80 Y/M with fever and burning micturation

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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

02-02-2022

A 80 year old male came to OPD with

CHEIF COMPLAINTS

Fever and chills since 11 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 11 days back since then he had fever which is insidious in onset, intermittent , high grade, with evening rise of temperature and associated with chills and rigors . Patient looks extremely lethargic, generalized weakness (patient is not able to carry out his daily routine and not able to sit or walk without attenders support, previously used to be active) and fever subsided on taking medication (paracetamol).

He has difficult while swallowing solid foods, able to drink liquids without any difficulty.

He has burning micturation since 1 week.

6 days ago they went to a local doctor where urine examination was done and said there is pus in the urine and treated him with antipyeretics and antibiotics.

He also has increased frequency of micturation and has dribbling of urine on straining and postvoidal residue since 6 days.

He also complains of being thirsty and feels dryness of tongue in spite of drinking water.

History of constipation since 5 days and he passed stool day before night after enema.

There is history of weight loss as noted by attenders.

Patient also complains of bilateral knee pain since 5 years and history of knee locking (suggestive of osteoarthritis).

No history of cough, body pains, shortness of breath, vomiting, diarrhea, shortness of breath.

PAST HISTORY:

No history of similar complaints in th past.

He is a known case of Hypertension and Diabetes since 5years and is on atenolol 50mg, Metformin 500mg and glipizide 5mg.

He is not a known case of asthma, epilepsy,CAD.

History of surgery done for benign prostatic hyperplasia (BPH).

PERSONAL HISTORY:

Daily routine:

He wakes up at 5am in the morning and gets freshened up and goes to get milk.He then drinks tea at 7am in the morning.Then he does few household chores like boiling water, cleaning the house.

Then at 9am he eats breakfast.

Then he takes rest for sometime and goes to a forest to get sticks and tie them together and make broomsticks.

Then at 2pm he eats his lunch and takes rest for sometime and goes out for a walk and then have dinner at 8pm.

He goes to bed by 9pm.

Diet-mixed

Appetite-decreased

Sleep adequate

Bladder movements-increased frequency.

Bowel movements- constipation since 6 days.

He drinks alcohol occasionally (90ml) and smokes daily 2to 3 beedi per day.

FAMILY HISTORY:

His 1st son died due to heart attack.

And his 2nd son died for liver failure secondary to shock

GENERAL EXAMINATION:

Patient is conscious non coherant cooperative

Moderately built and poorly nourished.

No pallor

Icterus is present

No cyanosis

No clubbing

No lymphadenopathy

No edema

Bilateral knee joint swelling(with flexion deformity)

VITALS:

BP: 130/80 mmHg

PR: 74 bpm

Temp : 98.6F

GRBS : 170mg/dl

SYSTEMIC EXAMINATION:

CENTRAL NERVOUS SYSTEM:

Conscious and non coherant

HIGHER MENTAL Functions Intact.

MMSE 24/30

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

3rd,4th,6th : pupillary reflexes present

EOM full range of motion present

5th : sensory intact

motor intact

7th : normal

8th : No abnormality noted.

9th,10th,11th,12th : normal.

MOTOR EXAMINATION:

SUPERFICIAL REFLEXES:

CORNEAL present

CONJUNCTIVAL present

DEEP TENDON REFLEXES:

Right Left

UL LL UL LL

BULK: Normal Normal Normal Normal

TONE : Normal Normal Normal normal

POWER : 4/5 4/5 4/5 4/5

DEEP TENDON REFLEXES:

Right left

BICEPS. 1 1

TRICEPS 2 2

SUPINATOR 1 2

KNEE 2 1

ANKLE 1 2

https://youtube.com/shorts/L9VKzyXRt_w?feature=share

https://youtube.com/shorts/3R5VfOPGimY?feature=share

https://youtube.com/shorts/MWi6csdneKI?feature=share

SENSORY EXAMINATION:

SPINOTHALAMIC SENSATION:

Crude touch Present

Pain Present

Temperature Present

DORSAL COLUMN SENSATION:

Fine touch Present

Vibration Present

Proprioception Present

CORTICAL SENSATION:

Two point discrimination Present

Tactile localisation Present

CEREBELLAR EXAMINATION:

Finger nose test able to perform

Heel knee test able to perform

https://youtu.be/6IUtiGy19K0

Dysdiadochokinesia Absent

Speech Normal

Rhombergs test Absent

SIGNS OF MENINGEAL IRRITATION:

Kernig's sign, brudzinski sign, neck rigidity

absent

RESPIRATORY SYSTEM:Bilateral air entry present,vesicular breath sounds heard, no adventitious sounds heard.

CARDIOVASCULAR SYSTEM:

S1 ans S2 geart sounds heard,no murmurs heard

ABDOMINAL EXAMINATION:

Soft and non tender,No organomegaly

PROVISIONAL DIAGNOSIS

UROSEPSIS(CUE -30-40pus cells,alb+)

With AKI(creat 1.7) - Resolved

Dyselectrolytemia (hypotonic hyponatremia improving with 0.9%NS Na 123 at presentation improved to 128,Hypokalemia 2.7 at presentation -after correction 2.9)

Acute liver injury

INVESTIGATIONS:

On 26-11-2022 :