CURRENT UNIT 6 PATIENTS SOAP UPDATES

total 9 cases : 


1 icu and 1 AMC
 5 in ward
 2 in superspeciality

female ward patients 

1)

45/f 

S- no fresh complaints
backache - subsided
sob -  subsided
fatiguability - subsided

o-
pr-84 bpm
bp-110/80 mm hg
cvs - s1,s2 +
rs- nvbs +
p/a - soft non tender

a-
 anemia under evaluation 
 ? IDA

P-

1.TAB PANTOP 40MG PO/OD
2.INJ BUSCAPAN 1AMP /IV /SOS
3.PLAN FOR BLOOD TRANSFUSION
4. SYP CREMAFFIN 15ML PO/HS

2)

60/f 

S: no fresh complaints .
vomitings-subsided 
loose stools-subsided 
pain in abdomen- subsiding
 

O:
 Dry tongue+.
 Pallor+.

Temp: afebrile
PR :84 bpm
BP:100/70 mmhg
RR: 18cpm
P/A: soft, tenderness noted in epigastric region.
CVS: S1,S2  heard, no murmurs 
RS: BAE+, NVBS heard.
CNS: NAD.
A-

 
 Acute gastroenteritis.
 
P-

1.IV FLUIDS 2NS, 1 DNS, 1 RL @ 100ml/hr.
2.INJ. PANTOP 40 mg /po/OD..
3. INJ.ZOFER 4 mg/IV/TID 
4. TAB. SPOROLAC -DS PO/TID.
5. ORS SACHETS 1 PACKET IN 1 LITRE , 200ML AFTER EACH STOOL.
6 INJ. BUSCOPAN 1  IV /SOS
7. TAB. CIFLOX 500MG PO/BD
8. INJ. METROGYL 500 MG /IV/TID
9. BP, PR CHARTING 2ND Hrly.

MALE WARD PATIENTS -

1)70/M

S- no fresh complaints
palpitations - subsiding 
sob-SUBSIDING 
chest pain-STILL PRESENT
epigastric pain -STILL PRESENT 
abd distension - subsided 

O- 
afebrile
pr-91 irregular
bp- 100/70 mm hg
cvs - s1,s2 heard
p/a - soft non tender

A-
CAD WITH HFREF (EF 35%) WITH LBBB 
AF WITH FVR .

P- 
1. FLUID RESTRICTION LESS THAN 1.5L/DAY
2. TAB LASIX 40MG PO/BD
3. TAB MET XL 25MG PO/BD
4. TAB ECOSPIRIN AV (75/10) PO / OD
5. INJ PANTOP 40MG IV/BD
6. INJ BUSCOPAN 1 AMP IV /SOS
7. SYP SUCRALFATE 10ML /PO/TID
8. I/O CHARTING
9. BP CHARTING 
10. GRBS  charting

2)

65/M
S:  pt  complaints lower backache 
   no freah compliants
o:
bp:150/80 mmhg
PR: 106 bpm
rr:20 cpm
cvs: s1, s2 heard
Rs: bae+   nvbs+
cns: not oriented to time ,place person.
       slurred speech+
a: acute inferct in left anterior temporal lobe , compressive myelopathy, old cva, vascular dementia, spondyloarthopathy, k/c/o DM, HTN.
p:
1.ivf 2 NS, 1RL @ 50ml/hr.
2. RF feeding 200ml milk with protein powder. 2nd hrly, 50 ml of water 2nd hrly
3. inj. pan 40mg iv od
4. inj. monocef 1 gm iv bd
5. tab. ecosprin av 75/20 po/od/Hs
6. inj. HAI Sc according to sliding scale
7. grbs charting 6th hrly
8. physiotherapy of b/l limbs.

3)

45/M
S: patient complaints of pedal edema, decreased shortness of breath, no fresh complaints.
o:
 afebrile
  bp: 120/90
pr: 94 bpm
rr:20 cpm
cvs: s1,s2 heard, no murmurs
RS: decreased breath sounds on right IAA
      no adventitious sounds.
p/A: soft, non tender, bowel sounds+
a:. CLD
P:1.Salt restriction <2g/day
   2. fluid restriction <1.5 litre/day
  3.inj. pan 40mg iv od
4.inj. thiamine 1 amp in 100ml NS iv/tid
5. inj. optineuron 1 amp in 100 ml NS iv/od
6. tab. lasilactone (40/100) mg od po


ICU PATIENTS-

1) 50 year old man with fever with thrombocytopenia with AKI on uremic encephalopathy, septic shock with k/c/O HTN since 6 years 
SOAP update :
S:     patient in altered sensorium 
O:      PR:110 bpm
          Bp:110/70mmhg on NORAD infusion                 11ml / hr 
          Spo2 : 95% with 15L of O2 
ABG 
           PH 7.35
          PCO2   29
          PO2   72.9 
        HCO3  15.6 

RFT 
UREA 234 
CREATININE 3.7 
URIC ACID  9 
CALCIUM 8.9
PO4    5 
Na    144
K  4.3 
CL  107 
 HB  10.7 g/dl 
TLC 14;800 
PLATELETS 11, 000
A:           fever with thrombocytopenia with AKI on uremic encephalopathy, septic shock with k/c/O HTN since 6 years 
P: 
1) INJ. NORADRENALINE 11ML /HR  MAINTAIN MAP 65mm of hg. 
2) INJ. PIPTAZ. 2.25 gm IV /TID 
3) IVF 2  UNITS OF NS 
             2 UNITS OF RL      AT 100 ML / HR
             2 UNITS OF DNS 
4) INJ PANTOP 40 MG IV /OD 
5) INJ. ZOFER 4 MG IV /BD 
6) O2 INHALATION TO MAINTAIN SPO2 >95% 
7)HOURLY PR, RR, SPO2, BP MONITORING.

AMC PATIENTS-

1)50/M. 

SOAP UPDATE:
S : FEVER SUBSIDED, LOOSE STOOLS SUBSIDED.. 
O: PR:84bpm
          Bp:140/90mmhg
ABG 
           PH 7.3
          PCO2   23.4
          PO2   96.2
        HCO3  14.8

HB  8.3g/dl 

A: AKI ON CKD, K/C/O DM 2 AND HTN 

P:salt and fluid restriction. 
INJ. Ceftriaxone 1 gm IU 
INJ. lasix 40 mg IU /BD 
TAB. DOLO 625 mg PO/SOS
TAB. SPORLAC -DC PO/SOS
INJ. HAI according to sliding scale sc 
Tab. Onofer -xt po/od 
Tab. Shelcal -ct po/od



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