80 year old male with fever and burning micturition

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Name: G Sai Manogna

Roll no: 41

I've 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 a diagnosis and treatment plan.

CASE PRESENTATION:

A 80 year old male patient with the chief complaints of

• Fever since 20 days
• Weakness of both lower limbs since 15 days
• Pain in right lower quadrant of abdomen since 10 days
• Decreased urine output since 5 days
• Burning sensation while passing urine since 5 days

History of presenting illness

Patient was apparently asymptomatic 20 days ago, then he developed fever since 20 days which is high grade, associated with chills and rigors, no diurnal variation, relieved with medication. He visited the local RMP for the same and got a CUE done and and was told by the RMP that he had urine infection. He had weakness of both lower limbs since 15 days( unable to stand and walk on his own ). Then he had pain abdomen in the right lower quadrant of abdomen and in the lower back which had no aggravating and relieving factors.

He also had decreased urine output and burning sensation while passing urine since 5 days

Shortness of breath present (on and off)

No h/o chest pain

No h/o headache

Past history

Patient is a k/c/o asthma and is not on medication

K/c/o hypertension since 10 years and is on amlodipine 5 mg once daily

H/o renal calculi 10 years back

K/c/o BPH 10 years back

Hospital admission for 15 days for decreased urine output and abdominal distension 10 years back. Was told that creatinine was raised. Underwent treatment for 6 months

Decreased hearing since 6 months

Urinary incontinence since 5 years

known case of hepatitis since 10 years

Not a k/c/o HTN, TB, asthma, epilepsy

Personal history

Diet- Mixed

Appetite- Decreased

Sleep- Disturbed

Bowel movements- Constipation since 5 days

Bladder movements- Decreased urine output and burning micturition since 5 days

Addictions- Consumes alcohol occasionally

On Examination

Patient is conscious, coherent, cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals

Temperature- 99.6 F

PR- 80 bpm

RR- 16 cpm

BP- 110/70 mmHg

SPO2- 98%

GRBS- 106 mg%

On systemic examination:

CVS- S1, S2 +

RS- BAE present

P/A- Soft, Nontender

CNS- 

1. Higher mental functions intact

Patient is conscious

oriented to time, place and person

dysarthria( difficult or unclear articulation of speech)

Memory- Immediate, recent, remote- Intact

No delusions, hallucinations

No emotional lability ( exaggarated changes in mood)

2. Cranial nerves         Right                    Left

a. Sense of smell             +                         +

b. Field of vision             N                        N

(Confrontational test)

    Colour vision               N                        N

(Ischiara test)

c. Direct light reflex         P                         P

   Consensual light reflex P                         P

   Accomodation reflex     P                         P

   Ptosis                             A                         A

   Nystagmus                     A                         A

d. Corneal reflex               P                          P

Conjunctival reflex           P                          P

e. Taste- 

Anterior 2/3 of tongue      N                          N

f. Vestibulo cochlear- Hearing aid was advised

g. No deviation of uvula

Gag reflex present

Motor System

Tone                            Right                    Left

 1. Upper limb               N                          N

 2. Lower limb               N                          N

Power                          Right                     Left

 1. Upper limb                N                          N

 2. Lower limb                N                          N

Reflexes

 1. Biceps                       +++                     +++

 2. Triceps                      +++                     +++

 3. Supinator                     +                          +

 4. Knee                            +                           -

 5. Ankle                           +                           -

Investigations:

(7/10/22)

CBP

1. Hb- 12.4 gm/dL

2. TC- 6300

3. PLT- 3.4 

RBS- 113 mg/dL

USG (Abdomen)

Chest Xray

RFT

1. Urea- 46

2. Creatinine- 2

3. Uric acid- 4.7

4. Sodium- 135

5. Potassium- 3.6

6. Chloride- 101

HBsAg- Positive

Anti HCV antibodies- Non reactive

HIV rapid test- Non reactive

8/10/22

1. 2D echo

2. LFT

TB- 0.99

DB- 0.26

SGOT-20

SGPT-18

ALP- 132

TP-5.9

3. Urinary electrolytes

Na+- 180

K+ - 27.7

Cl- 177

4. Urine protein/Creatinine ratio

Spot urine protein-81.8

Spot urine creatinine- 120

Ratio- 0.68

5. CUE

Colour- reddish

Appearance-cloudy

Pus cells- 25 to 30

RBC- 30 to 40

6. ABG

pH 7.474

pCO2-29.6

pO2-61.5

HCoO3- 23.8

7. Review USG

8. ECG

9. RFT

Blood urea- 44

Creatinine- 1.7

Na+ 137

K+ 3.9

Cl- 99

9/10/22

1. Hemogram

Hb 11.6

TLC- 7100

PCV 35.2

RBC 4.0

Plt 2.0

2. RFT

Blood urea- 39

Creatinine- 2 46

Na+ 138

K+ 3.3

Cl- 99

3. CUE

Colour-pale yellow

Appearance-clear

Pus cells- 5 to 6

RBC Nil

10/10/22

1. Hemogram

Hb 11.4

TC 5900

PCV 34.2

RBC 3.88

PLT 2.03

2. RFT

Blood urea 37

serum creatinine 1.5

Na+ 141

K+ 3.0

Cl 98

4. Urine culture and sensitivity

5. Blood culture and sensitivity

6. PLBS

7. HBA1C

11/10/22

1. Hemogram

Hb 12

TC 8500

PCV 36.4

RBC 4.15

PLT 2.6

2. RFT

Blood urea 27

Serum creatinine 1.2

Na+ 139

K+ 3.6

Cl 98

3. FBS 97

4. 24 hr urinary protein 258

5. 24 hr urinary creatinine 1900

12/10/22

1. CBP

Hb 11.9

TLC 9600

PLT 2.85

2. Blood urea 32

3. Serum creatinine 1.3

4. Serum electrolytes and serum calcium ionized

Na+ 134

K+ 4.1

Cl 104

5. NCCT KUB

Xray

14/10/22

1. Hemogram

Hb 12.3

TLC 8400

PLT 3.20

2. Blood urea 29

3. Serum creatinine 1.4

4. Serum electrolytes and serum ionized calcium

Na+ 131

K+ 3.9

Cl 101

5. Chest xray

6. ABG

pH 7.46

pCO2 23.6

pO2 41.8

HCO3 17

15/10/22

1. Hemogram

Hb 12.0

TLC 9100

PLT 2.92

2. RFT

Blood urea 27

Serum creatinine 1.2

Na+ 136

K+ 4.0

Cl 97

3. MRI

16/10/22

1. Hemogram

Hb 11.8

TLC 13700

PCV 34.8

2. RFT

Blood urea 36

Serum creatinine 1.1

Na+ 136

K+ 3.5

Cl 102

17/10/22

1. Hemogram

Hb 12.3

TLC 9600

Plt 3.30

2. RFT

Blood urea 43

Serum creatinine 1.7

Temperature charting

SOAP Notes :

AMC BED 1

Day 3 (9-10-22)

S :  Fever spikes present

      Pain in groin while walking

      Passed stools

O : 

Patient is conscious, coherent and co-operative

Temp : 99.1 F

BP : 110/60 mmHg

PR : 80 BPM

RR : 16 CPM

SpO2 : 98%

GRBS : 98 mg/dl

A : URINARY TRACT INFECTION WITH ACUTE KIDNEY INJURY 

P : 

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. ZOFER 4 MG/IV/SOS

5. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

6. SYP. CREMAFFIN 10 ML/PO/HS

7. T. AMLONG 5 MG/PO/OD

8. STRICT I/O CHARTING

9. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

AMC BED 1

Day 4 (10-10-22)

S : Pain in right loin

O : 

Patient is conscious, coherent and co-operative

BP : 130/80 mmHg

PR : 80 BPM

RR : 25 CPM

Temp : 96 F

SpO2 : 95%

GRBS : 92 mg/dl

A : COMPLICATED URINARY TRACT INFECTION WITH ACUTE KIDNEY INJURY 

P : 

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. PAN 40 MG/IV/OD

5. INJ. ZOFER 4 MG/IV/SOS

6. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

7. SYP. CREMAFFIN 10 ML/PO/HS

8. T. AMLONG 5 MG/PO/OD

9. IV FLUIDS NS @ 75 ML/HR

10. STRICT I/O CHARTING

11. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

MEDICAL WARD

Day 5 (11-10-22)

S : Pain in right loin

O : 

Patient is conscious, coherent and co-operative

BP : 130/80 mmHg

PR : 82 BPM

RR : 18 CPM

Temp : 96 F

SpO2 : 97%

GRBS : 105 mg/dl

A : COMPLICATED URINARY TRACT INFECTION WITH ACUTE KIDNEY INJURY 

P : 

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. PAN 40 MG/IV/OD

5. INJ. ZOFER 4 MG/IV/SOS

6. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

7. SYP. CREMAFFIN 10 ML/PO/HS

8. T. AMLONG 5 MG/PO/OD

9. T. RENERVE - P PO/HS

10. IV FLUIDS NS @ 75 ML/HR

11. STRICT I/O CHARTING

12. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

MEDICAL WARD

 (12-10-22)

S : Pain in right loin

O : 

Patient is conscious, coherent and co-operative

BP : 140/90 mmHg

PR : 90 BPM

RR : 18 CPM

Temp : 96 F

SpO2 : 97%

GRBS : 105 mg/dl

A : COMPLICATED URINARY TRACT INFECTION WITH ACUTE KIDNEY INJURY 

P : 

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. PAN 40 MG/IV/OD

5. INJ. ZOFER 4 MG/IV/SOS

6. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

7. SYP. CREMAFFIN 10 ML/PO/HS

8. T. AMLONG 5 MG/PO/OD

9. T. RENERVE - P PO/HS

10. IV FLUIDS NS @ 75 ML/HR

11. INJ. THIAMINE/IV/OD

12. STRICT I/O CHARTING

13. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

MEDICAL WARD

(13-10-22)

S : Pain in right loin

O : 

Patient is conscious, coherent and co-operative

BP : 130/90 mmHg

PR : 82 BPM

RR : 18 CPM

Temp : 96 F

SpO2 : 97%

GRBS : 105 mg/dl

A : COMPLICATED URINARY TRACT INFECTION WITH ACUTE KIDNEY INJURY 

P : 

1. Tab. Rantac 150mg IV/OD

2. T.TAXIM 200 mg PO BD

3. T. DOLO 650 mg/PO/TID

4. T. URIMAX-D 0.4/0.5 mg/ PO/H/S

5. T. AMLONG 5mg PO/OD

6. T. ULTRACET/PO/BD

7. T. RENERVE- P PO/TID

8. Syp. CREMAFFIN/5 ml/ PO/ HS

Medical ward (14/10/22)

S

Pain in the right loin

O

Patient is conscious, coherent, cooperative

BP- 140/90 mmHg

PR- 100 bpm

RR- 28 cpm

Spo2- 89%

Temp- 100 F

CVS- S1, S2 +

A

Complicated UTI with  resolved acute kidney injury ? Lumbar spondylosis

HTN + Infective spondylodiscitis @ D8-D9 level with anterior prevertebral collection

Epidural collection causing cord compression

P

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. PAN 40 MG/IV/OD

5. INJ. ZOFER 4 MG/IV/SOS

6. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

7. SYP. CREMAFFIN 10 ML/PO/HS

8. T. AMLONG 5 MG/PO/OD

9. T. RENERVE - P PO/HS

10. IV FLUIDS NS @ 75 ML/HR

11. INJ. THIAMINE/IV/OD

12. T. TAXIM 200MG/PO/BD

13. STRICT I/O CHARTING

14. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

Medical ward (15/10/22)

S

Pain in the right loin

Difficulty in walking

cough (on and off)

O

Patient is conscious, coherent, cooperative

BP- 130/90 mmHg

PR- 82 bpm

RR- 28 cpm

Spo2- 89%

Temp- 100 F

CVS- S1, S2 +

A

Complicated UTI with  resolved acute kidney injury ? Lumbar spondylosis

P

1. INJ. PIPTAZ 2.25 G/IV/TID

2. T. URIMAX-D 0.4/0.5 MG/PO/OD

3. T. DOLO 650 MG/PO/TID

4. INJ. PAN 40 MG/IV/OD

5. INJ. ZOFER 4 MG/IV/SOS

6. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

7. SYP. CREMAFFIN 10 ML/PO/HS

8. T. AMLONG 5 MG/PO/OD

9. T. RENERVE - P PO/HS

10. IV FLUIDS NS @ 75 ML/HR

11. INJ. THIAMINE/IV/OD

12. T. TAXIM 200MG/PO/BD

13. STRICT I/O CHARTING

14. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

Medical ward (16/10/22)

S

Pain in the right loin

Difficulty in walking

cough (on and off)

O

Patient is conscious, coherent, cooperative

BP- 140/90 mmHg

PR- 100 bpm

RR- 28 cpm

Spo2- 89%

Temp- 100 F

CVS- S1, S2 +

A

Complicated UTI with  resolved acute kidney injury ? Lumbar spondylosis

P

1. T. URIMAX-D 0.4/0.5 MG/PO/OD

2. T. DOLO 650 MG/PO/TID

3. INJ. PAN 40 MG/IV/OD

4. INJ. ZOFER 4 MG/IV/SOS

5. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

6. SYP. CREMAFFIN 10 ML/PO/HS

7. T. AMLONG 5 MG/PO/OD

8. T. RENERVE - P PO/HS

9. IV FLUIDS NS @ 75 ML/HR

10. INJ. THIAMINE/IV/OD

11. T. TAXIM 200MG/PO/BD

12. STRICT I/O CHARTING

13. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

Medical ward (17/10/22)

S

Pain in the right loin

Difficulty in walking

cough (on and off)

O

Patient is conscious, coherent, cooperative

BP- 140/90 mmHg

PR- 100 bpm

RR- 28 cpm

Spo2- 89%

Temp- 100 F

CVS- S1, S2 +

A

Complicated UTI with  resolved acute kidney injury ? Lumbar spondylosis

P

1. T. URIMAX-D 0.4/0.5 MG/PO/OD

2. T. DOLO 650 MG/PO/TID

3. INJ. PAN 40 MG/IV/OD

4. INJ. ZOFER 4 MG/IV/SOS

5. INJ. NEOMOL 1 G/IV/SOS (IF TEMP. >101 F)

6. SYP. CREMAFFIN 10 ML/PO/HS

7. T. AMLONG 5 MG/PO/OD

8. T. RENERVE - P PO/HS

9. IV FLUIDS NS @ 75 ML/HR

10. INJ. THIAMINE/IV/OD

11. T. TAXIM 200MG/PO/BD

12. STRICT I/O CHARTING

13. MONITOR VITALS (BP AND TEMP. EVERY 4TH HOURLY)

Medical ward (18/10/22)

S

Pain in the right loin

O

Patient is conscious, coherent, cooperative

BP- 140/90 mmHg

PR- 100 bpm

RR- 28 cpm

Spo2- 89%

Temp- 100 F

CVS- S1, S2 +

A

Complicated UTI with  resolved acute kidney injury ? Lumbar spondylosis

HTN + Infective spondylodiscitis @ D8-D9 level with anterior prevertebral collection

Epidural collection causing cord compression

P

1. Tab. Rantac 150mg IV/OD

2. T.TAXIM 200 mg PO BD

3. T. DOLO 650 mg/PO/TID

4. T. URIMAX-D 0.4/0.5 mg/ PO/H/S

5. T. AMLONG 5mg PO/OD

6. T. ULTRACET/PO/BD

7. T. RENERVE- P PO/TID

8. Syp. CREMAFFIN/5 ml/ PO/ HS