CASE 1:

 [01/09, 10:28] Rakesh Biswas: Corresponding serum protein and LDH? 

Also more importantly what about cell type and cell count?

[01/09, 10:28] Rakesh Biswas: Share the images

[01/09, 10:34] Chetana Keta: Total proteins: 4.5 gm/dl

[01/09, 12:04] Chetana Keta: Pleural fluid cell count -42,000 with predominant neutrophils sir..

[01/09, 21:50] Rakesh Biswas: Ask pulmonologist asap if that would be an indication for ICTD

[02/09, 11:08] Chetana Keta: soap notes 

2/9/23

ICU Bed 3

Dr.Zain(SR)

Dr.Nishita(PGY2)

DR.Govardhini(PGY1)

S: Continuous fever Spikes are present. Stools not passed since 3 days

O: Pt is on Mechanical Ventilator 

GCS- E1V1M1

PR-120bpm

RR-14cpm

BP-110/60 mmhg

@12ml/hr NORAD

@10ml/hr DOBU

@0.2 ml/hr VASOPRESSIN 

ACMV Mode

FiO2 @30

SPO2 94%

RS: BLAE +

Decreased BS in Rt IAA with crepts present in Rt Mammary,IAA

CVS: S1S2 +, No murmurs

CNS: 

Tone :Normal B/L both UL&LL

Power :  Unable to elicit

Reflexes: Absent B/L in both UL & LL

Brain stem reflexes:

Pupillary reflex- absent

Corneal reflex- absent

Conjunctival reflex- absent

Gag reflex- Present

Occulocephalic reflex- Present

P/A- Soft, NT

I/O 2500/200ml

GRBS 174mg/DK

A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago

S/P Post CPR status with chronic calcific Pancreatitis with hyperkalemia with sepsis

P: 

1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr 

2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr 

3. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr

4. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr

5.TAB AZITHROMYCIN 500 mg RT/OD 

6.NEB WITH BUDECORT + IPRAVANT 6 Th hourly 

7.INJ THIAMINE 1 Amp In 100 ml NS IV/BD

8.RT FEEDS 200 ml water 2 nd hourly

200 ml milk 4 Th hourly 

9.MONITOR VITALS TEMP; PR; RR ; spo2

10.POSITION CHANGE EVERY HOURLY

11.INJ HAI ACC to GRBS

12.INJ.MEROPENEM 500mg IV/BD

13.INJ HEPARIN 5000 IU S.c/ QID

14.INJ LEVIPIL 1gm IV/BD

15. T. TOLVAPTAN 15 MG 

RT/BD

16. T. ATORVASTATIN + T. ASPIRIN 10/75 MG PO/HS

17. INJ VANCOMYCIN 500 MG IV BD

T. FLUCONAZOLE 150 MG RT OD

[05/09, 09:23] Chetana Keta: soap notes 

5/9/23

ICU Bed 3

Dr.Zain(SR)

Dr.Nishita(PGY2)

DR.Govardhini(PGY1)

S: No fever spikes

O: Pt is on Mechanical Ventilator 

GCS- E1V1M1

PR-98bpm

RR-14cpm

BP-120/80 mmhg

@0.5ml/hr NORAD

@1.5ml/hr DOBU

ACMV Mode

FiO2 @30

SPO2 96%

RS: BLAE +

Decreased BS in Rt IAA with crepts present in Rt Mammary,IAA

CVS: S1S2 +, No murmurs

CNS: 

Tone :Normal B/L both UL&LL

Power :  Unable to elicit

Reflexes: Absent B/L in both UL & LL

Brain stem reflexes:

Pupillary reflex- absent

Corneal reflex- absent

Conjunctival reflex- absent

Gag reflex- Present

Occulocephalic reflex- Present

P/A- Soft, NT

I/O 1800/1400ml

GRBS 93mg/dl

A: 3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago

S/P Post CPR status with chronic calcific Pancreatitis with hyperkalemia with sepsis

P: 

1. INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr 

2. INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr 

3. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr

4.NEB WITH BUDECORT + IPRAVANT 6 Th hourly 

5.INJ THIAMINE 1 Amp In 100 ml NS IV/OD

6.RT FEEDS 80 ml water 2 nd hourly

100 ml milk 4 th hourly 

7. MONITOR VITALS TEMP; PR; RR ; spo2

8.POSITION CHANGE EVERY HOURLY

9.INJ HAI ACC to GRBS

10.INJ.MEROPENEM 500mg IV/BD

11.INJ HEPARIN 5000 IU S.c/ QID

12.INJ LEVIPIL 1gm IV/BD

13. T. ATORVASTATIN + T. ASPIRIN 10/75 MG PO/HS

14. INJ VANCOMYCIN 500 MG IV BD

15. T. FLUCONAZOLE 150 MG RT OD

16. T. OROFER XT PO/OD

17. DAILY DRESSINGS OF BED SORE

CASE II:

Soap notes :

4/9/23

AMC Bed 3

Dr. Zain (SR)

Dr. Nishitha(PGY2)

Dr. Govardhini (PGY1)

S: No fever spikes,Stools not passed.

O:

Pt is oriented to person

Not oriented to time and place

BP: 100/60 mmhg

PR: 96bpm

PR: 20 cpm

GCS: E4V5M6

CVS: S1 S2 +

RS: NVBS+ BLAE+

CNS: NFND

P/A: Diffuse Tenderness Present 

Guarding and rigidity present

A:

Altered sensorium secondary to hypoglycemia with ulcer over anterior aspect of right leg secondary to filariasis with k/c/o HTN and CAD.

P:

1. Iv Fluids NS @ 50 ml/hr

2. INJ LASIX 40 mg IV/BD

3. INJ. PIPTAZ 2.25 gm IV/BD

4. INJ PAN 40 mg IV/BD

5. INJ BUSCOPAN IV/BD

6. TAB. DIETHYL CARBAMAZINE PO/BD

7. TAB MVT PO/OD

8. INJ. ZOFER IV SOS