A 39year old male patient came with chief complaints of pain in the abdomen, headache, fever, burning micturition since 7days

 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 PRESENT 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.

HISTORY OF PAST ILLNESS :

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 test :












Doopler report :


Usg report :



ECG REPORT :


Treatment :






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