THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
Details of patient when admitted 2 months back in a health centre in the below link:
https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html
March 15,2022
30 years old female homemaker by occupation came to the General Medicine OPD with the
C.C:
- B/L joint pains associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days
- c/o dyspnea in rest since 4 days
-c/o cough since 4 days
H/O P.I.: Patient was apparently asymptomatic 12 months ago.
Then she developed symmetrical b/l joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg
Associated with morning stiffness.
Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black.
C/O Alopecia since 12 months. It was gradually progressive leading to severe hair loss over the past 12 months. Associated with thinning of hair.
C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands since 12 months
C/O generalised pain.
C/O Difficulty in walking.
C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt,
C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.
C/O vaginal discharge since 10 months. It was initially curdy white which later changed to watery discharge. Associated with itching.
C/O weight loss of 4 kg over the last 10 months.
C/O oral ulcers and genital ulcers since 10 months.
-C/O Dyspnea on exertion (NYHA- 3), gradually progressive since 6 months.
And 1.tab.wysolone 50mg po od
2.syp.mucaine 10ml/po/tid
3.tab.ultracet 1/2 po/QIT
4.candid cream for L/A is advised
Patient was referred to other health centre for muscle biopsy.
Patient went to health centre,her ANTI NUCLEAR ANTIBODY IMMUNOFLUOTESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA,histones.
HRCT WAS DONE ON 21/1/22
IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular distribution-s/o pneumonitis .Corads-4
She didn't undergo muscle biopsy as the doctors there advised it is not necessary
THEY PRESCRIBED:
1.TAB.CALTEN
2.TAB.AUGMENTIN
3.TAB.NAPROXEN SODIUM
4.TAB.FOLVITE
5.CANDID CREAM
6.TAB.WYSOLONE
7.TAB.ESOMEPRAZOLE
8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.
C/O Dyspnea on rest (NYHA- 4), gradually progressive since 4 days
-h/o fever since 4 days
C/o throat pain since 4 days
Past h/o: Not a k/c/o DM, HTN, BA, epilepsy, Asthma, CVA, CAD.
Had similar complaints in the past 2 months.
Menstrual h/o: AOM- 11 years
3/25-28, regular , no pains, no clots.
Marital h/o: ML- 14 years, NCM
Primary infertility (Nulligravida)
Has recently adopted a girl from her sister-in-law.
Family h/o: No similar complaints in the family
Personal h/o:
Diet- Mixed
Appetite- Decreased
Sleep- Inadequate since 12 months. WAKES AT 2 AM -3AM BECAUSE OF PAIN IN LEGS.
Bowel and bladder habits- IRREGULAR
C/O LOOSE STOOLS FOR 4 DAYS FOLLOWED BY CONSTIPATION FOR 3 DAYS SINCE 8 MONTHS
No addictions
No known drug allergies
General physical examination: The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished.
Pallor- present
No icterus, cyanosis, clubbing, lymphadenopathy.
Pedal Edema- present
O/E:
Patient images after treatment of 2 months:
Vitals:
Temperature- Afebrile
BP- 150/100 mm Hg
PR- 114bpm
RR- 30cpm
SpO2- 93% @ RA
SYSTEMIC EXAMINATION:
CVS- S1, S2 sounds heard. No murmurs
RS- BAE+ NVBS heard
CNS- NAD
P/A- Soft, non tender, Bowel sounds heard
Provisional diagnosis:
DERMATOMYOSITIS TO R/O ILD
BGT:AB POSITIVE
RBS:312 MG/DL
CUE
ALBUMIN-TRACE
SUGAR-NIL
PUS cells-2-3
EPITHELIAL cells: 2-3
TREATMENT:
1.T.SEPTRAN DS TID 1--1--1
2.TAB.FLUCONAZOLE 150 MG OD
1--X--X
3.OINT.CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.WYSOLONT 50 MG OD 1--X--X
5.TAB.FOLIC ACID 5 MG ONCE A WEEK.
PFT REPORT ON 16/3/22
SOAP NOTES DAY 1
ICU BED -4
S- COMPLAINTS OF SOB WHILE TALKING ASSOCIATED WITH COUGH AND GENERALIZED WEAKNESS
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 100°F
PULSE RATE - 117BPM
BLOOD PRESSURE -
150/100MM OF HG
RESPIRATORY RATE - 30
SPO2 - 97 % AT 4 lit O2
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
RBS-312
A-DERMATOMYOSITIS TO R/O ILD
P-
1.TAB.SEPTRAN DS TID (DAY -1)
2.TAB.FLUCONAZOLE 150MG OD(DAY-1)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.WYSOLONT 50 MG OD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.NEOMOL 1GM IV SOS
SOAP NOTES DAY 2
ICU BED -4
S- COMPLAINTS OF SOB grade -2 WITH COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 101F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 35
SPO2 - 93% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
RBS-121
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
A-DERMATOMYOSITIS TO R/O ILD
P-
1.TAB.SEPTRAN DS TID (DAY -2)
2.TAB.FLUCONAZOLE 150MG OD(DAY-2)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 3
AMC BED -3
S- COMPLAINTS OF SOB grade -2 WITH COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
PALLOR present. ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 100.6F
PULSE RATE - 98BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 35
SPO2 - 91% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
GRBS-138MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -3)
2.TAB.FLUCONAZOLE 150MG OD(DAY-3)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 4
AMC BED -3
S- COMPLAINTS OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.6F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 28
SPO2 - 94% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
GRBS-150MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -4)
2.TAB.FLUCONAZOLE 150MG OD(DAY-4)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 5
M Ward
S- OCCASIONALLY COMPLAINTS OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.6F
PULSE RATE - 107BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 24
SPO2 - 94% AT RA
GRBS-170MG/DL
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT-18,ALP-137,ALB-2,A/G: 0.62
GRBS-180MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -5)
2.TAB.FLUCONAZOLE 150MG OD(DAY-5)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.INJ.DEXA 6MG IV BD
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.INJ.LASIX 20MG IV BD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
SOAP NOTES DAY 6
M Ward
S- OCCASIONALLY COMPLAINTS OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 100.1F
PULSE RATE - 108BPM
BLOOD PRESSURE -
130/90MM OF HG
RESPIRATORY RATE - 22
SPO2 - 94% AT RA
GRBS-240MG/DL(8:00am)-fasting
320mg/dl(10:am)-post prandial
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-240MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -6)
2.TAB.FLUCONAZOLE 150MG OD(DAY-6)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-1)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
SOAP NOTES DAY 7
ICU BED-2
S- INCREASED EPISODES OF COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 101.8F
PULSE RATE - 144BPM
BLOOD PRESSURE -
80/40MM OF HG
RESPIRATORY RATE - 38
SPO2 - 97% AT 6 lit of O2
GRBS-247MG/DL(8:00am)-fasting
194mg/dl(10:am)-post prandial
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-247MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -7)
2.TAB.FLUCONAZOLE 150MG OD(DAY-7)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-2)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
11.INJ.CEFTRIAXONE 1GM/IV/BD(DAY-1)
Patient developed hypotension (80/40),tachycardia (114bpm), shifted to ICU FROM M WARD.
SOAP NOTES DAY 8
ICU BED -2
S- OCCASIONAL EPISODES OF COUGH AND NO fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.8F
PULSE RATE - 110BPM
BLOOD PRESSURE -
110/70MM OF HG
RESPIRATORY RATE - 21
SPO2 - 98% AT RA
GRBS-105MG/DL(8:00am)-fasting
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-105MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -8)
2.TAB.FLUCONAZOLE 150MG OD(DAY-8)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-2)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
SOAP NOTES DAY 9
AMC -5
S- OCCASIONAL EPISODES OF COUGH AND NO fever spikes present. Passage of stools for every 2 days.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99F
PULSE RATE - 123BPM
BLOOD PRESSURE -
150/100MM OF HG
RESPIRATORY RATE - 21
SPO2 - 96% AT RA
GRBS-182MG/DL(8:00am)-fasting
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-182MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -9)
2.TAB.DOXY 100MG PO BD (DAY-3)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-4)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
11.TAB.GLIMIPERIDE 500 MG OD
SOAP NOTES DAY 10
AMC -5
S- INCREASED EPISODES OF COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 102F
PULSE RATE - 120BPM
BLOOD PRESSURE -
140/80MM OF HG
RESPIRATORY RATE - 25
SPO2 - 96% AT RA
GRBS-60MG/DL(8:00am)-fasting
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-182MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -10)
2.TAB.DOXY 100MG PO BD (DAY-4)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-5)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
11.TAB.GLIMIPERIDE 500 MG OD
SOAP NOTES DAY 11
AMC -2
S- INCREASED EPISODES OF COUGH AND fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 102F
PULSE RATE - 124BPM
BLOOD PRESSURE -
160/100MM OF HG
RESPIRATORY RATE - 30
SPO2 - 93% AT RA
GRBS-62MG/DL(8:00am)-fasting
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-182MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
Hemogram(26/3/22)
Hb-10
Tlc-17500
N/L/E/M-86/8/1/5
RBC-3.54
PLT-3.73
Chest x ray on 26/3/22:
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.TAB.SEPTRAN DS TID (DAY -11)
2.TAB.DOXY 100MG PO BD (DAY-5)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 50 MG OD(DAY-6)
5.TAB.FOLIC ACID 5 MG ONCE WEEKLY
6.SYP.GRILINCTRUS BM
7.TAB.METFORMIN 500MG OD
8.INJ.OPTINEURON IAMP IN 5OML NS IV OD
9.TAB.DOLO 650MG PO TID
10.TAB.WYSOLONE 50 MG OD
11.TAB.GLIMIPERIDE 500 MG OD
SOAP NOTES DAY 12
ICU BED-4
S- IN CREASED EPISODES OF COUGH AND fever spikes present. PATIENT IS ON INTERMITTENT CPAP
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 103F
PULSE RATE - 124BPM
BLOOD PRESSURE -
150/80MM OF HG
RESPIRATORY RATE - 26
SPO2 - 92% AT RA
GRBS-98mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-98MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
Hemogram (26/3/22)
Hb-10
Tlc-17500
N/l/E/M-86/8/1/5
RBC-3.54
PLT-3.73
Hemogram (27/3/22)
Hb-10.3
Tlc-13400
N/L/E/M-85/10/4/1
RBC-3.72
PLT-3.54
HEMOGRAM(28/3/22)
HB-9.7
TLC-11500
N/L/E/M-88/7/2/3
RBC-3.44
PLT-3.32
Chest x ray(28/3/22)
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD
2.TAB.SEPTRAN DS TID (DAY -13)
3.TAB.DOXY 100MG PO BD (DAY-6)
4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 50 MG OD(DAY-7)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP.GRILINCTRUS BM
8.TAB.METFORMIN 500MG OD
9.ZYFER GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.TAB.WYSOLONE 50 MG OD
SOAP NOTES DAY 13
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99F
PULSE RATE - 97BPM
BLOOD PRESSURE -
140/90MM OF HG
RESPIRATORY RATE - 17
SPO2 - 98% AT RA
GRBS-88mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-88MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
Hemogram (26/3/22)
Hb-10
Tlc-17500
N/l/E/M-86/8/1/5
RBC-3.54
PLT-3.73
Hemogram (27/3/22)
Hb-10.3
Tlc-13400
N/L/E/M-85/10/4/1
RBC-3.72
PLT-3.54
HEMOGRAM(28/3/22)
HB-9.7
TLC-11500
N/L/E/M-88/7/2/3
RBC-3.44
PLT-3.32
LDH-230
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 4 )
2.TAB.SEPTRAN DS TID (DAY -13)
3.TAB.DOXY 100MG PO BD (DAY-7)
4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 50 MG OD(DAY-8)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP.GRILINCTRUS BM
8.TAB.METFORMIN 500MG OD
9.ZYFER GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.TAB.WYSOLONE 50 MG OD
SOAP NOTES DAY 14
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.3F
PULSE RATE - 84BPM
BLOOD PRESSURE -
120/70MM OF HG
RESPIRATORY RATE - 17
SPO2 - 98% AT RA
GRBS-99mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-99MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
Hemogram (26/3/22)
Hb-10
Tlc-17500
N/l/E/M-86/8/1/5
RBC-3.54
PLT-3.73
Hemogram (27/3/22)
Hb-10.3
Tlc-13400
N/L/E/M-85/10/4/1
RBC-3.72
PLT-3.54
HEMOGRAM(28/3/22)
HB-9.7
TLC-11500
N/L/E/M-88/7/2/3
RBC-3.44
PLT-3.32
HEMOGRAM-30/3/22
HB-9
TLC-10200
N/L/E/M-85/10/2/3
RBC-3.22
PLT-2.95
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 5)
2.TAB.SEPTRAN DS TID (DAY -14)
3.TAB.DOXY 100MG PO BD (DAY-8)
4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 50 MG OD(DAY-9)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP.GRILINCTRUS BM
8.TAB.METFORMIN 500MG OD
9.ZYFER GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.INJ.HYDROCORT 100MG /IV/BD(DAY -2)
SOAP NOTES DAY 15
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 99.3F
PULSE RATE - 93BPM
BLOOD PRESSURE -
140/90MM OF HG
RESPIRATORY RATE - 17
SPO2 - 97% AT RA
GRBS-123mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
HEMOGRAM
HB-9.9
TLC-9600
N/L/M/E-90/6/2/2
PLT-1.77
PCV-29.2
RBC-3.56
SERUM CREATININE-0.9
Na-137,k-3.5,Cl-98
LFT:TB-0.82,DB-0.24,AST-16,ALT
18,ALP-137,ALB-2,A/G: 0.62
GRBS-123MG/DL(8 AM)
Spot urine protein -27
Spot urine creatinine-19
Spot urine creatinineratio-1.42
PT-16 sec
APTT-32 sec
INR-1.11
24 hour urinary protein:59.9 mg/dl
24 hour urinary creatinine:0.5g/day
Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species
ABG ON 22/3/22
PH-'7.45
PC02-27.9
PO2-126
HCO3-19.3
O2 STAT-96.8%
BE ecf:-3.9
CBP-
HB-10.5
TLC-25900
N/L/E/M-94/3/1/2
PLT-2.63
THYROID PROFILE:
T3-0.65
T4-10.3
TSH-1.57
CBP:(24/3/22)
HB-9.8
TLC-13700
N/L/E/M-88/7/1/4
RBC-3.46
PLT-2.7 LAKH
HEMOGRAM (25/3/22)
HB-10
TLC-15300
N/L/E/M-86/8/1/5
PCV-30.5
MCV-82.7
RBC-3.68
PLT-3.71
Hemogram (26/3/22)
Hb-10
Tlc-17500
N/l/E/M-86/8/1/5
RBC-3.54
PLT-3.73
Hemogram (27/3/22)
Hb-10.3
Tlc-13400
N/L/E/M-85/10/4/1
RBC-3.72
PLT-3.54
HEMOGRAM(28/3/22)
HB-9.7
TLC-11500
N/L/E/M-88/7/2/3
RBC-3.44
PLT-3.32
HEMOGRAM-30/3/22
HB-9
TLC-10200
N/L/E/M-85/10/2/3
RBC-3.22
PLT-2.95
Hemogram (31/3/22)
Hb-8.9
TLC-10100
N/L/E/M-85/11/1/3
RBC-3.17
PLT-3.43
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 6)
2.TAB.SEPTRAN DS TID (DAY -15)
3.TAB.DOXY 100MG PO BD (DAY-9)
4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 50 MG OD(DAY-10)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP.GRILINCTRUS BM
8.TAB.METFORMIN 500MG OD
9.ZYFER GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.INJ.HYDROCORT 100MG /IV/BD(DAY -3)
http://nikitha0510.blogspot.com/2022/03/dermatomyositis.html
SOAP NOTES DAY 17
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 82BPM
BLOOD PRESSURE -
110/70MM OF HG
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-133mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 6)
2.TAB.SEPTRAN DS TID (DAY -16)
3.TAB.DOXY 100MG PO BD (DAY-9)4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 100 MG OD(DAY-11)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP SUCRALFATE 10ML TID
8.TAB.METFORMIN 500MG OD
9.ZYTEC GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.INJ.HYDROCORT 100MG /IV/BD(DAY -4)
SOAP NOTES DAY 16
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 82BPM
BLOOD PRESSURE -
110/70MM OF HG
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-133mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 6)
2.TAB.SEPTRAN DS TID (DAY -16)
3.TAB.DOXY 100MG PO BD (DAY-9)4.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
5.TAB.AZATHIOPRINE 100 MG OD(DAY-11)
6.TAB.FOLIC ACID 5 MG ONCE WEEKLY
7.SYP SUCRALFATE 10ML TID
8.TAB.METFORMIN 500MG OD
9.ZYTEC GEL FOR L/A
10.TAB.DOLO 650MG PO TID
11.INJ.HYDROCORT 100MG /IV/BD(DAy4)
SOAP NOTES DAY 17
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 80BPM
BLOOD PRESSURE -
110/80MM OF HG
RESPIRATORY RATE - 17
SPO2 - 96% AT RA
GRBS-133mg/dl
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 7)
2.TAB.SEPTRAN DS TID (DAY -17)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 100 MG OD(DAY-12)
5.SYP SUCRALFATE 10ML TID
6.TAB.METFORMIN 500MG OD
7.ZYTEC GEL FOR L/A
8.TAB.DOLO 650MG PO TID
9.INJ.HYDROCORT 100MG /IV/BD(DAY -5)
http://nikitha0510.blogspot.com/2022/03/dermatomyositis.html
SOAP NOTES DAY 18
ICU BED-4
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 86BPM
BLOOD PRESSURE -
110/80MM OF HG
RESPIRATORY RATE - 18
SPO2 - 97% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 8)
2.TAB.SEPTRAN DS TID (DAY -18)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 100 MG OD(DAY-13)
5.SYP SUCRALFATE 10ML TID
6.TAB.METFORMIN 500MG OD
7.ZYTEC GEL FOR L/A
8.TAB.DOLO 650MG PO TID
9.INJ.HYDROCORT 100MG /IV/BD(DAY -6)
http://nikitha0510.blogspot.com/2022/03/dermatomyositis.html
SOAP NOTES DAY 19
GM WARD
S- DECREASED EPISODES OF COUGH AND No fever spikes present.
O-
PATIENT IS CONSCIOUS , COHERENT COOPERATIVE
No PALOR, ICTRUS, CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA present
VITALS -
TEMPERATURE - 98.6F
PULSE RATE - 90BPM
BLOOD PRESSURE -
110/80MM OF HG
RESPIRATORY RATE - 18
SPO2 - 97% AT RA
SYSTEMIC EXAMINATION -
PER ABDOMEN : NON DISTENDED, SOFT NON-TENDER, NO GAURDING/RIGIDITY
CARDIOVASCULAR SYSTEM :
S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD
CBp (4/4/22)
Hb-9.6
TLC-15600
N/L/E/M-91/05/2/2
PLT-2.06
A-DERMATOMYOSITIS TO R/O ILD WITH RIGHT LOWER LOBE CONSOLIDATION.
P-
1.INJ.MEROPENEM 500MG IV BD(Day- 9)
2.TAB.SEPTRAN DS TID (DAY -19)
3.OINT. CANDID MOUTH PAINT IN ORAL CAVITY
4.TAB.AZATHIOPRINE 100 MG OD(DAY-14)
5.SYP SUCRALFATE 10ML TID
6.TAB.METFORMIN 500MG OD
7.ZYTEC GEL FOR L/A
8.TAB.DOLO 650MG PO TID
9.INJ.HYDROCORT 100MG /IV/BD(DAY -7)
Comments
Post a Comment