A 39 year old male with abdominal pain

 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 box.



39yrs od male came with the cheif  complaints of pain abdomen since 4 days andcomplaints of increased frequency of urination with burning micturition since 4 days,fever since 4 days.

[  ] HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 yrs back then he went to a hospital with complaints of increased frequency of urination and diagnosed to be as Type2 diabetes mellitusand startedhis medication taking  oral antidiabetic drugs,he was on regular followup.Since 1 month he is on routine checkup. He had uncontrolled sugars >300.Now presented with complaints of pain abdomen at umbilicus and at lower abdomen region since 4 days

C/O  b/l loin pain since 4 days,intermittent not associated with nausea ,vomiting,abdominal distension,loose stools.Burning micturition since 4 days with red colored urine.

C/O increased frequency of urination/urgency.Sometimes he is passing urine in his clothes before reaching the washroom (Urge incontinence)

Fever since 4 days,low grade,intermittent, not associated with cough,cold associated with chills and not associated with rigors .

No Shortness of breath

No palpitations

No pedal edema

PAST HISTORY: known case of DM 3years back.
Not a known case of  HTN ,ASTHMA,TB,EPILEPSY.

PERSONAL HISTORY:

Diet :mixed
Appetite:normal
Bowel :Regular
Bladder :increased frequency. 
Addictions:consumes alcohol occasionally. 

FAMILY HISTORY:
No significant family history.

[  ] GENERAL EXAMINATION:

No pallor , icterus , cyanosis , clubbing, lymphadenopathy , edema.
VITALS
Temp : 103*F

Pulse : 86bpm

RS : 20cpm

BP : 160/100mmhg

Spo2 : 98% at RA

GRBS : 274mg/dl

SYSTEMIC EXAMINATION:

CVS : S1,S2 heard

RS : BAE present.NVBS+

P/A : Tenderness present at lower abdominal region,B/L loin tenderness present

CNS : No focal neurological deficet


[  ] INVESTIGATIONS:







ECG:


USG ABDOMEN:

REVIEW OF USG:

2D ECHO:


PROVISIONAL DIAGNOSIS:

??ACUTE PYEONEPHRITIS 

TREATMENT:
1.inj meropenem 1gm/iv/bd

2.Tab.PAN 40MG OD

3.inj neomol 1gm/iv/tid

4.Tab.AMLONG 5mg PO OD

6.INJ.HUMAN INSULIN nph 8----8,regular 8---8---8

8.GRBS MONITORING

9.INJ.FALCIGO 120MG IV 8am today.

10.BP/PR/TEMP MONITORING



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