80 Yr Old male with altered sensorium

80Yr male with altered sensorium This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent

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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 competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

CHEIF COMPLAINTS:

Fever since 10 days 

Burning micturition since 1 day

Left loin pain since 1 day 

Decreased urine output since 1day

Blood in urine since 3 hrs

HISTORY OF PRESENTING ILLNESS

A 80Yr male, agriculture by occupation,clinically presented to casualty with complaints of high grade fever since 10 days (25th sep - 5th oct) , not associated with cold / cough/abdominal pain.which was releived on taking antipyretics and oral antibiotics . Afterday10 of illness his fever subsided . After 3 days i.e he had symptoms of burning micturition, abdominal distention and left loin pain , non radiating, dragging type and decreased urine output having dark yellowish coloured urine since 1 day. 

PERSONAL HISTORY:

80Yr male, married , agriculture by occupation, has normal appetite, mixed diet , regular bowels( not passed stools today), decreased urine output,no allergies, occasionally drinks ( once in a week) I.e (3.6 units of alcohol/week)

Smokes 10beedi/day (30 pack years)

No significant Family history

ON GENERAL PHYSICAL EXAMINATION 

Patient was drowsy , incoherent

GCS - E2( eye opening to pain)

            V2( verbal response- volcalises i.e                         makes sounds but no word)

             M3( motor response I.e abnormal flex     

ion to pain)

pallor present 

No icterus , cyanosis , clubbing, lymphadenopathy,edema

VITALS:  

On presentation 

Temp.-99.7

Bp- 120/90mmhg

PR-98bpm

RR-18cpm

Grbs-116mg/dl

SYSTEMIC EXAMINATIONS 

CVS: S1s2 heard

R/S : BAE+ , 

right infraxillary area crepts +

decreased breath sounds, 

P/A :scaphoid ,soft ,tenderness at umbilicus ,bowel sounds heard, stools passed yesterday 

Pleural tap was done on 15/10/22

X-ray after pleural tap

Pleural fluid(EXUDATE)

DIAGNOSIS:

ALTERED SENSORIUM SECONDARY TO ?HYPONATREMIA (resolved)- 

WITH CAP (RIGHT UL ANT LEFT LUNG)

? SEPTIC ENCEPHALOPATHY -LEFT PYELONEPHRITIS ( resolving)

WITH PRE RENAL AKI

with MICROCYTIC HYPOCROMIC ANEMIA SECONDARY TO  ?IRON DEFICIENCY 

? ANEMIA OF CHRONIC DISEASE 

WITH LEFT EMPYEMA 

WITH PNEUMOTHORAX WITH ICD DAY1

with k/c/o COPD and HTN