A case of 39 year old male
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39yrs od male came with complaints of pain abdomen since 4 days.complaints of increased frequency of urination with burning micturition since 4 days,fever since 4 days.
Patient was apparently asymptomatic 3 yrs back then he went to a hospital with complaonts of increased frequency of urination and diagnosed to be as Type2 diabetes mellitus(and started on OHD's),he was on regular followup.Since 1 month he is on routine checkup.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.Not associated with chills and rigors.
No Shortness of breath
No palpitations
No pedal edema
On examination
No pallor , icterus , cyanosis , clubbing, lymphadenopathy , edema.
Temp : 100*F
Pulse : 86bpm
RS : 20cpm
BP : 150/100mmhg
Spo2 : 98% at RA
GRBS : 274mg/dl
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
Provisional diagnosis :
?Acute pyeonephritis
? Acute cystitis
K/c/o diabetes mellitus type 2 since 3 years
ECG:-
USG abdomen
17/11/21
Ophthal referal was done to rule out diabetic retinopathy as the patient is a k/c/o diabetes mellitus type 2 since 3 years.
Review USG
2D ECHO
18/11/21
Soap notes :-
S-
Burning micturition reduced
C/O pain abdomen decreased
O -
Bp -130/90mmhg
Pr- 87bpm
temp - 99F
spo 2 -96% at RA
A-
? Acute pyelonephritis
?cystitis
known case of DM type 2 and denovo HTN
P -
1.IVF NS/RL @ 100ml/hr
2.INJ.PIPTAZ 4.5 gm/IV/BD
3.INJ.ZOFER 4mg/TID
4.INJ.HA1 S/C ACC TO SLIDING SCALE
5.INJ.OPTINEURON 1 amp in 100ml NS
6.TAB.PCM 650mg PO SOS
7.Tab.AMLONG 5mg OD
8.STRICT I/O CHARTING
9.GRBS Monitoring 6th hourly
10.Bp/pr/temp monitoring 4th hourly
19/11/21 :-
S
c/o Burning micturition present
Fever spikes +
Increased frequency of urination
O
BP- 130/80 MMHG
TEMP-100 ° F
PR- 88 BPM
CVS - S1S2 +
RS - BAE +
P/A- Soft ,non tender
CNS- NO FND
GRBS-151 mg/dl
I/O - 2000/1250
A
? ACUTE PYELONEPHRITIS /? CYSTITIS
K/C/O DM AND DENOVA HTN
P
TAB. CIPROFLOXACIN 500MG PO BD
TAB PAN 40 MG PO OD
INJ HAI S/C ACC TO GRBS
(BBF-BL-BD)
TAB PCM 1000MG PO QID
TAB AMLONG 5MG PO OD
GRBS 5TH HOURLY
MONITORING VITALS
SYP CITRALKA 10 ML IN 1GLASS OF WATER PO OD
TAB URISPAS PO BD
20/11/21
39 years male
AMC bed 1
S-
Burning micturition reduced
C/O pain abdomen decreased
C/O fever
O -
Bp -110/70mmhg
Pr- 89bpm
temp - 100F
spo 2 -98% at RA
A-
? Acute pyelonephritis
?cystitis
known case of DM type 2 and denovo HTN
P -
1.IVF NS/RL @ 100ml/hr
2.INJ.ZOFER 4mg/TID
3.INJ.HA1 S/C ACC TO SLIDING SCALE
4.INJ.OPTINEURON 1 amp in 100ml NS
5.TAB.PCM 1g 6 hrly
6.Tab.AMLONG 5mg OD
7.STRICT I/O CHARTING
8.GRBS Monitoring 6th hourly
9.Bp/pr/temp monitoring 4th hourly
21/11/21
S
- Continuous fever spikes present above 102 F associated with chills
C/o burning micturation subsides and increased frequency of urination,low backache increased on bending forward
O- TEMP-101F
Bp-110/70mmhg
Pr-90bpm
Cvs-s1,s2heard
Rs- NVBS
CNS-NAD
A
- Diagnosis is ? Acute pyelonephritis and urge incontinence .
Dm-2
?clinical malaria
Urine c/s - no growth
Sent repeat blood and urine c/s
Smear for mp - negative.
Repeat cue - no RBC casts and pus cells -8-10 .
Xray kub was done in view of ??emphysematous pyelonephritis .
P
1.Tab.CIPROFLOXACIN 50MG /BD
2.Tab.PAN 40MG OD
3.TAB.PCM 650mg QID
4.Tab.AMLONG 5mg PO OD
5.Tab.URISPAS PO BD
6.INJ.HUMAN INSULIN
7.Syp.CITRALKA 10ML IN ONE GLASS WATER POBD
8.GRBS MONITORING
9.INJ.FALCIGO 120MG IV STAT
10.BP/PR/TEMP MONITORING
22/11/21
S- no fever spike since 4pm yesterday, pt is feeling less lethargic, good appetite,
lowbackache+
no burning micturition
O- TEMP-98.6F
Bp-120/70mmhg
Pr-90bpm
Cvs-s1,s2heard
Rs- NVBS
CNS-NAD
A
- Diagnosis is ? Acute pyelonephritis and urge incontinence .
Dm-2
?clinical malaria
haemogram awaited
P
1.inj meropenem 1gm/iv/bd
2.Tab.PAN 40MG OD
3.TAB.PCM 650mg QID
4.Tab.AMLONG 5mg PO OD
6.INJ.HUMAN INSULIN nph 6----6,regular 6---6---6
7.Syp.CITRALKA 10ML IN ONE GLASS WATER POBD
8.GRBS MONITORING
9.INJ.FALCIGO 120MG IV 8pm today
10.BP/PR/TEMP MONITORING
23/11/21
S- loin pain+ but decreased,no burning micturition, chills at the time of fever spike, less lethargic,
last spike at 8 pm yesterday.
O- TEMP-98.6F
Bp-120/80mmhg
Pr-90bpm
Cvs-s1,s2heard
Rs- NVBS
CNS-NAD
A
- Diagnosis is UTI
Dm-2
?clinical malaria
P
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
24/11/21
S-
No Burning micturition
Lower bacheache decreased
O -
Bp -130/70mmhg
Pr- 88bpm
temp - 100F
spo 2 -98% at RA
A-
? Acute pyelonephritis
?cystitis
? Clinical malaria
? Acute prostatitis
known case of DM type 2 and denovo HTN
P -
1.Tab. FEROPENEM 200MG BD
2.Tab.DOXYCYCLINE 100MG PO OD
3.TAB PCM 650MG PO TID
4.INJ.HA1 S/C ACC TO SLIDING SCALE
5.TAB.PAN 40MG PO OD
6.Tab.AMLONG 5mg OD
7.STRICT I/O CHARTING
8.GRBS Monitoring 6th hourly
9.Bp/pr/temp monitoring 4th hourly
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