45 yr old male with urosepsis

 

A 45 yr old male patient resident of Cherlapally , Farmer by occupation came to the OPD with Chief complaints of Fever since 2 days and slurring of speech since 1 day(28/7/22).

HOPI

Patient was apparently asymptomatic 2 years back then his appetite increased( about 5- 6 times a day ) for which he came to KIMS hospital and diagnosed with Diabetes.He used oral hypoglycemic drugs for first 6 months.Then from past 1.5 years he is on insulin.

Urine output increased since 2 years about 10 times a day.

Decreased weight about 25kg since 2 years.

Then since 2 days he developed  fever which was high grade, continuos and associated with chills and rigor.

He developed slurring of speech since 1 day then he came to hospital the next day.

DAILY ROUTINE:

Wake up in the morning by 4am then he will have milk by 5am and then he eat food (rice)by8am  and then he goes for cattle rearing come back by 3pm then he takes some food rest and then he takes food at 6pm and goes to sleep by 7pm.

Daily routine not disturbed .

PAST HISTORY 

No similar complaints in the past

PERSONAL HISTORY 

Diet:mixed 

Appetite: increased

Sleep: adequate 

Bowel and bladder: loose stools.

Addictions: Alcohol every day about 180ml

Family history:No significant family history

Drug history:No history of allergy to any drugs 

GENERAL EXAMINATION 

Patient was conscious coherent and cooperative

Poorly  built and nourished  

pallor present

No Icterus

No cyanosi 

No clubbing

No generalized lymphadenopathy

Bilateral pedal edema (pitting) present












VITALS

Temp  Afebrile 

PR  65 bpm

BP  100/70 mm Hg 

RR  16 cpm

GRBS  249 mg/ dl

SYSTEMIC EXAMINATION 

CENTRAL NERVOUS SYSTEM EXAMINATION 

Higher mental functions:

Patient was drowsy 

Speech  slurred speech

Motor system :

Bulk decreased

Tone  normal in all 4 limbs

Power  4/5 in all 4 limbs

SUPERFICIAL REFLEXES:.         Right.      Left

Corneal reflex                                  present

Conjunctival reflex.                         Present


              DEEP TENDON REFLEXES:

                               Right.            Left

BICEPS JERK.     Absent             Present

TRICEPS.             Absent.           Absent

KNEE JERK         Absent.           Absent

ANKLE JERK       Present.         Present

SUPINATOR.       Absent.           Absent

Sensory system 

Crude touch ,pain, temperature, fine touch ,two point discrimination Normal


Signs of meningeal irritation  neck stiffness present


RESPIRATORY SYSTEM EXAMINATION 

Inspection: 

Shape of chest: Pectus excavatom.

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Palpable sounds are felt

Percussion: resonant

Auscultation 

Normal vesicular breath sounds heard all over the chest

PER ABDOMEN:

Inspection:

No abdominal distension

No scars, sinuses, masses visible

Umbilicus slit like

Palpation:

Inspectory findings are confirmed 

No Tenderness

Percussion: 

Shifting dullness present

Dull note Heard near the flanks

Auscultation: Normal bowel sounds heard

No bruit heard






CARDIOVASCULAR SYSTEM

Inspection : 

No scars, sinuses

No visible pulsations

Palpation:

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard

No murmurs or additional heart sounds

Investigations :

















Diagnosis:

Urosepsis with diabetes.

Treatment:

Pan 10mg IV OD

Vitamin K 10mg OD

Optineurin 1amp IV OD

Doxy 100mg BD

Meropenem 500mg IV BD

Sporolac TID

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