CBBLE UDHC SIMILAR CASES
Unit 3 and 6 admission
ICU bed 2
48 y / male toddy tree climber by occupation since past 30 years,
Pt came with C/o chest pain since yesterday ( evening 6 pm )
C/o fever, cold and cough since 3 - 4 days.
HOPI :
Pt was apparently asymptomatic 4 days back then developed fever - high grade associated with chills and rigor , on and off , relieves with medication.
C/o dry cough , aggrevates at night
C/o SOB due to excessive coughing, orthopnea - , PND -
C/o 1 episode of vomiting associated with food particles 1 day back - non bilious
Pt had similar complaints of fever associated chills and rigor in the past since 5 years
4 years back pt got hospitalized with fever and chills and got diagnosed with DM , on OHA ( met formin hydrogenchloride po/od ) - irregular medication.
In past 5 years , pt had 5 - 6 hospital admissions with similar complaints due to heavy drinking and got diagnosed with fatty liver and jaundice.
H/o seizures since 5 years
4 - 5 episodes in last 5 years , with gap of 1 year in between the episodes .
Last episode - 1 year back
Tongue bite + , Remains in unconscious state for 5 mins
H/o multiple RTA s with minor injuries over left hand, left knee, right eye, right ankle
H/o covid + 1 year back
Received 1 dose of vaccine - covishield
ATT :
Clinically and Radiologicaly , patient is having features of TB , so he was started on ATT on 24/2/22
Pleural tap was performed on 18/2/22 and it is a dry tap.
PAST HISTORY:
N/K/C/O HTN, TB , CAD, ASTHMA
No c/o abdominal pain , nausea , burning micturition
PERSONAL HISTORY : Appetite - normal
Bowel movements - Regular
Chronic alcoholic since past 30 years
Heavy drinking since past 10 years ( 360 - 480 ml/day )
Pt went to rehabilitation for 1 year ,but never stopped drinking, as told by patient attenders
O/E : Patient is C/C/C
Pallor -
Icterus +
Cyanosis -
Edema of feet -
Lymphadenopathy -
Clubbing -
VITALS :
Temp : Afebrile
PR : 92
BP : 120/80 mmhg
RR : 22
SPO2 : 88 % at RA
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM :
S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM :
Bilateral air entry present , reduced breath sounds in left IAA , IMA, ISA , on auscultation wheeze +
CNS : NAD
PA : soft, non tender
FAMILY HISTORY: Not significant
INVESTIGATIONS :
Repeat x ray 15/2/22 :
Diabetic ketosis ( resolved ) secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With DM since 4 years
With Alcohol dependence
TREATMENT:
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 8 U - 8 U
NPH 10 U 10 U 10 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. TusQ D capsule
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Tab. PCM 650 mg/po/TID x 3 days
15. Tab. Naproxen 250 mg /po/ BD x 3days
SOAP NOTES :
UNIT 3 AND 6 ADMISSION
ICU BED 2
Day 2
S : Chest pain reduced
1 episode of fever spike
C/o cough
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 100.1
PR : 101 bpm
RR : 19 cpm
BP : 160/90 mmhg
Spo2 : 87 % at RA
CVS : S1 S2 + , No murmurs
RS : BAE + , Reduced breath sounds in left lower lobe
PA : Soft, non tender
GRBS :
8 AM : 263 mg/dl
10 AM : 154 mg/dl
2 PM : 189 mg/dl
4 PM : 194 mg/dl
8 PM : 187 mg/dl
10 PM : 179 mg/dl
2 AM : 155 mg/dl
8 AM : 178 mg/dl
A :
Diabetic ketosis secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With DM since 4 years
P :
1. Inj PAN 80 mg/iv/stat
2. Inj. Zofer 4 mg/iv/stat
3. Inj. HAI 1 ml in 39 ml NS iv/according to grbs
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Inj. Optineuron 1 amp in 100 ml NS/iv/od
10. IVF NS, RL @ 100 ml/hr
11 Hourly GRBS charting.
UNIT 3 AND 6 ADMISSION
ICU BED 2
DAY 3
S : Pain reduced by 70% since admission
No fever spike
Cough reduced
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6
PR : 80 bpm
RR : 21 cpm
BP : 110/70 mmhg
Spo2 : 90 % at RA
CVS : S1 S2 + , No murmurs
RS : BAE +
PA : Soft, non tender
GRBS :
8 PM : 161 mg/dl
8 AM : 195 mg/dl
A :
Diabetic ketosis secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With GB sludge
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 6 U - 6 U
NPH 6 U 6 U 6 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
UNIT 3 AND 6 ADMISSION
AMC BED 4
DAY 4
S : C/o fever spikes
Cough reduced comparatively since admission
C/o pain while talking and sitting , relieved in supine position
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.3
PR : 98 bpm
RR : 26 cpm
BP : 130/70 mmhg
Spo2 : 91 % at RA
CVS : S1 S2 + , No murmurs 8
RS : Pleural rub noted in left infra axillary area
Bilateral inspiratory crepts noted in infra axillary region and infrascapular region
PA : Soft, non tender
GRBS :
8 PM : 157 mg/dl
8 AM : 210 mg/dl
A :
Diabetic ketosis secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With GB sludge
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 6 U - 6 U
NPH 6 U 6 U 6 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Inj. Tramadol in 100 ml NS over 30 mins
UNIT 3 AND 6 ADMISSION
AMC BED 4
DAY 5
S : C/o fever spikes
Cough reduced comparatively since admission
Pain did not relieve
Pain increases while talking and coughing.
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.8
PR : 96 bpm
RR : 24 cpm
BP : 110/80 mmhg
Spo2 : 92 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
Bilateral inspiratory crepts noted in infra axillary region and infrascapular region
PA : Soft, non tender
GRBS :
8 PM : 225 mg/dl
8 AM : 164 mg/dl
A :
Diabetic ketosis secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With GB sludge
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 6 U - 6 U
NPH 6 U 6 U 6 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Inj. Tramadol in 100 ml NS over 30 mins
UNIT 3 AND 6 ADMISSION
WARD
DAY 6
http://vamshichandhan172.blogspot.com/2022/02/cbble-udhc-similar-cases.html
S : C/o fever spike
Pain reduced comparatively since admission
Cough reduced
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 97.8 F
PR : 92 bpm
RR : 22 cpm
BP : 110/90 mmhg
Spo2 : 94 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
8 PM : 337 mg/dl
8 AM : 187 mg/dl
A :
Diabetic ketosis secondary to ? sepsis
? Irregular medication
With ? Left Lower lobe consolidation
With cholelithiasis
With GB sludge
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 6 U - 6 U
NPH 6 U 6 U 6 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Inj. Augmentin 1.2gm /iv/tid
7. Tab. Azithro 500 mg po/od
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Inj. Tramadol in 100 ml NS over 30 mins
UNIT 3 AND 6 ADMISSION
AMC BED 4
DAY 7
http://vamshichandhan172.blogspot.com/2022/02/cbble-udhc-similar-cases.html
S : C/o fever spike
Cough reduced by 75 % since admission
C/o pain only while coughing
C/o sleeplessness at night.
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.4 F
PR : 94 bpm
RR : 24 cpm
BP : 130/90 mmhg
Spo2 : 94 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
8 PM : 214 mg/dl
8 AM : 117 mg/dl
Scheduled for BAL today.
A :
Diabetic ketosis ( resolved )
With ? Left Lower lobe consolidation
With cholelithiasis
With GB sludge
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 8 U - 8 U
NPH 10 U 10 U 10 U
4. Inj. PAN 40 mg/iv/bd
5. Inj. Zofer 4mg /iv/tid
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. TusQ D capsule
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 5ml PO/TID
10. Inj. PCM 1g /iv/sos
11 Hourly GRBS charting.
12. Syp. Cremaffin 30 ml/po/HS
13. Inj. KCL 2 amp in 500 ml /HS/IV over 5 hrs
14. Tab. PCM 650 mg/po/TID x 3 days
15. Tab. Naproxen 250 mg /po/ BD x 3days
UNIT 3 AND 6 ADMISSION
AMC BED 4
DAY 9
S : C/o dry cough
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.2 F
PR : 86 bpm
RR : 21 cpm
BP : 130/90 mmhg
Spo2 : 94 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
8 PM : 186 mg/dl
8 AM : 102 mg/dl
A :
Diabetic ketosis secondary to sepsis ( resolved )
Consolidation in Rt. Upper and lower lobes and atelectasis in both lower lobe
With moderate loculated Lt. Pleural effusion
With cholelithiasis
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 10 U - 10 U
NPH 10 U 10 U 10 U
4. Tab. PAN 40 mg po/od
5. Inj. Augmentin 1.2gm iv/bd ( D7 )
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. Ultracet 1/2 tab po/qid
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 10ml PO/TID
10.Tab. PCM 650mg po/qid
11. Tab. Azithromycin 500 mg /po/od ( D7 )
12. GRBS charting 6th Hourly
UNIT 3 AND 6 ADMISSION
AMC BED 4
DAY 10
S : C/o dry cough
No fever spikes
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6 F
PR : 92 bpm
RR : 20 cpm
BP : 110/70 mmhg
Spo2 : 96 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
8 PM : 235 mg/dl
2 AM : 94 mg/dl
8 AM : 137 mg/dl
A :
Diabetic ketosis secondary to sepsis ( resolved )
Consolidation in Rt. Upper and lower lobes and atelectasis in both lower lobe
With moderate loculated Lt. Pleural effusion
With cholelithiasis
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 10 U - 10 U
NPH 10 U 10 U 10 U
4. Tab. PAN 40 mg po/od
5. Inj. Augmentin 1.2gm iv/bd ( D7 )
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. Ultracet 1/2 tab po/qid
8. Inj. Thiamine in 100 ml NS/iv/tid
9. Syp. Benadryl 10ml PO/TID
10.Tab. PCM 650mg po/qid
11. Tab. Azithromycin 500 mg /po/od ( D7 )
12. GRBS charting 6th Hourly
UNIT 3 AND 6 ADMISSION
ward
DAY 11
S : C/o dry cough
& 1 fever spikes
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6 F
PR : 78 bpm
RR : 20 cpm
BP : 140/90 mmhg
Spo2 : 96 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
8 PM : 408 mg/dl
8 AM : 2237 mg/dl
A :
Diabetic ketosis secondary to sepsis ( resolved )
Consolidation in Rt. Upper and lower lobes and atelectasis in both lower lobe
With moderate loculated Lt. Pleural effusion
With cholelithiasis
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 10 U - 10 U
NPH 10 U 10 U 10 U
4. Tab. PAN 40 mg po/od
5. Inj. Augmentin 1.2gm iv/bd ( D7 )
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. Ultracet 1/2 tab po/qid
8. Inj. Thiamine in 100 ml NS/iv/OD
9. Syp. Benadryl 10ml PO/TID
10.Tab. PCM 650mg po/qid
11. Tab. Azithromycin 500 mg /po/od ( D7 )
12. GRBS charting 6th Hourly
UNIT 3 AND 6 ADMISSION
ward
DAY 12
S : C/o dry cough
& SOB
NO FEVER spikes
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6 F
PR : 82 bpm
RR : 20 cpm
BP : 140/90 mmhg
Spo2 : 96 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
1PM:- 222mg/dl
8 PM : 197 mg/dl
8 AM : 147mg/dl
A :
Diabetic ketosis secondary to sepsis ( resolved )
Consolidation in Rt. Upper and lower lobes and atelectasis in both lower lobe
With moderate loculated Lt. Pleural effusion
With cholelithiasis
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 10 U 10 U 10 U
NPH 10 U 10 U
4. Tab. PAN 40 mg po/od
5. Inj. Augmentin 1.2gm iv/bd ( D8)
6. Tab. Cetrizine 5mg /Po/BD
7. Tab. Ultracet 1/2 tab po/qid
8. Inj. Thiamine in 100 ml NS/iv/OD
9. Syp. Benadryl 10ml PO/TID
10.Tab. PCM 650mg po/qid
11. Tab. Azithromycin 500 mg /po/od ( D8)
12. GRBS charting 6th Hourly
UNIT 3 AND 6 ADMISSION
ward
DAY 13
DAY 2 OF ATT
S : C/o dry cough
& SOB
NO FEVER spikes
O :
O/E
No pallor/cyanosis/generalized lymphadenopathy
Temp : 98.6 F
PR : 82 bpm
RR : 20 cpm
BP : 140/90 mmhg
Spo2 : 96 % at RA
CVS : S1 S2 + , No murmurs
RS : Pleural rub noted in left infra axillary area
PA : Soft, non tender
GRBS :
1PM:- 233 mg/dl
8 PM : 100 mg/dl
8 AM : 84 mg/dl
A :
Diabetic ketosis secondary to sepsis ( resolved )
Consolidation in Rt. Upper and lower lobes and atelectasis in both lower lobe
With moderate loculated Lt. Pleural effusion
With cholelithiasis
With DM since 4 years
With Alcohol dependence
P :
1. Normal diet
2. IVF NS , RL @ 75 ml/hr
3. 8 am 2 pm 8pm
Inj. HAI 10 U 10 U 10 U
NPH 10 U 10 U
2. Syp. Benadryl 10ml PO/TID
3. GRBS charting 6th Hourly
