45y/Male with c/o altered sensorium

DOA: 19/05/2022
CC:
46y/M came with c/o drowsiness (altered sensorium) since 19/05/2022 morning,
c/o vomiting (3-4 episodes) since 2 days
Hiccups since 3 days
Burning micturition present since 10 days

HOPI:
Pt was apparently asymptomatic 
5 days back, then pt developed c/o vomiting ,had 4-5 episodes, containing food particles,non bilious.
Pt c/o deviation of mouth and giddiness since yesterday night(18/05/2022)
Yesterday night(18/05/2022)- GRBS recorded high value for which he was given NPH 10 IU and HAI 10 IU
No c/o fever/cough/cold
No significant h/o previous UTIs
No c/o chest pains/palpitations/syncopal attacks

Past History:
10yrs back pt had c/o polyuria and was diagnosed with Type 2 DM, started on OHA 10 yr back, 
h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation 1yr back i/v/o development of wet gangrene
OHAs been converted to Insulin since 2 yrs
Delayed Wound healing present- wound healing took 2 months time to heal
3 years back pt underwent Cataract surgery

K/c/o DM type 2 on medication-insulin

Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD
Not on any other medication
No h/o blood transfusion

Personal History:
Married
Appetite-Normal
Diet-Vegetarian
Bowel and Bladder - Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol- 
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
Also 1 month on & off   consumption pattern previously present

Family history:
Not significant

Vitals @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 101F
SpO2: 98% on RA
GRBS: 124 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
Pt is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
Normal

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

Clinical Images:
Provisional Diagnosis:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

Investigations Reports:
19/05/2022:


XRay- KUB
20/05/2022:
Pus cells- 

2D Echo:


21/05/2022:




22/05/2022:



23/05/2022:


24/05/2022




25/05/2022:



Xray KUB:

26/05/2022





27/05/2022




28/05/2022




29/05/2022



30/05/2022



Xray KUB-

USG Abdomen & Pelvis-



Treatment:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water

SOAP NOTES:
DAY1
SOAP NOTES ICU BED-6, DAY -1
DOA: 19/05/2022
S:
C/o vomitting present
Pt is c/c/c
Pt is not drowsy
Pt c/o mild abdominal pain- diffuse
O:
BP: 120/70 mmHg
HR:96 bpm
RR: 20 cpm
TEMP: 98.7 F
SPO2:98% on RA
GRBS: 256 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
Pt is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs
A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs
P:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water


DAY2
SOAP NOTES ICU BED-6, DAY -2
DOA: 19/05/2022
S:
C/o vomitting present
Pt is c/c/c
Pt is not drowsy
Pt c/o mild abdominal pain- diffuse
O:
BP: 120/70 mmHg
HR:96 bpm
RR: 20 cpm
TEMP: 98.7 F
SPO2:98% on RA
GRBS: 256 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
Pt is having altered sensorium
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs
A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs
P:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water


DAY4
SOAP NOTES ICU BED-6, DAY -4
DOA: 19/05/2022
S:
No new complaints 
O:
BP: 100/60 mmHg
HR:76 bpm
RR: 20 cpm
TEMP: 98.7 F
SPO2:98% on RA
GRBS: 148 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs
A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion
IV Fluids- NS,RL @ 100 mL/hr
SYP. POTCHLOR 10 mL in 1 glass of water TID
SYP. MUCAINE GEL 10 mL PO TID
7 point profile
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water


DAY5
SOAP NOTES ICU BED-6, DAY -5
DOA: 19/05/2022
S:
No new complaints 
O:
BP: 100/60 mmHg
HR:78 bpm
RR: 20 cpm
TEMP: 98.7 F
SPO2:98% on RA
GRBS: 148 mg/dL
I/O:2950mL/1700mL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+

Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs
A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion
IV Fluids- NS,RL @ 100 mL/hr
SYP. POTCHLOR 10 mL in 1 glass of water TID
SYP. MUCAINE GEL 10 mL PO TID
7 point profile
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water


DAY6
SOAP NOTES ICU BED-6, DAY -6
DOA: 19/05/2022
S:
Diffuse abdominal pain present aggravated upon consuming food
1 fever spike yesterday evening
Encephalopathy resolving
No other complaints

O:
BP: 110/70 mmHg
HR:74 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 170 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
INJ. MEROPENEM 500mg IV BD (Day 6)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly


DAY7
SOAP NOTES ICU BED-6, DAY -7
DOA: 19/05/2022
S:
No complaints

O:
BP: 110/70 mmHg
HR:72 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 215 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
INJ. MEROPENEM 500mg IV BD (Day 7)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly


DAY8
SOAP NOTES ICU BED-6, DAY -8
DOA: 19/05/2022
S:
1 fever spike since yesterday 
Sensorium improving
Abdominal pain subsided

O:
BP: 110/70 mmHg
HR:74 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 215 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
NBM till further orders
INJ. MEROPENEM 500mg IV BD (Day 8)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly


DAY9
SOAP NOTES ICU BED-6, DAY -9
DOA: 19/05/2022
S:
Sensorium improving
Abdominal pain subsided

O:
BP: 120/70 mmHg
HR:72 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 164 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
NBM till further orders
INJ. MEROPENEM 500mg IV BD (Day 9)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly

SDP Transfusion done I/v/o low platelet count
Pre transfusion counts
Hb: 7.0 g/dL
TLC:22000
PLt:26000
Post transfusion counts
Hb:6.5 g/dL
TLC: 17700
PLt:7000

DAY 10
SOAP NOTES ICU BED-6, DAY -9
DOA: 19/05/2022
S:
Sensorium improving
Abdominal pain subsided

O:
BP: 120/70 mmHg
HR:72 bpm
RR: 20 cpm
TEMP: 98.3 F
SPO2:98% on RA
GRBS: 164 mg/dL

General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:
NBM till further orders
INJ. MEROPENEM 500mg IV BD (Day 10)
INJ. COLISTIN IV OD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly

Temperature Charting:
DAY 11
SOAP NOTES ICU BED-6, DAY -11
DOA: 19/05/2022
S:
Previous complaints resolving 
O:
BP: 120/80 mmHg
HR:98 bpm
RR: 20 cpm
TEMP: 100.8 F
SPO2:98% on RA
GRBS: 175 mg/dL


General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:

INJ. COLISTIN 2.25 MU IV OD(Day 4)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting hrly


SDP Transfusion done I/v/o low platelet count 
Pre transfusion counts:
Hb:6.2 g/dL
TLC:14700
PLt:6000
Post transfusion counts:
Hb:6.4
TLC:13700
PLt:50000

DAY 12
SOAP NOTES ICU BED-6, DAY -12
DOA: 19/05/2022
S:
Previous complaints resolving 
O:
BP: 110/80 mmHg
HR:89 bpm
RR: 20 cpm
TEMP: 99.7 F
SPO2:98% on RA
GRBS: 148 mg/dL


General Examination: 
Pallor present
No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
No dehydration
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS: 
NAD
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)-
+
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs

No meningeal signs

A:
Right Emphysematous Pyelonephritis with Left Acute Pyelonephritis with Encephalopathy secondary to Sepsis
H/o Type 2 DM since 10 yrs

P:

INJ. COLISTIN 2.25 MU IV OD(Day 5)
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. LASIX 40 mg IV BD
IV Fluids- NS,RL @ 100 mL/hr
SYP. MUCAINE GEL 10 mL PO TID
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting hrly





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