GM Case 05

General medicine case 05

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A 39 year old male who works as chef stays at Miryalaguda came to OPD with Chief complaints of fever since 10 days, headache since 3 days, abdomen pain since 3 days, increased frequency of urination with pain and burning micturition since 3 days.

History of Present illness:-

Patient was apparently asymptomatic since 3 years ago. 

Three years ago patient suffered from frequent urination cannot sustain with abdomen pain,back ache , headache diagnosed as Type 2 Diabetes and he is on routine check up.

One month ago onwards his sugar levels are fluctuaed and rise above 300 . From past 4 days he complaints of low grade intermittent fever not associated  with chills . And also complaints of abdomen pain , buring sensation while micturition with red coloured urine.Sometimes he is passing urine in his clothes before reaching the washroom. Also complaints of loin pain.

Routine:- He used wake up at 8 A.M have breakfast by 9 A.M go to work by 10 A.M. Have lunch at work everyday by 2 P.M and continues to work . Return home by 10 P.M have dinner and sleep by 12 A.M

Past History:-

Patient was diabetic. Hypertension since 4 days ago. 

No history of tuberculosis, asthma, epilepsy.

No history of previous surgeries.

Personal History:-

Patient takes mixed diet.

Sleep is abnormal .

Appetite is normal.

Bowel and bladder movement normal.

Consumption of alcohol occasionally.

Smoking cigarettes occasionally.

Family history :- 

No members of family has similar complaints.

Treatment History:-

Patient is on oral diabetics drugs.

General Examination:-

Patient was conscious and cooperative.

Patient shows generalised weakness.

No Pallor , no cyanosis, no icterus, no generalised lymphadenopathy.

No pedal edema.

Vitals:-

Temperature- febrile

Pulse rate- 98 per min

Respiratory rate- 22 per min

Blood pressure- 150/80 mmHg 

Systemic Examination:-

CVS -- Cardic sounds s1, s2 

            No Cardiac murmurs

Respiratory system --- No Dyspnoea

                                        No wheezing sound 

                                Position of trachea is central

CNS ---- Patient is conscious

              Speech is normal

              Reflexes are normal

 

Abdomen--- abdomen is  tender

                   bowel sounds heard   

                   No palpable mass or free fluid.

Investigations:-

Provisional diagnosis:-

Acute pyelonephritis. 

Treatment:-

1.Tab. FEROPENEM 200MG BD

2.Tab.DOXYCYCLINE 100MG PO OD

3.TAB PCM 650MG PO TID

4.INJ.HA1 S/C ACC TO SLIDING SCALE 

5.TAB.PAN 40MG PO OD

6.Tab.AMLONG 5mg OD