65y/F with On & off fever. Left lower and middle lobe consolidation. Pulmonary TB(AFB>3)

HISTORY:
CC: 65y/F came with c/o on and off fever since 2-3 months
HOPI:
Pt was apparently asymptomatic 10yrs ago diagnosed with DM on OHAs
Since 4 yrs c/o generalized weakness, on and off fever
c/o fever since 15 days, high grade, with chills, cough with whitish sputum
c/o SOB grade 3 on exertion, chest pain on exertion since 5-6 months, 
No h/o burning micturition, vomitting,loose stools
c/o constipation on and off since 5-6months
No c/o orthopnea, PND, pedal edema
PAST HISTORY:
K/c/o DM since 10 yrs
Not a k/c/o HTN, CAD

SOAP NOTES DAY 2
ICU BED-6

S-   DECREASED EPISODES   OF COUGH.  Fever spikes present. 

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 103.3F
PULSE RATE - 84BPM
BLOOD PRESSURE - 
100/60 mmHg
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-96mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD


HEMOGRAM
HB-8.0
TLC-21,600
N/L/M/E-90/6/2/2
PLT-4.37 lakh/mm3
SERUM CREATININE-2.3
Na-134
K-4.0
Cl-97
Ca: 9.6
LFT:
TB:0.41
DB:0.13,
AST:29,
ALT:14
ALP:166,
TP:5.7
ALB:2.31
A/G: 0.68
GRBS-96 mg/dL(8 AM)
ABG - 01/04/2022:
PH-7.43
PCO2: 20.1
PO2-76.1
HCO3:13.3
O2 SAT-96.8%
A:
 Left Middle Lower lobe consolidation  
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) Inj. PIPTAZ 2.25g IV TID
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

Reports and Radiology images:

SOAP NOTES: 
SOAP NOTES DAY 1
ICU BED-6

S-   DECREASED EPISODES   OF COUGH.  Fever spikes present.
C/o chest pain and shivering

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 104F
PULSE RATE - 104BPM
BLOOD PRESSURE - 
140/60 mmHg
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-96mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) Inj. PIPTAZ 2.25g IV TID
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

DAY 2:
SOAP NOTES DAY 2
RICU

S-   DECREASED EPISODES   OF COUGH. Fever spikes present.
C/o chest pain and shivering

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 104F
PULSE RATE - 104BPM
BLOOD PRESSURE - 
140/60 mmHg
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-96mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) ATT 3 Tablets/ day
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

SOAP NOTES DAY 3:
SOAP NOTES DAY 3
RICU

S-   DECREASED EPISODES   OF COUGH.  Fever spikes present.
C/o chest pain and shivering

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 104F
PULSE RATE - 104BPM
BLOOD PRESSURE - 
140/60 mmHg
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-96mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) ATT 3 Tablets/ day
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

SOAP NOTES DAY-4:

SOAP NOTES DAY 4
RICU

S-   EPISODES   OF COUGH.  
No fever spikes
C/o chest pain and shivering reduced

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 98 F
PULSE RATE - 95 bom
BLOOD PRESSURE - 
100/60 mmHg
RESPIRATORY RATE - 20 cpm
SPO2 - 96% @ RA
GRBS-136 mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
AKI on ? CKD
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) ATT 3 Tablets/ day
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

Reports:


SOAP NOTES DAY 5
RICU

S-   EPISODES   OF COUGH.  
No fever spikes
C/o chest pain and shivering reduced

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 98 F
PULSE RATE - 95 bom
BLOOD PRESSURE - 
100/60 mmHg
RESPIRATORY RATE - 20 cpm
SPO2 - 96% @ RA
GRBS-136 mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) ATT 3 Tablets/ day
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID


SOAP NOTES DAY 6
RICU

S-  No complaints 

O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA


VITALS - 

TEMPERATURE - 98 F
PULSE RATE - 95 bom
BLOOD PRESSURE - 
100/60 mmHg
RESPIRATORY RATE - 20 cpm
SPO2 - 96% @ RA
GRBS-136 mg/dl

SYSTEMIC EXAMINATION - 
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM : 

S1 AND S2 HEARD  , NO MURMURS
RESPIRATORY SYSTEM : BAE +, Crepts + IAA,IMA,ICA
CENTRAL NERVOUS SYSTEM : NAD

A:
 Left Middle Lower lobe consolidation
Pulmonary TB
P:
1) IV Fluids: NS, RL @ U.O+ 30mL/hr
2) ATT 3 Tablets/ day
3) O2 inhalation SOS to maintain SpO2 >92%
4) Tab.DOLO 650mg PO TID
5) Inj. NEOMOL 1g IV SOS
6)Neb. DUOLIN INH 6th hrly
    Neb.BUDECORT INH 6th hrly
7) GRBS 6th hrly monitoring
8) Inj. HAI S/C 
9) Syp. ASCORYL LS 10 mL PO TID

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