39 years old patients with chief complaints of abdominal pain ,fever , burning micturition
A 39year old male patient cooking master by occupation resident of miryalagudam presented with chief complaints of fever since 7days, pain in the abdomen since 7days, burning of urine during passage and increased in frequency of urine passage since 7days
History of presenting illness:
The patient was apparantely asymptomatic 3 years back then he was diagnosed with type 2 diabetes and he is on medication. Since 1 month on routine checkup he had uncontrolled sugar levels of 300mg.now presented with pain in the abdomen at umblicus and lower abdomen since 7days which is squeezing type of pain and continuous in nature not associated with nausea, vomiting, abdominal distension and loose stools.
Burning micturition since 7days, increase in frequency sometimes he pass urine in his clothes before he reached bathroom.
Low grade Fever since 7days which is continuous in nature, associated with headache not associated with chills and rigor.
Cough since 2 days back.
Past History:
he is a known case of diabetes mellitus since 3 year's
No h/o hypertension, asthma, tb, epilepsy
PERSONAL HISTORY :
diet :mixed
Appetite :decreased
Sleep :disturbed
Bowel movements :normal
Bladder movements:increased frequency
Weight loss is present due to exercise
No addictions
FAMILY HISTORY :not significant
GENERAL EXAMINATION :patient is examined with an informed concent in a well illuminated room.
Patient is conscious, coherent and cooperative moderately built and moderately nourished.
No pallor
No icterus
No clubbing
No kolionychia
No lymphedenopathy
No Edema
Vitals :
Temperature :100f
RR:20cpm
PR:86bpm
BP:150/100mmhg
GRBS:274mg/dl
SYSTEMIC EXAMINATION :
CVS:S1and S2 Heard
RS:BAE+
Abdomen examination :
Shape of abdomen :obese
Tenderness :present at Lower abdomen and b/l loin tenderness
Palpable mass :no
Hernial orifice :normal
Free fluid :no
Bruits :no
Liver:not palpable
Spleen :not palpable
Bowel sounds :heard
Cns examination :
Level of consciousness :conscious
Speech :normal
Signs of meningeal irritation :absent
Cranial nerves: normal
Motor system :normal
Sensory system :normal
Reflexes :KAP:normal
Cerebellar signs:finger nose in coordination :present
Knee heel in coordination :present
Provisional diagnosis :pyelonephritis or cystitis
Lab reports :
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