Burning micturition

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Oct 10,2022

 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. 

A 67 yr old male patient came to the causality with chief complaints of 

- fever since 10 days body pains and generalized weakness since 10 days ,shortness of breath since 5 days 


History of presenting illness

Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature fever since 10 days ,body pains and generalized weakness since 10 days shortness of breath since 5 days 

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History of presenting illness

Patient was apparantly asymptomatic 10 days back later he developed fever associated with chills with evening of rise of temperature /o dry cough , generalized weakness and body pains . vomiting had food particles as content which was no bilious and non projectile breathlessness  since 5 days epigastric pain since 4 days abdominal pain since 2 days


PAST HISTOR  he underwent Surgery for Aortic dissection.And after 10 months Underwent ESWL for kidney stones in Right Kidney. Hypertension since 15 years. H/O Diabetes;Asthma;Tuberculosis;Epilepsy.


PERSONAL HISTORY :

-He wakes up at 5:00 am Eat's mp for 3 times a day  

adequate sleep 

-Bowel 

burning micturition ,No addictions.


FAMILY HISTORY:

No similar complaints in any one of his family members. 


GENERAL EXAMINATION:

Patient is Conscious; Coherent and Cooperative and Well oriented to time;place and person. 



Pallor                                            - Abs

Icterus                                          - positive 


Clubbing                                      - Absent 

Kolinychia                                    -Absent

Generalised Lymphadenopathy -Absent 

Bilateral Pedal Edema                 -




(

Pulse Rate          -   102 bpm

Blood pressure   -  90/60 mm of Hg

Respiratory Rate - 26cpm






ABDOMEN EXAMINATION:


INSPECTION:

Shape of abdomen- distended 

Engorged veins       -Absent


PALPATION:

No rise of temperature 

 Epigastric tenderness 

No palpable mases

No hepatomegaly

No splenomegaly 

 

PERCUSSION:

normal liver span


ASCULTATION :

bowel sounds heard




Respiratory system;

-Shape of the chest normal, Trachea appears to be in centre ,Normal vesicular breath sounds heard 

Cardiovascular system;

- S1 S2 heard  No murmors


CNS EXAMINATION 

-pateint is conscious ,speech normal ,no neurologic defivits


INVESTIGATION










USG 

 
I
Provisional diagnosis
 Urinary tract infection 
Treatment:
Iv 20NS 20 RL @75ml /hr 
- Inj pan 
- Inj ceftriaxone  
- Tab dolo 


As per today: follow up:

Thrombophlebitis is observed 


Murmur grade 1 heard 



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