80 year old Male with chief complaints of burning micturition, pain abdomen and SOB

80yr old male came to the OPD with chief complaints of:

Fever since 10days

Burning micturition since 1day

Decrease urine output since 1day

Pain in left loin region since 1day

Shortness of breath

HOPI:

Patient was apparently asymptomatic 10days back then he developed fever which is high grade , intermittent which is not associated with cold/cough/chills and rigors which subsided on taking medication.

Later he developed burning micturition, pain abdomen ( left loin region) which is non radiating and dragging and decreased urine output with dark yellow coloured urine since 1day.

He had a sudden episode of diminished mentation associated with spontaneous micturition yesterday

PAST HISTORY:-

K/c/o hypertension since 1 year

N/k/c/o DM, TB, Asthma, Thyroid disorder, Epilepsy.

H/o kidney infection 4 years back which relieved on treatment (similar  loin pain- may be pyelonephritis - complained hematuria and burning micturition)

H/o trauma to Right Lower end of tibia- fracture, malunion

FAMILY HISTORY:

Not significant 

PERSONAL HISTORY:

Diet        -  Mixed

Appetite -  decreased from the onset of fever

B&B      -  Regular ( not passed yesterday)

Sleep     -    Adequate 

Addiction - Smoking- 10 beedi/ day,Alcohol - once in a week


GENERAL EXAMINATION:-

Patient is in altered sensorium i.e, drowsy but arousable

No ?, icterus, cyanosis, clubbing , lymphadenopathy, pedal edema

Mild pallor

Pt was tachypneic on observation 

GCS Score- E2 V2 M5













VITALS:-




BP - 120/90mmHg

PR - 98bpm     

Temp- 99F

RR - 18cpm

SpO2 - 99%

GRBS - 116mg/dL

On 10/10/2022 

PR- 119bpm

SpO2 - 99%






SYSTEMIC EXAMINATION:-

CVS - S1,S2 heard , no murmurs 

P/A  - Soft, Non tender, bowel sounds +

RESPIRATORY SYSTEM:

Inspection:

Shape of chest - barrel shaped

Asymmetric chest - slight bulging on right side compared to flat on left side

Apex beat - Not visible 

Dipping of sternum (lower part)

No scars

No pulsations


Palpation:-

Chest movements equal on both sides 

Tracheal postion- central

Vocal fremitus- patient is not cooperative 

Apex beat - felt


Percussion:-

Dull on left 4th,5th intercoastal space compared to right side

Auscultation:-

Decreased air entry on left side


Provisional diagnosis:-

Septic encephalopathy- (pyelonephritis/lung infection)?

Metabolic encephalopathy d/t Hyponatremia( Na+ - 129)?

Anemia of chronic disease- hyptn/copd

INVESTIGATIONS:













TREATMENT

9/10/2022

IVF- 3% NS infusion @ 10mL/min

Inj.Meropenem 500mg/IV/BD

Inj.PAN 40mg/iv/OD

Inj.Tramadol 1amp in 100mL NS/iv/OD

Inj.Neomol 1gm/iv/sos if Temp>101F

Tab. Dolo 650mg/PO/TID ( after checking temp)

Vital monitoring 2hrly and temp charting 4hrly

GRBS 6th hrly

Ryles tube insertion

Foleys catheterisation

I/O monitoring



 

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