • Koilonychia: - Not seen
  • Lymphadenopathy: - Not seen
  • Edema: - Not seen
 

                                                 
                                      






VITALS : 
  •  Temp: 98.7 F 
  • PR: 60 bpm 
  • BP: 110/70 mm hg 
  • RR: 18 cpm 
  • Spo2 - 98%
CVS : S1, S2 heard , No murmurs




RS : 
  • Position of trachea: central 
  • Dyspnea +
  •  Wheeze +
  •  BAE present decreased in rt side 
  • Expiratory wheeze + on rt IMA,ISR,IAA 
  • B/L Inspiratory crepts + in ISA +,IAA +

                                                

PER ABDOMEN: Soft, non tender
  • Bowel sounds +



CNS: 

  • Patient is Conscious ,oriented to time,place and person 
  • HMF -intact
  •  Motor & sensory system: normal 
  • Reflexes: present
  •  Cranial nerves: intact 
  • No meningeal signs
PROVISIONAL DIAGNOSIS- ?AKI WITH COPD

INVESTIGATIONS :     
                                                    URINARY SODIUM 


ULTRASOUND


LIVER  FUNCTION  TEST


SERUM  ELECTROLYTES


SERUM CREATININE


COMPLETE  URINE  EXAMINATION


                                                                   

                                                                   HEMOGRAM  

ERYTHROCYTE  SEDIMENTATION RATE


                                            URINE PROTEIN/ CREATININE RATIO
                       


Day 1 soap notes : 
S : SOB decreased 
O  : O/E
       Pt is C/C/C 
       Temp : afebrile 
       BP : 
       PR :
       CVS :S1S2 +
       RS : BAE +
      Tubular sounds + at rt IMA, ISA 
       P/A : soft , NT
       CNS : : no focal deficit 
 A : ? PRE RENAL AkI with COPD 
 P : 
     1. IVF :NS,RL @ 50 ml / HR 
     2. Inj. Augmentin 2 GM IV BD
     3. Inj . Pan 40 mg IV OD BBF 
     4. TAB. DOLO 650 MG OD SOS 
     5. SYP. ASCORIL.10 ML PO/ BAD 
     6. NEBULISATION WITH 
          Duolin- 8 the hourly 
          BuDicort -17 th hourly
          Furacort - 8 th hourly 
    7. BP charting 8 th hourly






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