A 80 year old female with fever and burning micturition
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 comments.
Chief complaints:
-Fever since 3 months
-Burning micturition since 3 months
History of presenting illness :
Patient was apparently asymptomatic 3 months back Then she developed low grade continuous , Fever which was temporarily relieved on medication for 1 month associated with burning micturition for which she came to our hospital and was admitted for a week and she got alright and was discharged.after discharged she did not develop any fever for 20 days and then she got an episode fever which was associated with chills and rigors at mid night 1 am then got admitted at local hospital for 3 days where she was given antibiotics but she didn't get any relief and was brought to our hospital.3days back she had pain in the lower left neck region non radiating which was relieved on medication.
Fever was not associated with vomiting,nausea
PAST HISTORY:
K/c/o Hypertension since 20yrs and was on Amlodipine + atenolol
K/c/o Type 2 diabetes mellitus since 22 yrs and is onTab. Glimepiride+Tab. Metformin
PERSONAL HISTORY:
Appetite: decreased,
Diet:mixed
Burning micturition present
No allergies
Family history:no relevant family history
GENERAL PHYSICAL EXAMINATION t
Patient wasconscious coherent cooperative Moderately built and nourished.
Pallor present
No Icterus, cyanosis, clubbing,oedema,lymphadenopathy
Vitals:
Bp:140/90mm
RR:19cpm
PR-98b
TEMP-98.4F
SYSTEMIC EXAMINATION ;
RESPIRATORY SYSTEM EXAMINATION
Inspection
Drooping of right shoulder
No engorged veins , scars
Apex beat cannot be seen
Trachea appears to be central
Palpation ;
Inspectory findings are confirmed
Trachea central
Decreased movements on right side
Percusion:
Dull note on right side
Auscultaion:
Inspiratory crepts in the right inframammary are
Rest of the lung fields normal vesicular breath sound
CVS: S1 , S2 heard
No murmurs present
CNS: NAD
INVESTIGATIONS:AS on 8/12/2022
Liver function test;
Comments
Post a Comment