2. PATIENT DETAILS:
IP No: 8374
Age: 87 years
Gender: Male
Department: Internal medicine
Conultant name: Dr. T N J Rajesh
Date of admission: 11/9/22
3. SOAP NOTES
SUBJECTIVE EVIDENCE:
CHIEF COMPLAINTS:
3 episodes of black colored vomitings since 2-3
days, 1 episode of black color stool since 2 days
accompanied with loss of appetite and generalised
weakness. No stool passage yesterday.Aphasia
since 2-3 days.
MEDICALAND MEDICATION HISTORY:
Hypertension – On TELMA40mg OD
Diabetes mellitus – On Janumet 50/500mg OD
Hemiarthroplasty
On Ecosprin 75mg OD
4. OBJECTIVE EVIDENCE AND ASSESSMENT:
1. Accelerated Hypertension – constantly elevated blood
pressure
2. Upper GI bleed – drug induced due to long term usage
of ecosprin
CT SCANABDOMEN:
Mild bilateral perinephric fat stranding
Oesophageal and gastric ulcers
Evidence of large hiatus hernia, faecal loaded colon
Mild pleural effusion noted on right side
12/922 13/9/22 14/9/22 15/9/22 16/9/22 17/9/22
VITALS BP(mmHg) 160/90 180/80 163/75 160/70 140/70 140/60
HR(bpm) 78 95 99 99 98 90
Spo2(%) 96 95 99 99 98 98
5. 3. Hypertensive encephalopathy – due to
high blood pressure characterised by mental
status changes
CT SCAN BRAIN:
Bilateral chronic hypertensive ischemic
encephalopathic changes
Age related atrophy
EEG:
Grade II encephalopathy
Glasgow coma scale:
12/9/22 13/9/22
E4V4M6 E4V5M5
6. 4. UTI (Urosepsis) – based on findings in CUE and
sepsis profile
URINE EXAMINATION:
RBC: 6-10 hpf
PUS CELLS: plenty
PROTIEN: 2+
CULTURE SENSITIVITY TEST:
Urine (aerobic) – E Coli (ESBL negative)
SEPSIS:
12/9/22 13/9/22 14/9/22 15/9/22
Temperature Afebrile 98.6 98 Low
TLC 6.4 7.7 10.2 5.9
CRP 27 61 185
Microbiology - Magnex forte Magnex forte Blood – SFNG
Urine - Ecoli
7. 5. AKI – due to decreased urine output
6. Hypokalemia – based on K+ levels
12/922 13/9/22 14/9/22 15/9/22 16/9/22 17/9/22
Potassium 4.1 4.4 4.2 3.6 3.0 3.4
10. PLAN:
12/9/22
1.On examination patient BP was high so
Tab Amlong 10mg OD started
2.IV NS 200+100ml bolus @80ml/hr, Inj
PAN infusion @8ml/hr, Inj Magnex forte
1.5gm IV BD, Syp Sucralfate 10ml q6h
was started initially as the patient was
suffering from vomitings
3.CT abdomen, CT brain, 2D echo and
EEG investigations to be done
11. 13/9/22
1.Patient taken to endoscopy with decreased
sedation. During the procedure vitals were
BP-220/112mmHg, PR-156bpm, Spo2-90%
Treatment: Intubated with LMA and
controlled ventilation done and nitroglycerin
infusion started
Then the vitals were BP-177/89mmHg, PR-
108bpm, Spo2-100% (facemask
O2@4l/min)
*Continue treatment as per chart
12. 14/9/22
1.RTF after confirming RT position
2.Continue pan infusion and sucralfate
syrup
3.Start RT feed 50ml/hr
(formula: critipro DM – 6 scoops in 150ml
water and make upto 200ml)
4.Patient complained of cough with
expectoration
*Continue rest treatment as per chart
13. 15/9/22
1.Urine culture – Ecoli (ESBL
negative), so magnex forte is
escalated to meropenem
2.Restart Bactrim DS
3.Continue RT feed @50ml/hr
16/9/22
*Continue treatment as per chart
*Monitor vitals
14. MEDICATION CHART
MEDICATION DOSE ROUTE FREQUENCY START
DATE
Inj Magnex Forte 1.5g IV BD 12/9/22
Inj Thiamine 2amp IV BD 12/9/22
Inj Optineuron 2amp IV OD 12/9/22
T. Cinod 10mg RT OD 12/9/22
Enema BD 12/9/22
Syp Sucralfate 10ml PO TID 12/9/22
T. Bactrim DS 1 tab PO BD 12/9/22
Syp Lactihep 15ml PO TID 13/9/22
T. Mucinac 600mg PO BD 14/9/22
Inj Meropenem 1g IV TID 15/9/22
Syp Potklor 15ml RT QID 16/9/22
