November 19,2021

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November 19,2021

A 39 yr old male patient presented opd with chief complains of burning micturition , increase  in frequency of urination  , pain in the abdomen and fever since 4 days. 

History of present illness

-Patient was apparently asymptomatic 3 years back ,with chief complaint of  increase in frequency of urination  , and is consulted  to  nearby hospital there he  was diagnosed with Type-2 diabetes mellitus.

- Now he came with a complaint of  pain in the abdomen and lower abdomen near umbilicus, increase in frequency(3-4 times in half-an-hour  of urination and burning micturition and low grade intermittent of fever since 4 days which is not associated with cough and cold.

Past History:

-History of diabetes and hypertension since 3 years

-No history of tuberculosis ,epilepsy and asthma .

-No allergy to known drugs

Family History:

-No such relevant history is seen in the family.

Treatment History:

-Patient was on  oral hypoglycemic drugs since 3 years.

-No treatment is taken for present illness.

Personal History:

-Patient takes  mixed diet.

-Inadequate sleep.

-appetite normal 

-Bowel and bladder movement -loose stools and burning sensation during micturition.

General Examination:

Patient was conscious ,coherent and cooperative and well oriented to time person place.

-Moderately build 

-No pallor

-No icterus

- No cyanosis

-No clubbing

-No generalized Lympadenopathy.

Vitals:

Temperature : 100°F.

Pulse rate : 86bpm.

Respiratory rate:20 cycles/min

Blood pressure : 150/100mm of hg. 

Spo2 : 98%.

GRBS:274 mg%

Systematic examination:

    cardio vascular system 

        Inspection:

     Chest wall is bilateral symmetry

      No visible pulsations, no scars, engorged veins. 

       No precodial bulge 

Palpation:

JVP is normal. 

Auscultation-

                   S1 and S2 are heard. 

Respiratory system-

Bilateral airway. 

Position of trachea is central. 

Normal vesicular breath sounds are heard. 

No added sounds are heard. 

Per abdomen:

Abdomen is soft and tender at lower abdomen region. 

Bowel movements are heard. 

No palpable mass or fluid is found. 

Central nervous system:

Patient is conscious. 

Reflexes are normal. 

Provisional diagnosis:

Acute Pylonephritis

Investigation:

Graph

 

Ultra sound scan;

                                 

Complete Urine Examination(CUE):

Hemogram:

Liver Function Test(LFT):

Serum Creatinine:

                

Treatment: