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56 YR OLD MALE WITH COMPLAINTS OF BURNING MICTURITION AND BACKACHE
A 56 year old male farmer by occupation came to the OPD with the complaints of:
- high grade fever since 3 days
- burning micturition since 3 days
- lower backache since 3 days
Patient was apparently asymptomatic 3 days back after which he developed high grade fever with chills associates with burning micturition, decreased urine output, history of vomiting with food and bile as content since 3 days- 2 episodes yesterday. Complains of SOB since 3 days.
No complaints of cough, loose stools, rashes, body pains, pedal edema.
PAST HISTORY
4 years ago, patient had history of fever, burning micturition for which he was admitted in KIMS. He was diagnosed with DM, underwent dialysis once and discharged thereafter. (?AKI)
Patient was diagnosed with DM 4 years back, on Inj. Human Actrapid (15 U --- x --- 12 U)
Was informed to have a renal problem. Not on any medication.
Not a Hypertensive
No smoking history. Patient used to occasionally consume alcohol which he stopped in 2019 before he underwent dialysis
VITALS
PR- 90 bpm
BP- 120/80 mmHg
RR- 35 cpm
Spo2- 98% at RA
GRBS- 180 mg%
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
No signs of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy or Edema.
SYSTEMIC EXAMINATION
CVS: S1 S2 heard, no murmurs/thrills
RS: BAE+, NVBS heard
PA: Soft, non tender. Liver and Spleen not palpable. Bowel sounds heard.
CNS: NFND
PROVISIONAL DIAGNOSIS
1. UTI
2. AKI on? CKD
3. Thrombocytopenia
INVESTIGATIONS
Outside Reports:
Serum Creatinine- 3.6
Platelet count- 4,7000
Hb- 14 mg/dl
CUE- 8-10 pus cells
2/12/21
Hb- 14.4 mg/dl
TLC- 7390
PLT- 25,000
Hct- 42.3
BGT- O Positive
pH- 7.34
pCO2- 24.4
pO2- 74.8
HCO3- 13.1
RBS- 99 mg/dl
DENGUE- NEGATIVE
Serum Urea- 94
Serum Creatinine- 3.1
Serum Uric Acid- 7.1
Na- 141
K- 4.2
Cl- 102
Total Bilirubin- 4.44
Direct Bilirubin- 2.24
AST- 52
ALT- 22
ALP- 103
TP- 5.5
ALB- 3.3
A/G- 1.61
USG ABDOMEN
ECG
XRAY CHEST
DIFFERENTIAL DIAGNOSIS
1. UTI
2. THROMBOCYTOPENIA
3. AKI on? CKD
TREATMENT
1. IVF 2 NS, 2 RL @ 75 ml/hr
2. Inj. PANTOP 40 mg IV OD
3. Inj. ZOFER 4 mg IV BD
4. Syp. Citralka 10 ml in 1 glass of water PO BD
5. Inj. Human Actrapid SC TID
6. Tab. Dolo 650 mg PO TID
7. Inj. Neomol 1 gm IV SOS if Temp > 101 F
SOAP NOTES
Date: 04/12/21
AMC 56/M
SOAP notes
S:
Fever spike @5 pm; C/o nausea; abdominal distension+
O:
Pt c/c/c
BP- 120/80 mmHg
PR- 76 bpm
RR- 20/min
Spo2- 98% @ RA
CVS - S1 S2 +
R/S - BAE +, NVBS
A:
AKI on CKD 2° to UTI (?complicated)
Sepsis with thrombocytopenia 2° to UTI
DM +
Rt mild Hydroureteronephrosis
Cholelithiasis
P:
1. IVF NS, RL @ U/O + 30ml/hr slow IV
2.Inj.CIPROFLOXACIN 500 mg IV BD
3.Inj.PANTOP 40 mg IV OD
4.Inj.ZOFER 4 mg IV OD
5.Inj.HAI S/C acc to grbs
6.Inj.NEOMOL 1g IV SOS (if temp >101°F)
7.T.DOLO 650 mg PO SOS
8.Syp.ARISTROZYME 10ml PO BD
9.Syp.SUCRALFATE 10ml PO BD
10.Inj.METACLOPRAMIDE 1amp IV BD
11.Syp.CITRALKA 10ml PO BD
12.T.TAMSULOSIN 0.4mg PO HS
13.T.UTIFYTE 1tab PO TID
14.Inj.THIAMINE 100mg in 100ml NS IV OD
15.Temp/BP/PR monitoring 4th hrly
Grbs monitoring 6th hrly
Strict I/o charting, w/f bleeding manifestations
Date: 05/12/21
AMC 56/M
SOAP notes
S:
Fever spike @4am a/w chills
C/o back pain
O:
Pt c/c/c
BP- 120/70 mmHg
PR- 78 bpm
RR- 22/min
Spo2- 98% @ RA
CVS - S1 S2 +
R/S - BAE +, NVBS
A:
AKI on CKD 2° to UTI (?complicated)
Sepsis with thrombocytopenia 2° to UTI
DM +
Rt mild Hydroureteronephrosis
Cholelithiasis
P:
1. IVF NS, RL @ U/O + 30ml/hr slow IV
2.Inj.CIPROFLOXACIN 500 mg IV BD
3.Inj.PANTOP 40 mg IV OD
4.Inj.ZOFER 4 mg IV OD
5.Inj.HAI S/C acc to grbs
6.Inj.NEOMOL 1g IV SOS (if temp >101°F)
7.T.DOLO 650 mg PO SOS
8.Syp.ARISTROZYME 10ml PO BD
9.Syp.SUCRALFATE 10ml PO BD
10.Inj.METACLOPRAMIDE 1amp IV BD
11.Syp.CITRALKA 10ml PO BD
12.T.TAMSULOSIN 0.4mg PO HS
13.T.UTIFYTE 1tab PO TID
14.Inj.THIAMINE 100mg in 100ml NS IV OD
15.Temp/BP/PR monitoring 4th hrly
Grbs monitoring 6th hrly
Strict I/o charting, w/f bleeding manifestations
Date: 06/12/21
AMC 56/M
SOAP notes
S:
No fresh complaints
O:
Pt c/c/c
BP- 120/80 mmHg
PR- 81 bpm
RR- 18/min
Spo2- 98% @ RA
CVS - S1 S2 +
R/S - BAE +, NVBS
A:
AKI on CKD 2° to UTI (?complicated)
Sepsis with thrombocytopenia 2° to UTI
DM +
Rt mild Hydroureteronephrosis
Cholelithiasis
P:
1. IVF NS, RL @ U/O + 30ml/hr slow IV
2.Inj.CIPROFLOXACIN 500 mg IV BD
3.Inj.PANTOP 40 mg IV OD
4.Inj.ZOFER 4 mg IV OD
5.Inj.HAI S/C acc to grbs
6.Inj.NEOMOL 1g IV SOS (if temp >101°F)
7.T.DOLO 650 mg PO SOS
8.Syp.ARISTROZYME 10ml PO BD
9.Syp.SUCRALFATE 10ml PO BD
10.Syp.CITRALKA 10ml PO BD
12.T.TAMSULOSIN 0.4mg PO HS
13.T.UTIFYTE 1tab PO TID
14.Temp/BP/PR monitoring 4th hrly
Grbs monitoring 6th hrly
Strict I/o charting, w/f bleeding manifestations.
Date: 07/12/21
AMC 56/M
SOAP notes
S:
C/o decreased appetite and burning micturition
O:
Pt c/c/c
BP- 110/70 mmHg
PR- 72 bpm
RR- 21/min
Spo2- 98% @ RA
CVS - S1 S2 +
R/S - BAE +, NVBS
A:
AKI on CKD 2° to UTI (?complicated)
Sepsis with thrombocytopenia 2° to UTI
DM + since 4 years
Rt mild Hydroureteronephrosis, Cholelithiasis
P:
1. Collect Hemogram report
2. IVF NS, RL @ U/O + 30ml/hr slow IV
3. Inj.CIPROFLOXACIN 500 mg IV BD
4.Inj.PANTOP 40 mg IV OD
5.Inj.ZOFER 4 mg IV SOS
6Inj.HAI S/C acc to grbs
7.Inj.NEOMOL 1g IV SOS (if temp >101°F)
8.T.DOLO 650 mg PO SOS
9.Syp.SUCRALFATE 10ml PO BD
10. Syp.CITRALKA 10ml PO BD
11.Inj.THIAMINE 100mg in 100ml NS IV OD
12. SYP. CREMAFFIN BD
13. Temp/BP/PR monitoring 4th hrly
Grbs monitoring 6th hrly
Strict I/o charting, w/f bleeding manifestations
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