A 58yr old female ,house wife by occupation came to Casualty with C/O
•Shortness of breath (grade-4) since 1 week
•Loss of appetite since 1 week
•Fever since 1 week
HOPI: Patient was apparently asymptomatic 1and half year ago then she developed shortness of breath which was gradual , decreased Appetite and fever which is on &off for which she consulted a local RMP and found that her serum creatinine
Was 2 and HB is 4mg/dl. Then she was reffered to a higher centre for nephrology opinion. She had 2 blood transfusions and her hb improved to 6. She was given iron injections for further improvement of hb.then she was fine for the next 1 year. She used to do all the household works by herself.now she developed fever, sob,decreased output since 1week.then here her hb was 5gm/dl and creatitine came to be 14, so 3 blood transfusions was done and started dialysis.after dialysis her creatinine came to be 2 and her hb improved to 9gm/dl.
Past history:
Not K/C/O DM,HTN
GENERAL EXAMINATION:
Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
PROVISIONAL DIAGNOSIS:
ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 2
S- Decreased SOB post dialysis
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.4F
Pulse rate - 90BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 3
S- Pain over the neck region, aggravating on swallowing.
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 86BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 4
S- Pain over the neck region, aggravating on swallowing.
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 5
S- Pain over the neck region, aggravating on swallowing.
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 6
S- Pain over the neck region, aggravating on swallowing.
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 7
S- Pain over the neck region decreased, pain during swalloing present. Hematoma pain at the neck region decreased
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
SOAP NOTES DAY 8
S- Pain over the neck region decreased, pain during swalloing decreased . Hematoma pain at the neck region decreased
O- Patient is consious, co-herent, co-operative,
No pallor,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
- 98.4F
Pulse rate - 92BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-130/90MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
P/A : Non distended, soft,non-tender,BS +
CVS : S1 S2 heard , no murmurs
RS : BAE +, NVBS
CNS : NAD
A - ACUTE KIDNEY INJURY WITH CKD WITH VIRAL PYREXIA
