60 year old male with high grade fever

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


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


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