GEN MED Elog

14 December 2021

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 70 year old male patient resident of Miryalguda  labourer by occupation came with complains of fever , burning micturition , pain during micturition along with abdominal  pain and decreased urine output. 

CHIEF COMPLAINTS 

Patient complains of fever since 1 week . 

Burning micturition since 5 days 

Pain during micturition since 5 days 

Abdominal pain since 5 days 

HOPI - 

Patient was apparently asymptomatic 1 week back then he developed fever . Then he developed pain abdomen since 5 days  . He experienced pain and burning sensation during micturition since 5 days . 

H/o burning and Pain during micturition since 5 days 

H/o stomach pain since 5 days 

H/o decreased urine output since 5 days 

Patient also has weakness. 

No H/o of Blood in urine 

                 Increased urination

                 Increased frequency of micturition 

                 Bed wetting  

                 Slow stream , hesitancy and terminal dribbling 

PAST HISTORY 

Not  a known case of Hypertension , Diabetes Mellitus , Asthma , Epilepsy, CAD . 

Patient had H/o TB 20 years back which lasted for 6 months . He took treatment in Miryalguda . And has no associated symptoms. 

FAMILY HISTORY 

Not significant 

PERSONAL HISTORY 

Diet - mixed 

Appetite- adequate 

Bowel and bladder- not regular 

                                 Pain and burning during micturition 

Addictions- Bidi  (3-4 ) In a day 

                    Alcohol- weekly once  

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative 

No Pallor, Icterus , Cyanosis, Clubbing , lymphadenopathy, Edema. 

VITALS 

Temperature- Afebrile 

BP- 80/60 mmHg 

PR - 72 bpm

RR- 14 cpm 

SpO2 - 96%

SYSTEMIC EXAMINATION

PROVISION DIAGNOSIS 

AKI ? UTI

INVESTIGATIONS

ECG 

BLOOD AND URINE TEST 

LIVER FUNCTION TEST 

RENAL FUNCTION TEST 

SEROLOGY 

CULTURE AND SENSITIVITY REPORT (didn’t receive)

TREATMENT