A 63 yr old male patient with fever and burning micturition

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment.

A 63 year old male patient residence of Marripeda bangla came with

Chief Complaints:-

 Burning micturition and increased frequency of passage of urine since one month.

Fever since 1 month

Back pain since 15 days

Vomiting Since 3 days

History of presenting illness

Patient was apparently asymptomatic one month back then he developed burning micturition which was insidious in onset, no aggravating and relieving factors  

Complaints of increased frequency of urine approximately 20 times a day and increased passage of urine during night Times approximately 5 times since 1 month.

fever was insidious in onset, gradually progressive ,intermittent , associated with chills and rigors, low grade, relieved on medication

Back pain sudden in onset dull aching which started after fall from an accident.

Complaints of vomiting 3 days back  non projectile, non bilious 4 episodes, food as content.

No history of cold and cough

No history of chest pain, palpitation ,syncope

Daily routine:

He wakes up 6am in the morning and have breakfast (idly upma dosa) at 8am and goes to work by 9am he working in a garage of tailor machine repairs and reach home for lunch at 1pm (rice and curry) and sleeps for till 3 pm and again go back to work and return by 7pm in the evening and has his dinner at 8 am and goes to sleep

Past history

History of RTA 1 year back, where he got admitted in the hospital used medication for diabetes, continued for 3 months, stopped by the patient as he felt alright after using the medication for 3 months,from then he has knee pains.

History of Road traffic accident 15 days back started to develop back pains since then

Uses NSAIDs daily to relieve the pain

No history of similar complaints in the past

No history of hypertension,epilepsy , asthma, TB

Personal history

Patient works in a garage(tailor machine repair)as a daily worker

He maintain mixed diet and normal appetite 

He sleep is adequate

Patient has constipation 15 days back passes stools after 4 days only after using medication

Bladder moments increased frequency of passage of urine since 1 month

Addictions consumes alcohol occasionally

Family history

No significant family history 

General examination 


Patient was conscious, cooperative, coherent

No pallor, icterus,cyanosis,lympadenopathy,edema of foot

Scars over the right hand on dorsal region,scar on shin of right and left lower tibia


Vitals on presentation 

Temp:- 99.5F

Pr:- 108 bpm

Rr:- 30 cpm

Bp:-120/70 mmHg

Spo2:- 97% on RA 

GRBS:- 505mg/dl



On Respiratory system examination:-

On inspection:- normal shaped chest, trachea appears to be in centre, no scars and sinuses present,abdomino thoracic type of respiration, normal respiratory movements present

On palpation:- all inspectory findings are confirmed on palpation. 

On percussion:- right.                   left              

Infraclavicular resonant             resonant

Mammary          resonant          . resonant                                            

Axillary.                 resonant          resonant 

Infraaxillary.         resonant         resonant

Suprascapular.     resonant.            resonant

Infrascapular.        resonant.           resonant

Upper, mid, lower. resonant.         resonant

Interscapular

On auscultation:- normal vesicular breath sounds heard 


On CVS examination:-normal JVP, S1,S2 present,no murmurs

2D


Per abdomen:- soft and diffuse tenderness, central umbilicus. 


CNS :

Right Handed person.

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

speech : normal

Behavior : normal

Memory : Intact.

Intelligence : Normal

Lobar Functions : No hallucinations or delusions.

MOTOR EXAMINATION: 

                          Right                           Left

                       UL.       LL.               UL          LL

BULK     Normal    Normal        Normal           Normal

TONE    Normal     Normal         Normal         Normal

   POWER  4/5.        4/5.                   4/5            4/5

SUPERFICIAL REFLEXES:

                                       R.                . L

 CORNEAL            present.                present       

CONJUNCTIVAL     present              present

ABDOMINAL                  present

   DEEP TENDON REFLEXES:


                                          R                L

   BICEPS                       2+                   2+

   TRICEPS                    2+                  2+

   SUPINATOR.               2+                  2+

  KNEE.                          2+.                 2+

  ANKLE                         2+.                 2+

SPINOTHALAMIC SENSATION:

Crude touch

pain

temperature

DORSAL COLUMN SENSATION:

Fine touch

Vibration

Proprioception

CORTICAL SENSATION:

Two point discrimination

Tactile localisation.

steregnosis

Graphasthesia.

PROVISIONAL DIAGNOSIS:-  Newly diagnosed TYPE II DIABETES MELLITUS with ?UTI with ?cystitis


Investigations:-



Input output monitoring charts


Hemogram

Hb:-11.8

TLC:-16400

Platelet:-3.44


APTT:- 34sec

PT:- 17

INR:- 1.2


Blood grouping and Rh typing:- O positive 

Serology (HbsAg,HIV,HCV):-Negative

Urine for ketone bodies:- negative 

Troponin-I :- 18.3


 RFT on 3/12/23:-

Blood urea:- 94

Serum creatinine:-2.2

Serum electrolytes

Na+ 135

K+ 4.8

Cl- 99


 Repeat RFT on 4/12/23

Blood urea:- 79

Serum creatinine:- 1.6

Serum electrolytes

Na+ 137

K+ 4.5

Cl- 99


LFT:-

Direct bilirubin :- 1.05

Total bilirubin:- 0.18

SGOT:- 10

SGPT:- 19

Alkaline phosphate:- 336

Total proteins:- 7.9

Albumin: 3.3

A/g ratio:- 0.75


Lipid profile

Total cholesterol:- 205mg/dl

Triglycerides:- 549mg/dl

HDL:- 39mg/dl

Ldl:- 111mg/dl


Cue

Sugars:- ++++

Albumin:- ++

Pus cells:- 3-6 cells

Epithelial cells:- 2-3 

Ketone bodies:- positive 


HbA1C:- 7.5

FBS after 1 day of admission:- 411mg/dl

Rbs on admission:- 442mg/dl 

ABG on admission 

Ph:- 7.251

Pco2:- 22.3

PO2:-51.8

O2 sat :- 87.2 %

Repeat ABG

Ph:- 7.341

Pco2:- 23.2

PO2:-106

HCO3 :- 9.4

O2 sat :- 96.7 %

Ortho refferal was done i/v/o back pain and h/o RTA 15 days back


DIAGNOSIS:- URINARY TRACT INFECTION with newly diagnosed type II DM 

TREATMENT:-

IV fluids NS @ 100ml/hr

Inj.ceftriaxone 2gm IV BD

Tab.Nitrofurantoin 100mg BD

Inj.Human actrapid insulin s/c TID according to GRBS

Inj.Pcm 1gm IV sos (if temp >101F

Tab.pan 40 mg IV OD

Tab.Etoricoxib 90mg OD 

Tab ultracet BD

Voveron gel for local application 

Inj.Tramadol 1amp+500 ml NS IV slow over 5 hours

HAI insulin 8IU s/c before breakfast

8IU s/c before lunch

8IU s/c before dinner

Comments

Popular posts from this blog

GENERAL MEDICINE ASSIGNMENT-56 MAHENDRA

56 Kancharla Mahendra