60 year old male patient

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 A 60 year old male patient resident of Nalgonda,Farmer by occupation with known history of diabetes and hypertension came to OPD with chief complaints of 

burning micturation since 10 days,

Dry cough since 6 days,

high grade fever since 5 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days ago,later he developed burning micturation which was associated with difficulty in urination.History of dry cough which was non productive.History of fever which was high grade,intermittent associated with chills and relieved on medication.This was associated with constipation which was on and off.

PAST HISTORY:

History of

 DIABETES MELLITUS  20years ago 

HYPERTENSION 20 years ago

No history of asthma,epilepsy, tuberculosis.

FAMILY HISTORY:

No relevant family history.

TREATMENT HISTORY:

For DIABETES MELLITUS,he was administered with DAPAGLIFLOZIN 10mg OD and TAB.VOGLIBOSE 0.3mg OD and on INSULIN since 2 days MIXTARD as Serum creatinine 2mg/dl.

For HYPERTENSION,he was administered with TAB.AMLONG 2.5mg OD.

PERSONAL HISTORY:

Diet :- MIXED 

APPETITE :- Normal 

SLEEP :- Adequate

BOWEL AND BLADDER MOVEMENTS :- decreased

ADDICTIONS :- Consumes alcohol occasionally

GENERAL EXAMINATION:

patient is concious,coherent,cooperative

                   moderately built and nourished.

No Pallor

No Icterus

No Cyanosis

No Clubbing

No Lymphadenopathy

No Edema.

Vitals Signs:

                       Temp- 101 F

                       PR- 80 BPM

                      RR- 19 CPM

                      BP- 120/70 mm Hg

                      SpO2- 98%@ RA

                     GRBS- 387 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard ,NO MURMURS.

RS: BAE+, Normal Vesicular Breath Sounds

CNS: Intact and No Neurological deficit

P/A: SOFT, DISTENDED, Non Tender ,BS Positive

INVESTIGATIONS:

COMPLETE BLOOD PICTURE:

COMPLETE URINE EXAMINATION:

BLOOD SUGAR ESTIMATION:

LIVER FUNCTION TEST:

BLOOD UREA:

SERUM CREATININE:

SERUM ELECTROLYTES:

SERUM POTASSIUM:

ECG REPORT:

USG REPORT:

FEVER CHART:

BACTERIOLOGICAL CULTURE SENSITIVITY  AND REPORT:

X-RAY:

PROVISIONAL DIAGNOSIS:

 Chronic Cystists

TREATMENT:

KCl one ampoule in 10 ml NS over 4 hrs.

Inj.MONOCEF 1gm IV BD

Inj PANTOP 40 mg IV OD

Inj.ZOFER 4 mg IV SOS

Inj.NEOMOL 1 gm IV SOS

Tab.DOLO 650 mg PO TID

Tab.AMLONG 2.5 mg PO OD

Inj.HUMAN ACTRAPID SC Acc to GRBS

Syp.LACTULOSE 10 ml PO BD

Syp.GRILLINCTUS 10 ml PO BD