58 Yr Old Male presenting with burning micturition


E LOG GENERAL MEDICINE




Hi, I am Rishitha, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!



CASE SHEET


 

58 year old male patient brought to casualty with chief complaints of

SOB since 15
Fever since 15 days
Burning micturition since 15 days

HOPI:
He was apparently a symptomatic six months back And then develop lower back and abdominal pain for which he was taken to a local practitioner where the diagnosed it as a renal failure and patient has taken a conservative management for three months and then patient has stopped taking medication. Then two months back, he developed swelling in the both lower limbs, which was gradually progressive. 
Then he had developed fever, 15 days back which is of low-grade, intermittent on and off associated with cough and vomiting. 3 to 4 episodes For one day and was not associated With chills, cold And raise of temperature. 
At the same time, he has developed a burning maturation which is associated with pain, non-radiating type and non-associated with hesitancy and urgency. 
Then he has developed shortness of breath. 15 days back, which was grade 2 MMRC. associated with cough with scanty mucoid sputum(white in color)

Past history:

He was a known case of CAD4 years back
He is a known case of TB for which he has used medication for six months
He is a known case of asthma for which he is using medication from three years
He is N/K/C/O of diabetes, hypertension epilepsy

Personal history:

He consumes a mixed type of diet
Decreased appetite
Inadequate sleep
Bowel and bladder movements are regular
Addictions:
Stopped consumption of alcohol 4 years back
Beedi smoking started when he was 30 years back and smokes 1 katta of beedi daily 

Family history: Not significant 

General examination :

Patient is conscious coherent cooperative
Thin built and well nourished
No signs of 
Pallor
Icterus
Cyanosis
Clubbing
Lymphadenopathy
Pedal oedema 

Vitals:
BP:150/80 mmHg
Pulse:84bpm
RR: 18cpm

Systemic examination:
CVS:S1 and S2 heard no murmurs heard

Respiratory system:
Bilateral equal chest expansions
Trachea central
Bilateral air entry present
Expiratory ronchi heard on in all lung fields

CNS: 
Normal
No focal neurological deficits

Abdominal examination:
GSoft and non tender 
ANo palpable mass
No organomegaly 
















Provisional diagnosis:

Pyrexia under evaluation
UTI
URTI

Treatment 

Salt restriction <1.2gm/day
IV NS 30ml/hr
Inj monocef 1gm IV/Bd
Inj pan IV/od 

















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