78yr old Male with fever, increased frequency of urination and burning micturation

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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 Fever since 4 days

       Increased frequency of urination and             burning micturation since 2days


Patient was apparently asymptomatic 4 days ago then he developed fever low grade  insidious in onset gradually progressive associated with chills with diurnal variation relieved on medication.

Increased frequency of urination since 2days associated with burning micturation.

H/O B/L pedal edema, decreased urine output 1 week back. They went to local hospital and their the problem was managed.

No H/O abdominal pain, nausea vomiting, constipation, chest pain, orthopnea, PND.


No similar complains in the past

Not a known case of DM,HTN,TH,CAD,CKD,CVA, Asthma,Epilepsy


Personal history

Diet is Mixed, Appetite is normal, Bladder and bowel are movements regular, 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,Edema- Absent 

Vitals-

Temperature afebrile

Respiratory rate 24cpm

Pulse rate 72bpm

Blood pressure 90/60mmHg

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, non tender, no organomegaly.


Investigations:

On 11/1/24


On 10/1/24





On 10/1/24


On 11/1/24







Provisional Diagnosis:

CAD with Heart failure with midrange ejection fraction.

Urosepsis with AKI on CKD

Anemia NCNC


Treatment:

INJ PIPTAZ 2.25MG IV/TID

TAB ECOSPORIN-AV 75/10 PO/OD

INJ HEPARIN 5000IU S/C TID

INJ PAN 40MG IV/OD

TAB DOLO 650MG PO/SOS

TAB NODOSIS 500MG PO/BD

INJ OPTINUERON 1AMP in 500ML NS IV/ID

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