80 year old male patient with fever and burning micturition and decreased urine output

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. 

A 80 year old male patient came to general medicine opd with complaints of 

1) fever since 10 days

 2) burning micturition since 8 days 

3) decreased urine output since 5 days which progressed to anuria since 1 day 

4) both lower limb swellings 

HOPI :- Patient was apparently normal 10 days back then he developed fever of continous type and was diagnosed with typhoid by a local doctor Then developed burning micturition 8 days ago and then had decreased urine output since 5 days which then progressed to anuria lasting on day, then they approached us He also developed swellings in both lower limbs extending upto ankles He also had cough and cold during these days. 5 days back he also sustained a distal left radial fracture on which cast was placed There is no associated flank pain, dribbling of urine and urine incontenance, breathlessness 

Past history : k/c/o hypertension since 5 years and diabetes mellitus since 4 years N/k/c/o of asthma, TB, epilepsy 

No previous surgeries were performed on him

 Personal history : diet -- mixed

 Appetite -- decresed

 Sleep -- disturbed

 Bowel-- normal 

Bladder -- decreased urine output and associated with burning sensation 

Addictions :- alchol --> regular intake almost 4 to 5 times a week Tobbaco- beedis one pack day ---> since 40 years---> 40 pack years 

Family History :- No similar complaints found in family 

Treatment history:-

 HTN -- AMLODIPONE + ATENOLOL

 DM -- GLIMEPERIDE + METFORMIN 

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

 Edema- b/l pedal edema extending upto to ankles And of pitting type

Systemic examination:- 

Cvs :- S1 and S2 are heard and no abnormal heart sounds were heard 

Repsiratory system :- BAE + , b/l basal crepitations 

Per abdomen:- slightely distended All quadrants equally move with repisration No scars, sinuses and hernial orifices No organomegaly Normal bowel sounds were heard

CNS :- Concious and agitated Eyes : right -- constricted left -- dilated Motor system Tone - normal Power --- normal able to move four limbs Reflexes :-

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 :

TREATMENT:- 

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 

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 

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 H

S 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 . 

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 

SYP. 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 

Reference :- investigations and treatment https://medhakesani.blogspot.com/2022/12/80yr-old-male.html?m=1