Outside the hsptl:
24 hr urinary protein: 236 mg/day
24 hr urinary volume :1500 ml
24hr creatinine: 0.6g/day
Usg:
Salt restriction lessthan 2.4g per day
Fluid restriction lessthan 1.5 l/day
Inj Lasix 40 mg iv/bd
Inj Ceftriaxone 1gm IV/bd
Inj. PANTOP 40mg IV/od
Inj.zofer 4mg IV/sos
Inj Neomol 100 ML NS IV/sos
T.Pcm 500 mg po/bd
T.orofer xT po/od
Bp/PR/TEMP/RR CHARTING 4TH HRLY
Grbs charting 6th hrly
Inj HAI s/c acc to sliding scale
I/o charting
T.cilnidipine 5 mg od
T.Arkamine 0.1 mg po/od
On 5/9/21:
S-
Vomitings of 2episodes since yesterday
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-190/100 mmHg
PR -120bpm
Spo2-96 %on RA
RR-21cpm
Grbs-134
I/o-900/550
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj Ceftriaxone 1gm IV/bd
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj pantop 40 mg iv/od
Inj zofer 4mg IV/sos
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
Inj.HAI s/c acc to sliding scale
Inform Grbs
Strict i/o charting
On 6/9/21:
S-
No fresh complaints
Vomitings subsided
Decreased appetite
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-160/190 mmHg
PR -106bpm
Spo2-96 %on RA
RR-21cpm
Grbs-112mg/dl
I/o-900/550
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj Ceftriaxone 1gm IV/bd
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj pantop 40 mg iv/od
Inj zofer 4mg IV/sos
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
Inj.HAI s/c acc to sliding scale
Inform Grbs
Strict i/o charting
Syp.cremaffin plus po/hs
On 7/9/21:
S-
No fresh complaints
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-170/190 mmHg
PR -98bpm
Spo2-98 %on RA
RR-20cpm
Grbs-186
I/o-1300/1150
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard ,decreased breath sounds in b/l IAA,ISA
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj Ceftriaxone 1gm IV/bd
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj pantop 40 mg iv/od
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
On 8/9/21:
S-
No fresh complaints
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-130/80mmHg
PR -86bpm
Spo2-98 %on RA
RR-22cpm
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard ,decreased breath sounds in b/l IAA,ISA
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj Ceftriaxone 1gm IV/bd
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj pantop 40 mg iv/od
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
On 9/9/21:
S-
No fresh complaints
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-150/60 mmHg
PR -88bpm
Spo2-98 %on RA
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
On 10/9/21:
S-
No fresh complaints
Stools not passed
O-
Pt is c/c/c
Afebrile
BP-140/80 mmHg
PR -84bpm
Spo2-98 %on RA
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
On 11/9/21:
S-
No fresh complaints
Stools passed yesterday night
O-
Pt is c/c/c
Afebrile
BP-140/80 mmHg
PR -82bpm
Spo2-98 %on RA
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
On 12/9/21:
S-
No fresh complaints
Stools not passed
O-
Pt is c/c/c
Afebrile
BP- mmHg
PR -bpm
Spo2-98 %on RA
CVS- s1 s2 heard
Cns- NAD
R/s- NVBS heard
P/A- soft
A-
AKI SECONDARY TO?viral infection/NSAID ABUSE with k/c/o HTN and DM-ll
P-
Fluid restriction lessthan 1l per day
SALTRESTRICTION lessthan 2.4g per day
Inj lasix iv/tid(60mg-60mg-40 mg)
Inj zofer 4mg IV/sos
T.Metformin 500 mg po/od
T.CINOD 10mg po/bd
T.Arkamine 0.1 mg po/bd
T.Nodosis 500mg po/bd
T.orofer xT po/od
T.Pcm 500mg po/sos
T.Aldactone 25mg po/od
2-3egg whites /day
Grbs -6th hrly
Monitor vitals 4th hrly
Strict i/o charting
Protein powder-D (sugar free) 2 spoons in one glass of milk -bd
