75yr old male with fever,pain abdomen,burning micturition.

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  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 inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment



C/O Burning micturition since 10days,Fever since 5days, pain abdomen since 3days.


Pt was apparently asymptomatic 10days back then he developed burning micturition insidious in onset gradually progressive a/w increased frequency.

Then he developed fever since 5 days low grade a/w chills gradually progressive no aggravating and relieving factors. 

Then he developed pain abdomen since 3 days burning type insidious in onset non radiating no aggravating and relieving factors.

No H/O cough, breathlessness, orthopnea, chest pain, PND

No H/O DM, HTN, TB, CAD, CVA, CKD, Epilepsy.


Urology referral was done and adviced 

PIPTAZ 2.25GM IV/BD

LIMIT WATER INTAKE 

SYP ALKASTONE B6 

TAB TAMSULOSIN 0.4MG PO/HS

SYP CREMAFFIN 15ML H/S


Personal history

Diet is Mixed, Appetite is normal, Sleep is adequate. No Allergies, No Addictions.

General examination:







Patient is conscious coherent and cooperative well oriented to time place and person. He's moderately built and nourished.

Pallor, Icterus, Cubbing, Cyanosis, Lymphadenopathy- Absent 


Vitals-

Temperature 103F

Respiratory rate 17cpm

Pulse rate 72bpm

Blood pressure 120/60mmHg

Spo2 95%


Systemic examination:

CVS- S1 S2 heard, No added murmurs.

RS- BAE+, Normal vesicular breath sounds

CNS - No focal neurological deficit.

P/A-Soft, no organomegaly.


Investigations:

On Admission-




















Serology- NEGATIVE 


On Day 4








ECG







Provisional Diagnosis:

UROSEPSIS 

AKI-PRE RENAL (RESOLVED)

DENOVO DM2

WITH B/L RENAL CALCULUS 

BPH


Treatment:

IVF NS,RL @50ML/HR

INJ PIPTAZ 2.25GM IV/BD

INJ MEROPENAM 1GM IV/BD 

INJ PAN 40MG IV/BD

INJ HAI SC/TID 

INJ NPH SC/BD

INJ OPTINEURON 1AMP 100ML NS/IV/OD

INJ NEOMOL 1GM IV/SOS

TAB DOLO 650MG PO/TID

TAB TAMSULOSIN 0.4MG PO/HS

SYP ALKASTONE B6 15ML IN 1/2 GLASS OF WATER PO/BD

SYP CREMAFFIN PO/HS

NEB WITH BUDECORT + IPRAVENT 6TH HRLY 


Day 1





Day 2





Day 3





Day 4






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