60 year old male with high grade fever

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A 60 year old male patient came to casualty with c/o high grade fever since 5 days,

Dry cough since 6 days,

SOB on exertion since 4 days.

C/o constipation since 4 days.

C/o burning micturation since 10 days.

No c/o decreased urine output.

HOPI

: Patient was apparently asymptomatic 10 days back, then he had burning micturation,and high grade fever a/w nausea and dry cough, not a/w chills and rigor,he had constipation since 4 days.

 

PAST HISTORY: Patient is a k/c/o DM since 30 yrs and was on medication DAPAGLIFLOZIN 10 MG OD and TAB. VOGLIBOSE 0.3 MG OD and  on insulin since 2 days MIXTARD as his Sr.Creatinine is 2 mg/dl

K/C/O HTN since 30 years on TAB. AMLONG 2.5 MG OD .

PERSONAL HISTORY

DIET- MIXED

APPETITE- Normal

SLEEP- Adequate

Bowel and blader movement- Decreased

ADDICTIONS- Consumes alcohol occasionally.

GENERAL EXAMINATION:

patient is concious/coherent/cooperative, moderately built and nourished.

No pallor

No icterus

No clubbing

No edema

No lymphadenopathy.

Vitals: Temp- 101 F

            PR- 80 BPM

            RR- 19 CPM

            BP- 120/70 mm Hg

            SpO2- 98%@ RA

            GRBS- 387 mg/dl

Systemic examination:

CVS: S1 S2 + ,NO MURMURS

RS: BAE+, NVBS

CNS: INTACT

P/A: SOFT, DISTENDED, GUARDING + ,BS SLUGGISH.

PLAN OF TREATMENT

KCl one ampoule in 10 ml NS over 4 hrs.

Inj.MONOCEF 1gm IV BD

Inj PANTOP 40 mg IV OD

Inj.ZOFER 4 mg IV SOS

Inj.NEOMOL 1 gm IV SOS

Tab.DOLO 650 mg PO TID

Tab.AMLONG 2.5 mg PO OD

Inj.HUMAN ACTRAPID SC Acc to GRBS

Syp.LACTULOSE 10 ml PO BD

Syp.GRILLINCTUS 10 ml PO BD

Day 1 

O/E:Pt is c/c/c

BP :110/80 

PR :86bpm

Cvs: S1&S2 heard 

Rs: Bae present 

P/a : soft and non tender 

CNS: no abnormalities detected 

Provisional diagnosis: 

UTI with chronic cystitis with post renal Aki secondary to stricture urethra 

Known case of dm&htn

PLAN OF TREATMENT

KCl one ampoule in 10 ml NS over 4 hrs.

Inj.MONOCEF 1gm IV BD

Inj PANTOP 40 mg IV OD

Inj.ZOFER 4 mg IV SOS

Inj.NEOMOL 1 gm IV SOS

Tab.DOLO 650 mg PO TID

Tab.AMLONG 2.5 mg PO OD

Inj.HUMAN ACTRAPID SC Acc to GRBS

Syp.LACTULOSE 10 ml PO BD

Syp.GRILLINCTUS 10 ml PO BD

Foleys Catheterisation 

Day-2

O/E:Pt is c/c/c

BP :90/60

PR :96bpm

Cvs: S1&S2 heard 

Rs: Bae present 

P/a : soft and non tender 

CNS: no abnormalities detected 

PLAN OF TREATMENT

KCl one ampoule in 10 ml NS over 4 hrs.

Inj.MONOCEF 1gm IV BD

Inj PANTOP 40 mg IV OD

Inj.ZOFER 4 mg IV SOS

Inj.NEOMOL 1 gm IV SOS

Tab.DOLO 650 mg PO TID

Tab.AMLONG 2.5 mg PO OD

Inj.HUMAN ACTRAPID SC Acc to GRBS

Syp.LACTULOSE 10 ml PO BD

Syp.GRILLINCTUS 10 ml PO BD

Foleys Catheterisation 

 

Day-3

O/E:Pt is c/c/c

BP :100/70

PR :90bpm

Cvs: S1&S2 heard 

Rs: Bae present 

P/a : soft and non tender 

CNS: no abnormalities detected 

Grbs: 132mg/dl

Urea:104

Creatinine:2.4

Potasium:3.6

PLAN OF TREATMENT

KCl one ampoule in 10 ml NS over 4 hrs.

Inj.MONOCEF 1gm IV BD

Inj PANTOP 40 mg IV OD

Inj.ZOFER 4 mg IV SOS

Inj.NEOMOL 1 gm IV SOS

Tab.DOLO 650 mg PO TID

Tab.AMLONG 2.5 mg PO OD

Inj.HUMAN ACTRAPID SC Acc to GRBS

Syp.LACTULOSE 10 ml PO BD

Syp.GRILLINCTUS 10 ml PO BD

Tab Nodosis po/tid

Cap bio D3 po/O.D

Day-4

S- No fever spikes, Burning micturition +, cough+

O- Pt is C/C/C

      BP- 90/70mmhg

      PR- 96 bpm

      CVS- S1,S2 sounds heard

      RS- BAE+

      P/A- Soft, Non tender

      CNS- NO FND

      I/O-3300/1200

A- UTI WITH CHRONIC CYSTITIS with postrenal AKI 2° to stricture urethra. 

 K/C/O DM, HTN

P- 

1. IVF- NS and RL @ Urine output + 30 ml/hr

2.INJ. MONOCEF 1 gm I.V. BD

3.INJ. PAN 40 mg I.V. OD

4.INJ. NEOMOL 1 gm I.V. OD

5.TAB. DOLO 650 mg PO TID

6.SYP. GRILLINCTUS 10 ml PO BD

7.SYP. LACTULOSE 10 ml PO BD

8.INJ. ZOFER 4 mg I.V. SOS

9.INJ. NPH insulin S.C BD(12U)

10.INJ.HUMAN ACTRAPID S.C TID.(6U)

11.TAB. AMLONG 2.5 mg PO/OD

12.Inj.Lasix 40mg iv bd

13.Tab.Nodosis 500mg po bd

14.GRBS CHARTING 6th hourly

15.BP/PR/TEMPERATURE charting 4th hourly