URINARY TRACT INFECTION

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History :

A 80 year old male patient came with 

Chief complaints :

Fever since 20 days 

Weakness of both lower limbs since 15 days

Pain in Rt. lower quadrant of abdomen since 10 days

Decreased urine output since 5 days

Burning sensation while passing urine since 5 days

HOPI : 

Patient was apparently asymptomatic 20 days back, then he developed fever since 20 days which is high grade, associated with chills and rigors, no diurnal variation, relieved with medication. He visited the local RMP for the same and got a CUE done and was told by the RMP that he had urine infection. He had weakness of both lower limbs since 15 days(unable to stand and walk on his own). Then, he had pain abdomen in the right lower quadrant of abdomen and in the lower back which had no aggravating and relieving factors. He also had decreased urine output and burning sensation while passing urine since 5 days. 

Shortness of Breath present (on and off)

No h/o chest pain

No h/o headache.

Past History :

Patient is a k/c/o Asthma and is not on medication

K/c/o Hypertension since 10 years and is on Amlodipine 5 mg once daily.

H/o renal calculi 10 years back.

K/c/o BPH 10 years back

Hospital admission for 15 days for Decreased urine output and abdominal distension 10 years back. Was told that the Creatinine was raised. Underwent treatment for 6 months.

Decreased hearing since 6 months

Uinary incontinence since 5 years.

Known case of Hepatitis since 10 years.

Not a k/c/o TB, DM, ASTHMA, EPILEPSY 

Personal History :

Diet : mixed

Appetite : Decreased

Sleep : Disturbed

Bowel movements : Constipation since 5 days 

Bladder movements : Decreased urine output and burning micturition since 5 days

Addictions : Consumes alcohol occasionally

On General Examination :

Patient is conscious, coherent and cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS :

AT THE TIME OF ADMISSION :

TEMP. : 99.6 F

PR : 80 BPM

RR : 16 CPM

BP : 110/70 MM HG

SpO2 (on Room air) : 98%

GRBS : 106 mg%

On Systemic Examination:

CVS : S1, S2 heard

RS : BAE present

P/A : soft, Non tender

PROVISIONAL DIAGNOSIS:

urinary tract infection

Investigations:

Complete blood picture

Urinalysis 

TREATMENT:

1. TAB. NITROFURANTOIN 100 MG PO/BD

2. INJ. NEOMOL 1 G/IV/SOS (IF TEMP.>101 F)

3. IV FLUIDS NS @ 75 ML/HR

4. INJ. PIPTAZ IV/OD

5. TAB. DOLO 650 MG PO/TID

6. INJ. PAN 40 MG /IV/OD

7. T. TAMSULOSIN 0.4 MG/PO/HS

8. INJ. ZOFER 4 MG/IV/OD