80yr old Male with fever and burning micturition

19/12/22:

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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K.Medha Reddy, intern 

Roll No: 61

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE:

A 80 year old male patient came with cheif compliants of 

fever since 10days

burning micturition since 7 days

B/L pedal edema since 5 days 

Decreased urine output since 5days

No urine output at the time of presentation.

HOPI:

Patient was apparently assymptomatic 10 days back then he developed fever high grade, no evening rise of temperature.

C/O cold and cough since 7-8days, cough not associated with sputum, non blood tinged.

H/O burning micturition 7 days ago

No H/O Hematuria

NO H/O frothing of urine

H/O decreased urine output + since 5 days and No Urime Output at the time of presentation 

No H/O flank pain, dribbling of urine and urine incontenance

H/O swelling of both lower limbs extending upto ankles since 5-6 days

No H/O chest pain, dyspnea, palpitations and sweating.

5 days back he sustained a distal left radial fracture on which cast was placed

Past history : 

k/c/o HTN since 5 years and is on medication (Tab. Amlodipine 5mg + Tab Atenolol 50mg)

K/c/o DM since 4 years and is on Glimiperide 1mg + Tab. Metformin 500mg)

No H/O asthma/TB/epilepsy

No previous surgericqk history

No allergic history 

Personal history : 

diet - mixed

Appetite - decresed

Sleep - disturbed

Bowel habits - normal

Bladder - decreased urine output and associated with burning sensation

Addictions :

Consumes alcohol regularly almost 4 to 5 days in a week.

Tobbaco: beedis one pack/day since 40 years

40 pack years

Family History:

Insignificant 

GENERAL EXAMINATION:

 

patient was concious coherent, incooperative and irritable during the time of examination.

GCS:10 at the time of examination

Pallor: absent

Icterus: absent

Cyanosis : absent 

Clubbing : absent 

Koilonychia: absent 

Lymphadepathy: absent 

Pedal Edema: B/L putting type of pedal edema extending upto to ankles (grade1)

SYSTEMIC EXAMINATION:

CVS:

S1 and S2 are heard

no abnormal heart sounds were heard

RS: B/L air entry present

B/L basal crepitations +

P/A:  

slightely distended 

All quadrants are moving equally with repisration

No scars, sinuses and hernial orifices

No organomegaly

Bowel sounds+

CNS :

Concious and agitated

Motor system:

Tone:              R.      L

                       N.       N

Power:          R.         L

                      N.        N

Reflexes.             R.             L

Biceps                ++.           ++

Triceps               ++.           ++

Supinator.          ++.           ++

Knee.                  ++.           ++

Ankle.                 ++.           ++

Plantar             flexion     Flexion

PROVISIONAL DIAGNOSIS:

Altered sensorium secondary to hyponatremia (resolved)

Hepatic encephalopathy? 

True hyponatremia secondary to hypovolemia

Dyselectrolemia secondary to pre-renal AKI (resolved)

Uncontrolled sugars (resolved)

? Sepsis with MODS

INVESTIGATIONS :

Fever chart : 

On 19/12/22:

GRBS: monitoring:

 on 20/12/22:

On 21/12/22:

On 24/12/22:

Sodium trends from the date of admission until now:( 19/12/22 to 25/12/22) 

On 22/12/22: Inj. 3% NS IV 10ML/HR was given.

 

TREATMENT:

On 20/12/22: 

O/E: 

Pt is irritable

PR : 78bpm 

BP: 80/60 mmHg 

RR: 18cpm

SpO2: 98% on RA

GRBS: @8AM 76mg/dl

Input: 1450

Output: 350

TEMP: 98.6F

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, 

Crepts + in RT IAA

P/A: soft, non tender, bowel sounds +

CNS: Pt is conscious but irritable

Pupils Rt - constricted

Lt- Dilated 

TREATMENT GIVEN:

IVF NS RL @50 ML/HR

INJ. KCL 2AMP IN 500ML NS IV OVER 5HOURS STAT

INJ. PIPTAZ 2.25GM IV TID

INJ LASIX 40 MG IV BD

INJ PAN 40MG IV OD

SYP. POTCHLOR 15ML IN A GLASS OF WATER PO TID

INJ. HAI SC TID PREMEAL SOS

STRICT INPUT OUTPUT CHARTING 

ON 21/12/22: 

O/E: 

Pt is conscious, irritable

PR : 88bpm 

BP: 100/70 mmHg 

RR: 28cpm

SpO2: 97% on RA

GRBS: @8AM 141mg/dl

Input: 2350 ml

Output: 1100 ml

TEMP: 99.5F

STOOLS : PASSED 

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, NVBS

P/A: soft, non tender, bowel sounds +

CNS: Pt is conscious but irritable

TREATMENT GIVEN:

IVF NS RL @50ML /HR

INJ. PIPTAZ 2.25GM IV TID

INJ LASIX 40 MG IV BD

INJ PAN 40MG IV OD

INJ. HAI SC TID PREMEAL SOS

TAB. SHELCAL CT PO OD

TAB. CHYMEROL FORTE PO TID

SYP. LACTULOSE 30ML PO HS

TAB. TOLVAPTAN 15MG PO BD 

TAB. AZITHROMYCIN 500MG PO OD

NEBULISATION WITH SALBUTAMOL 4TH HRLY AND BUDECORT 12TH HRLY.

STRICT INPUT OUTPUT CHARTING

ON 22/12/22: 

O/E: 

Pt is conscious, irritable

PR : 92bpm 

BP: 110/70 mmHg 

RR: 24cpm

SpO2: 95% on 6LTR O2

GRBS: @8AM 178 mg/dl

Input: 2250 ml

Output: 1700 ml

TEMP: 99.5F

STOOLS : PASSED 

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, 

DIFFUSE WHEEZE IN B/L LUNGS. 

P/A: soft, non tender, bowel sounds +

CNS: Pt is conscious but irritable

TREATMENT GIVEN:

IVF NS RL @50ML /HR

INJ. PIPTAZ 2.25GM IV TID

INJ LASIX 40 MG IV BD

INJ PAN 40MG IV OD

TAB. TOLVAPTAN 15MG PO BD 

TAB. AZITHROMYCIN 500MG PO OD

TAB. CHYMEROL FORTE PO TID

TAB. SHELCAL CT PO OD

SYP. LACTULOSE 30ML PO HS

NEBULISATION WITH SALBUTAMOL 4TH HRLY AND BUDECORT 12TH HRLY

INJ. HAI SC TID PREMEAL SOS

INJ. HYDROCORT 100MG PO TID

INJ. NEOMOL 100ML (IF TEMP INCREASES >101.1F)

INJ. 3% NS IV 10ML/HR

LIMB ELEVATION

INJ. MEROPENEM 250MG IV BD 

STRICT INPUT OUTPUT CHARTING

ON 23/12/22:

O/E: 

Pt is conscious, coherent to place and person 

PR : 76bpm 

BP: 110/70 mmHg 

RR: 16cpm

SpO2: 99% on RA

GRBS: @8AM 338 mg/dl

Input: 2300 ml

Output: 1100 ml

TEMP: 98.5F

STOOLS : PASSED 

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, 

B/L CREPTS IN IAA. 

P/A: soft, non tender, bowel sounds +

CNS: Pt is conscious, coherent to place and person

TREATMENT GIVEN:

IVF NS RL @50ML /HR

INJ. MEROPENEM 250MG IV BD 

INJ LASIX 40 MG IV BD

INJ PAN 40MG IV OD

INJ. HYDROCORT 100MG PO TID

INJ. NEOMOL 100ML (IF TEMP INCREASES >101.1F)

TAB. TOLVAPTAN 15MG PO BD 

TAB. AZITHROMYCIN 500MG PO OD

TAB. CHYMEROL FORTE PO TID

TAB. SHELCAL CT PO OD

SYP. LACTULOSE 30ML PO HS

NEBULISATION WITH SALBUTAMOL 8TH HRLY AND BUDECORT 12TH HRLY

INJ. HAI SC TID PREMEAL SOS

CHEST PHYSIOTHERAPY 

LIMB ELEVATION

STRICT INPUT OUTPUT CHARTING

TAB. UDILIV 300MG PO BD

TAB ALDACTONE 50mg PO OD

TAB RIFAGUT 550mg PO OD 

AMBULATION OF THE PATIENT .

ON 24/12/22:

O/E: 

Pt is conscious and coherent 

PR : 72bpm 

BP: 100/60 mmHg 

RR: 15cpm

SpO2: 99% on RA

GRBS: @8AM 120 mg/dl

TEMP: 98.5F

STOOLS : PASSED 

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, NVBS

P/A: soft, non tender, bowel sounds +

CNS: Pt is conscious, coherent. NFND 

TREATMENT GIVEN:

IVF NS RL @50ML /HR

INJ. MEROPENEM 250MG IV BD 

INJ PAN 40MG IV OD

INJ. HYDROCORT 100MG PO TID

INJ. NEOMOL 100ML (IF TEMP INCREASES >101.1F)

TAB. TOLVAPTAN 15MG PO BD 

TAB. AZITHROMYCIN 500MG PO OD

TAB RIFAGUT 550mg PO OD

TAB. CHYMEROL FORTE PO TID

TAB. SHELCAL CT PO OD

TAB. UDILIV 300MG PO BD

TAB ALDACTONE 50mg PO OD

SYP. LACTULOSE 30ML PO HS

NEBULISATION WITH SALBUTAMOL 8TH HRLY AND BUDECORT 12TH HRLY

INJ. HAI SC TID PREMEAL SOS

SYP. POTCHLOR 15ML IN A GLASS OF WATER PO TID 

CHEST PHYSIOTHERAPY 

STRICT INPUT OUTPUT CHARTING

AMBULATION OF THE PATIENT .

On 25/12/22

Pt came with cheif compliants of fever since 10days, burning micturition since 7 days, B/L pedal edema since 5 days and decreased urine output since 5 days and anuria since 1day.

S: 

GCS: E4V5M6

Stools passed

No fever spikes

TB: 6.60

DB: 5.47

AST: 58

ALT: 108

ALP: 2489

Urea: 115

S. Creat : 1.7 

Na+ : 140

K+: 2.9

Cl-: 98

O: 

Pt is conscious and coherent 

PR : 96bpm 

BP: 140/80 mmHg 

GRBS: 329 mg/dl, 16units of HAI GIVEN 

Input: 1900

Output: 1600

TEMP: 98F, no fever spikes 

Stools passed

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, lungs are clear( normal vesicular breath sounds heard)

P/A: soft, non tender, bowel sounds +

CNS: No Focal Neurologic Defect 

 

A:

Altered sensorium (resolved) secondary to hyponatremia 

Hepatic encephalopathy? 

True hyponatremia secondary to hypovolemia

Dyselectrolemia secondary to pre-renal AKI 

Uncontrolled sugars (resolved)

? Sepsis with MODS

P: 

IVF NS, RL @50ml/hr

Inj. Meropenum 250mg IV BD 

Inj. Pan 40mg IV OD 

Inj HYDROCORT 100mg IV SOS

Inj. Neomol 1gm sos

Inj. HAI SC TID Premeal 

Tab tolvaptan 15mg PO BD 

Tab AZITHROMYCIN 500mg PO OD 

Tab Rifagut 550mg PO OD 

Tab. Chymerol forte PO TID 

Tab shelcal PO OD 

Tab aldactone 50mg PO OD 

Sup. Lactulose 30ML PO OD HS 

Neb. With salbutamol 8th hrly, Budecort 12th hrly

Syp. Potklor 15ml in a glass of water

Chest physiotherapy

Ambulation of the patient

On 26/12/22:

AMC Bed 2: 

Day 7

Unit 1 

Pt came with cheif compliants of fever since 10days, burning micturition since 7 days, B/L pedal edema since 5 days and decreased urine output since 5 days and anuria since 1day.

S: 

No fresh complaints 

Stools passed

No fever spikes.

HB: 9.2

TLC: 9100

PLT: 2.00

TB: 3.73

DB: 3.19

AST: 50

ALT: 100

ALP: 1574

ALB: 1.9

Urea: 111

S. Creat : 1.3 

Na+ : 134

K+ : 2.9

Cl- : 103

Ca+2(i) : 0.84

O: 

Pt is conscious and coherent 

PR : 92bpm 

BP: 130/80 mmHg 

GRBS: 174 

Input: 1900

Output: 1450

TEMP: 97F, no fever spikes 

Stools passed

CVS: S1, S2 heard, no murmurs

RS: B/L air entry+, crepts heard in rt. ISA, normal vesicular breath sounds heard.

P/A: soft, non tender, bowel sounds +

CNS: No Focal Neurologic Defect 

 

A:

Altered sensorium (resolved) secondary to hyponatremia 

Hepatic encephalopathy? 

True hyponatremia secondary to hypovolemia

Dyselectrolemia secondary to pre-renal AKI (resolved)

Uncontrolled sugars (resolved)

? Sepsis with MODS

GRADE 1 BED SORE AT NATAL CLEFT REGION

P: 

IVF NS, RL @50ml/hr

Inj. Meropenum 250mg IV BD 

Inj. Pan 40mg IV OD 

Inj HYDROCORT 100mg IV SOS

Inj. Neomol 1gm IV sos

Inj. HAI SC TID Premeal 

Tab tolvaptan 15mg PO BD 

Tab Rifagut 550mg PO OD 

Tab. Chymerol forte PO TID 

Tab shelcal PO OD 

Tab aldactone 50mg PO OD 

Sup. Lactulose 30ML PO OD HS 

Neb. With salbutamol 8th hrly, Budecort 12th hrly

Syp. Potklor 15ml in a glass of water

Chest physiotherapy

Ambulation of the patient

Explained protein rich diet

2-3 egg whites per day

Protein powder 2tbsp in a glass of water/milk PO TID