not associated with vomiting or loose stools,
Fever was releived with treatment
pain in the abdomen, burning sensation since yesterday
not associated with chest pain, palpitations and pedal edema
thin stream of urine
deibbling+
increased frequency
burning micturition
pt is not a k/c/o DM, HTM, TB, asthma, epilepsy
6months back- UGIE was done for pain abdomen
retrosternal heart burn
O/E-
afebrile
PR- 76, irregularly, irregular
BP-100/50
RR- 22
CVS- S1 S2 +
RS- NVBS
Provisional diagnosis- Hypovolemic shock with MAT
UTI- AKI
HFrEF- CAD
IVF- NS 50ml/hr
inj. nor ad 2amp with 47ml NS
inj lasix 40mg iv
inj dobutamine infusion 1 amp in 48ml.ns/hr (MAP greater than 60mm hg)
tab dolo 650 po/tid
Inj neomol 1gm iv temp greater than 101F
inj pan 40mg iv
Fosfomycin satchet
ECG ON 11/10 AT 6:45
ECG AT 7AM
Subjectively c/o cough with expectoration and respiratory distress
Objectively C/C distressed
BP -110/70 PR-120bpm irregular
Cvs-s1s2
Resp- fine end inspiratory crepitations in
B/L basal areas Wheeze- mid inspiratory in b/L ISA Cough with copious amount of sputum +
Assessment- ?AECOPD
Interventions done
Inj Hydrocortisone 100mg IV Inj Pheniramine maleate (Avil) 25mg IV
Nebulisation with budesonide and ipratropium bromide
After 30-40mins SOB subsided PR-90bpm regular.
Pt symptomatically feeling better
Soap notes day 2
ICU bed 4
Patient subjectively feeling better Cough and sob decreased when compared to yesterday
Objectively
Bp 100/80 mm hg on 2 ml NA
Pr: 76 bpm regularly regular
Cvs: s1 s2 heard
Grbs 160 mg/dl
I/O: 1550/1200
Rs: Bae+ nvbs
P/a soft non tender
Assesment: Cardiogenic shock (resolving)with paroxysmal AF
Plan: Taper ionotropes
IVF NS 1AMP of optineuron
Inj monocef 1gm.iv bd
Inj pan 40mg iv bd
Inj neomol 1gm Iv T greater than 101F
Tab dilo 650 po sos
SYP mucaine gel 10ml.po tid
Inj nor ad infusion(tapering)
ECG ON 12/10/21
Soap notes day 3
Icu bed 4
Patient subjectively feeling better Cough and sob decreased when compared t...
Icu bed 4
Subjectively Patient is feeling better
No cough and sob
Objectively
Bp 90/60 mm hg on Nor adrenaline 4ml/hr
Pr 80 bpm
Rr 18 cpm
Grbs 170 mg/dl
Temp 97.5 F
Cvs s1 s2
Rs bae, Nvbs
P/a soft nt
Assesment: Cardiogenic shock/ ? Septic shock (TLC 22,000) with paroxysmal AF
Plan Increase nor adr to maintain map 65 mm hg Taper iontrope once bp stabilises
Subjectivity patient is feeling better
Objectively
Bp 110/60 mm hg
Pr- 55 bpm
Rr 20
Grbs 124 mg/dl
Temp 97.5 F
Cvs s1 s2
Rs bae, Nvbs
P/a soft nt
Assesment: Cardiogenic shock with
acute LV Failure secondary to MAT
MAT secondary to AECOPD
? viral pyrexia(resolved)
Plan- continue iv fluids
inj. monocef
inj Pan 40mg
inj neomol (if temp greater than 101F)
AMC bed 3
Subjectivity
patient complained of pain on left upper limb
Objectively
Bp 110/70 mm hg
Pr- 68 bpm
Rr 20
Grbs 78 mg/dl
Temp 97.8 F
Cvs- S1 S2 +
Rs BAE, Nvbs
P/a soft nt
Assesment: Cardiogenic shock with
acute LV Failure secondary to MAT
MAT secondary to AECOPD
? viral pyrexia(resolved)
Plan- continue iv fluids
inj. monocef
inj Pan 40mg
inj neomol (if temp greater than 101F)
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