AKI WITH COPD

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 70 year old female came with c/o SOB since 7 days ( progressed from Grade 2 to grade 3)
HOPI:
SOB Associated with cough with expectoration,scanty sputum present 
No h/o pedal edema , decreased urine output, hematuria,frothy urine
Past history:
K/c/o HTN since 5 yrs on medications (T.telma H 40 mg )
Similar complaints in the past since 2 years ? Seasonal variation +


PERSONAL HISTORY
Appetite-decreased
Regular bowel and bladder movements
No addictions


GENERAL EXAMINATION : 
Patient is conscious, coherent and cooperative  
Malnutrition+,mild dehydration
No pallor, Icterus, cyanosis, clubbing, lymphadenopathy , edema

VITALS : 
Temp: 98.7 F
PR: 60 bpm 
BP: 110/70 mm hg 
RR: 18 cpm  
Spo2 - 98%

CVS : 
S1, S2 heard , No murmurs 

RS : 
Position of trachea: central 
Dyspnoea +
Wheeze +
BAE present decreased in rt side 
Expiratory wheeze + on rt IMA,ISR,IAA
B/L Inspiratory crepts + in ISA +,IAA +


PER ABDOMEN: Soft,non tender

Bowel sounds +

CNS: 
Patient is Conscious ,oriented to time,place and person 
HMF -intact 
Motor & sensory system: normal 
Reflexes: present 
Cranial nerves: intact 
No meningeal signs 

PROVISIONAL DIAGNOSIS-
? PRE RENAL AKI WITH COPD
Day 1 soap notes :

S : SOB decreased
O  : O/E
     Pt is C/C/C
      Temp : afebrile
      BP :
       PR :
        CVS :S1S2 +
        RS : BAE +
Tubular sounds + at rt IMA, ISA
Added sounds at B/L ISA, IMA
P/A : soft , NT
BS +
CNS : : no focal deficit
A : ? PRE RENAL AkI with COPD
P :
1. IVF :NS,RL @ 50 ml / HR
2. Inj.Augmentin 2 GM IV BD
3. Inj . Pan 40 mg IV OD BBF
4. TAB. DOLO 650 MG OD SOS
5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITH 
 Duolin- 8 the hourly
BuDicort -17 th hourly
Furacort - 8 th hourly

7. BP charting 8 th hourly
 8. I/O charting

Day 2
S : SOB decreased

Fever spike +
O : O/E
Pt is C/C/C
Temp - 100.1F
BP - 90/60 mmHg
PR -76 bpm
CVS :S1S2+
RS : BAE +

RT tubular sounds at IMA, ISA
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR

2. Inj.Augmentin 2 GM IV BD

3. Inj . Pan 40 mg IV OD BBF

4. TAB. DOLO 650 MG OD SOS

5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly

Furacort - 8 th hourly

7. BP charting 8 th hourly

 8. I/O charting
Plan for discharge

Day 3
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 100/70 mmHg
PR -74 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR

2. Inj.Augmentin 2 GM IV BD

3. Inj . Pan 40 mg IV OD BBF

4. TAB. DOLO 650 MG OD SOS

5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly

Furacort - 8 th hourly

7. BP charting 8 th hourly

 8. I/O charting


Day 4
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 110/70 mmHg
PR -64 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI WITH COPD
P 1. IVF :NS,RL @ 50 ml / HR

2. Inj.Augmentin 2 GM IV BD

3. Inj . Pan 40 mg IV OD BBF

4. TAB. DOLO 650 MG OD SOS

5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly

Furacort - 8 th hourly

7. BP charting 8 th hourly

 8. I/O charting

Day 5
S : no fresh complaints
O : O/E
Pt is C/C/C
Temp - afebrile
BP - 110/60mmHg
PR -64 bpm
CVS :S1S2+
RS : BAE +
CNS : no focal deficit
P/A : soft , non tender
A : PRE RENAL AKI (resolved ),Acute exacerbation of COPD, Anemia
P 1. IVF :NS,RL @ 50 ml / HR

2. Inj.Augmentin 2 GM IV BD

3. Inj . Pan 40 mg IV OD BBF

4. TAB. DOLO 650 MG OD SOS

5. SYP. ASCORIL.10 ML PO/ BAD
6. NEBULISATION WITh BuDicort -12th hourly

Furacort - 8 th hourly

7. BP charting 8 th hourly

 8. I/O charting
Plan for discharge

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