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:
Serum Creatinine:
Treatment:
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