59 K. Rithika Vasantha

A 52 YR OLD MALE WITH CHIEF COMPLAINTS OF PUS IN URINE AND FEVER

July 13 , 2021

Medical Case Discussion

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 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 inthe comment box are welcome

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan


A 52 yr old male patient who is a farmer by occupation

Presented to hospital on 14 June 2021 with  Chief Complaints of  

Fever since 4 days

 Pus in the Urine

History of presenting illness

Patient was apparently asymptomatic 5years back, On routine investigations diagnosed with type 2 diabetes and on treatment Tab GLIMI M1 and goes for regular check up.

 1 year back, he gradually developed drippling of urine, Hesitation, reduced flow of urine, Difficulty in void initially not associated with suprapubic pain or burning micturition

But,since 3 months patient had burning micturition not associated with fever or suprapubic pain then he consulted a urologist, where he was told , He had Prostomegaly (60gm) and advised TURP preoperative patient sugars were high and serum creatinine 2.2mg/dl and serum bilirubin 2.8mg/dl Before preoperative patient had fever associated with chills and rigor and yellowish discolouration of eyes, treated accordingly ( given iv antibiotics)

underwent TURP on 24th March 2021

Patient had 1 episode of fever after 2 days of surgery .  On 27 th March 2021, his serum creatinine was 7.2mg/dl  and on 

29th March 2021  it was 6.2 mg/dl and on 6thApril it was 4mg/dl and serum bilirubin was 1.7mg/dl

Few days after his surgery, He presented to the hospital on 14th April 2021 with decreased Appetite and Generalised weakness  and he was treated and discharged (1st admission in hospital)

Again he  presented to the hospital with drowsiness on  27 April 2021  and excessive sleep that attenders felt difficult to wake him up from sleep and attenders were regularly monitoring his BP , which was found to be fluctuating and patient was brought to the hospital and was found with Hyponatremia, After correction patient improved symptomatically within 2 days  and also his creatinine levels were elevated upto 5.2mg/dl , was  given treatment and it was decreased to 3mg/dl when he got discharged (2nd admission )

 He presented to the hospital on 17May 2021 with SOB since 4 days which is on exertion , High grade Fever since 2 days associated with chills and rigor , burning micturition since 4 days ( 3rd admission)

And there was raised creatinine levels upto 10mg/dl

There is a history of fleshy mass like  and foamy passage in his urine 6 days back (as said by patient's attender)       





He presented to the hospital on june 14th 2021 with complaints of High grade fever and pus in the Urine ( 4th Admission )

Past History

He is a known case of Diabetes since 5 years, previously took oral hypoglycemics and now he's taking insulin.

No history of HTN, Asthma, Tuberculosis, Epilepsy, CVDs

H/o Transurethral Resection of Prostrate


Personal history

Diet - mixed diet

Appetite - decreased

Sleep - adequate

Bowel - regular

Bladder - Increased frequency

Addictions - occasional Alcohol consumption

Allergies - No known allergies


Family History

 Not significant


General Examination

The patient was conscious,coherent and cooperative
He is well oriented to time place and person

He is moderately built and moderately nourished

Vitals

Temperature - Afebrile
Pulse - 88beats per min, regular, normal in volume and character, there is no radioradial and radiofemoral delay
BP - 100/70mmHg
Respiratory rate -14 cycles per minute
JVP - Normal

No pallor 
No icterus
No Clubbing
No Lymphadenopathy
No Edema

Systemic Examination

Abdominal Examination 

 Soft and obese
non tender
 
Respiratory system

Elliptical and bilaterally symmetrical chest
Both sides moving equal with respiration
B/L air entry present
Normal vesicular breath sounds

Cvs Examination

S1 and S2 heard
No murmurs


COURSE IN THE HOSPITAL

DAY 1

C/O FEVER - 1 EPISODE LAST NIGHT
PUS IN THE URINE
TREATMENT GIVEN:
1.SALT AND FLUID RESTRICTION
2. INJ. HAI 16U S/C TID
3. TAB. PCM 650 MG PO/BD

DAY 2

C/O FEVER
SAME TREATMENT FOLLOWED
TAB. NITROFURANTOIN 100MG BD ADDED

DAY 3

C/O FEVER
SAME TREATMENT FOLLOWED
INJ. ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
TAB ULTRACET 1/2 TAB QID ADDED

DAY 4

SUBJECTIVELY FEELING BETTER
SAME TREATMENT FOLLOWED

DAY 5

SAME TREATMENT FOLLOWED

DAY 6

SAME TREATMENT FOLLOWED

DAY 7

C/O LOW GRADE FEVER
SAME TREATMENT FOLLOWED

DAY 8

C/O LOW GRADE FEVER
COUGH DECREASED
SAME TREATMENT FOLLOWED

DAY 9 

C/O SWEATING AT NIGHT
FEVER+
SAME TREATMENT FOLLOWED

DAY 10,12,13

SUBJECTIVELY FEELING BETTER
SAME TREATMENT FOLLOWED
6TH SESSION OF DIALYSIS WAS DONEON 26TH JUNE (DAY 11) 

DAY 14

SAME TREATMENT FOLLOWED EXCEPT SYP. ASCORYL-LS
SYP. DEXTROMETHORPHAN 5ML/TID
NEBULIZATION WITH IPRAVENT, BUDECORT 12TH HOURLY ADDED

DAY 15

SAME TREATMENT FOLLOWED EXCEPT SYP. DEXTROMETHORPHAN
INJ PAN 40MG/IV/OD ADDED

DAY 16

SAME TREATMENT FOLLOWED
7TH SESSION OF DIALYSIS DONE

DAY 17

SAME TREATMENT FOLLOWED

DAY 18

C/O LOW GRADE FEVER
SAME TREATMENT FOLLOWED
INJ ERYTHROPOIETIN 4000IU WEEKLY TWICE
INJ LASIX 40MG IV/BD ADDED

DAY 19

SAME TREATMENT FOLLOWED
TAB MVT PO/OD ADDED
8TH SESSION OF DIALYSIS DONE

DAY 20

SAME TREATMENT FOLLOWED

DAY 21

C/O LOW GRADE FEVER
C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED EXCEPT TAB NITROFURANTOIN

DAY 22

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED

DAY 23

C/O LOW GRADE FEVER
C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED
TAB BENADION PO/OD
TAB PREGABALIN 75 MG/HS ON ALTERNATE DAYS ADDED

DAY 24

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED

DAY 25

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED EXCEPT TAB MVT
INJ OPTINEURON IM/OD
TAB EVION 400MG/PO/OD
TAB NEUROBION FORTE/PO/OD
TAB VIT C (LIMCEE) PO/OD

DAY 26

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED
9TH SESSION OF DIALYSIS DONE

DAY 27

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED
ATT PO/OD ADDED

DAY 28

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED EXCEPT ATT AND TAB BENADION
TAB RAMIPRIL 2.5 MG PO/OD
INJ MONOCEF 1G/IV/BD ADDED

DAY 29

C/O B/L PEDAL EDEMA
SAME TREATMENT FOLLOWED


    INVESTIGATIONS 

14th June 2021

       RBS - 98
       Creatinine - 3.8 mg/dl
       Urea - 70mg/dl









                          17 JUNE 2021



       

              21 JUNE 2021








                    25 JUNE 2021




                  28 JUNE 2021











                                                       29 JUNE 2021







30th June









1st July








2nd July


3rd July



4th July




5th July


6th July



7th July




8th July




9th July


Hemogram




Complete Urine Examination

11th July





12th July 





14th July























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