A 65 yr old male with pyrexia secondary to UTI

 A 65 yr old female from Narketpally labourer by occupation came to the OPD with cheif complaints of Fever since6 days and burning micturition since 6 days

HOPI:

patient was apparently asymptomatic 6days back then she developed fever which is insidious in onset and intermittent in nature which aggravated during night and relieved on medication associated with generalised weakness and not associated with chills , rigors , cough, cold, headache, night sweat.

H/O  burning micturition 

No H/O sore throat ,vomitings 


since 6days difficulty in passing urine, decreased urination  ,unable to pass urine without strain.


PAST HISTORY 

Not a k/c/o DM,HTN,TB, EPILEPSY,ASTHMA,CAD


5years back patient had swelling at sacral area progressively increased in size, surgical removal was done.

2 years back patient developed tingling and numbness of  lowerlimbs and used medications and was subsided.weakness of upperlimbs and lowerlimbs gradually progressed.

1year back patient was unable to walk ,used to walk with support for 4months later weakness progressed and was unable to walk

7months back patient developed pedal edema, burning sensation of feet, investigated to  compressive myelopathy with spastic qaudriparesis

planned for cervical laminnectomy

1and half month back surgery was done

burning, tingling sensation reduced,pain reduced

6days back patient developed fever.



DAILY ROUTINE 

She usually wakes up in the morning around 7 am ,she drinks tea around 8 am ,doesn't have breakfast.She will have lunch around 12 in the noon with rice and vegetable curry in her meal.She takes a nap in between 1 pm to 3 pm. She will have fruits around 4pm.Then she ll have her dinnerby 8pm .She will go to bed by 9 pm.she stays on the bed for whole day.


PERSONAL HISTORY

Diet: mixed

Appetite: decreased appetite

Sleep: inadequate 

Bowel : decreased bowel movements since 5 days

Bladder:difficulty to void

No addictions.

FAMILY HISTORY

Not significant .


GENERAL EXAMINATION

I took the consent of the patient.

Patient is conscious, coherent, cooperative. Moderately built and nourished.

Vitals : 

 Temperature :normal

Pulse rate : 75 beats / min

BP : 128/86 mm Hg

RR : 18 cycles/ min

 pallor present , icterus, cyanosis , clubbing , generalised lymphadenopathy, slight pedal edema present.


SYSTEMIC EXAMINATION


CVS- S1S2+,no murmurs heard

RS-trachea central,BAE+,

ABDOMEN:soft,nontender,no palpable mass,liver and spleen not palpable

CNS: pt is conscious

  speech-normal

HMF : Intact

no meaningeal signs


TONE :      RT       LT

UL            N.         decreased 

LL             N.         decreased 

REFLEXES:  B.       T.       S.      K.     A.     Plantar

RT.                 + + +   ++    ++     ++        +     extension 

LT.                 ++         +        +       ++    +     extension 

POWER   RT         LT

UL.          5/5.        1/5

LL.           5/5.       3/5

INVESTIGATIONS:

2/1/23

Haemogram:

Hb - 9.3 g/dl(12-15)

TLC : 4100/ ml

RBC : 3.3 million/ml ( 3.8 -4.8)

Platelet count: 2.6 L/ml

Blood Urea : 13 mg /dl ( 12-42)

Serum creatinine:0.6 mg/dl ( 0.6-1.1)

Electrolytes:

Serum Na : 135mEq/ L (135-145)

Serum K : 3.6mEq/ L (3.5-5)

Serum Cl : 99 mEq/ L(98- 107)

CUE: 

No pus cells

Albumin : +


30/12/22


Fever chart:


USG










DIAGNOSIS:

Pyrexia with UTI

Cervical laminectomy (1month back )  


TREATMENT 


IVF NS 100ml/hr

Inj.neomol 1gm/IV

Tab nitrofurantoin 100mg po/bd

Tab baclofen10mg po

Syrup potchlor 15mlpo/ TD

Syrup Cremaffin 15ml po/TD
















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