59 year old female with community acquired pneumonia

 Case:

A 59 year old female, homemaker by occupation, came to the causality with c/o fever since 6 days, cough since 5 days, SOB since 2 days, pain abdomen since afternoon 

History of presenting illness:

Patient was apparently asymptomatic 6 days back. Then she developed fever which was high grade, associated with chills

Fever subsided now.

-Cough with sputum , blood tinged since 5 days

- chest pain since 5 days

-Grade 4 Shortness of breath since 2 days

-No H/o vomitings, diarrhea 

-No h/o palpitations.

-She was diagnosed with DM last year and is on ayurvedic medication for it.

- k/c/o CKD ?

Past history:

K/c/o DM on medication

K/c/o ckd?

Personal history:

Mixed diet

Appetite normal

Micturition normal

Bowels normal

No addictions

Family history:

Not significant 

General examination:

Patient is c/c/c

Moderately built and nourished

Pallor present 

No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals:

Temp- afebrile 

BP- 130/80 mm hg

PR -120 bpm 

RR- 56/min 

SpO2 - 93% at room air 

GRBS - 241 mg/dl

Systemic examination:

CVS: s1s2 heard

RS: BAE + B/L coarse crests heard in R>>L

P/A: soft, non tender, BS+

CNS: NFND 

Investigations:

Serum creatinine- 4.9mg/dl

Blood urea - 177 mg/dl 

ALP- 234 IU/L

X ray: abdomen:

Chest x ray

Ecg: 

Provisional diagnosis:

Community acquired pneumonia 

With k/c/o DM 

With k/c/o HTN??

With AKI on CKD with sepsis

? Pyelonephritis 

Treatment:

1. Inj. Meropenem 1g/IV/STAT f/b 500 mg IV/BD
2. Inj pan 40 mg IV/OD
3. IVF: NS and RL @50ml/hr
4. Inj OPTINEURON 1 ampoules in 100 ml NS IV/OD
5. Temp charting 4th hrly & tepid sponging
6. Nebulisation with Duolin and bud escort 8th hourly
7. O2 inhalation
8. GRBS charting 6th hourly
9. Inj HAI s/c/TID
10. Strict I/o charting
11. Monitor BP, PR, RR

DAY 2:

Subjective-

Shortness of breath present 

No complaints of fever and cough 

Objective 

Temp- afebrile

BP - 130/90mmhg 

PR - 110 bpm 

RR - 48/min 

Spo2 - 92% with 8L of O2 .

Assessment-

Community acquired pneumonia (right side )with k/c/o DM

? AKI on CKD.

Plan of care-

On intermittent CPAP since yesterday night.

-Inj meropenem 500 mg

-Inj pan 40 mg

-Inj optineuron 

-IV fluids NS, RL- continuous infusion @50ml/hr

-Neb with Duolin and budecort 8th hourly 

-Inj HAI s/c

DAY 3:

Subjective-

Shortness of breath present 

fever spikes present

Objective 

Temp- 102.4 F

BP - 120/90mmhg 

PR - 131 bpm 

RR - 43/min 

Spo2 - 99% with 14L of O2 and BiPAP

Biochem inv: 

serum creatinine-6.0

Assessment-

Community acquired pneumonia (right side )with k/c/o DM

? AKI on CKD.

Plan of care-

-Inj meropenem 500 mg

-Inj pan 40 mg

-Inj optineuron

-IV fluids NS, RL- continuous infusion @50ml/hr

-Neb with Ipravent, budecort and mucomist 4th hourly 

-Inj HAI s/c

- intermittent CPAP ventilation

Referral taken I/v/o of CKD component of the patient’s diagnosis: