70 year old male with fever and dribbling of urine

 This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.


PRESENTING COMPLAINTS: 

 Complaints of Dribbling of urine since 10 days.

C/O Fever since 7 days.

C/O Myalgia since 5 days.

C/O Dry cough since 2 days.


HOPI:

A 70 year male, labourer by occupation presented to the casuality with complaints of dribbling of urine since 10 days. No history of dysuria/ burning micturition/ hematuria. History of high grade Intermittent fever associated with chills releived on taking medication since 7 days relieved on medication. History of myalgia since 5 days and history of dry cough since 2 days.


PAST ILLNESS:

The patient had complaints of severe low back pain, paresthesia in the lower limbs and sough for consultation and underwent L-S spine fixation under GA in 2004, which was uneventful.

He was diagnosed with Diabetes Mellitus on regular health checkup which were conducted in the Health center; and started on Oral hypoglycemic agents since 2010.

History of loin pain radiating to the groin on the right side in the year 2017; Patient soughted for consultation for the same and treated conservatively.


PERSONAL HISTORY:

He was moderately built and nourished.

Diet: mixed

Sleep was adequate.

Appetite decreased.

Bowel and bladder are irregular.

Smoker: started at the age of 24 years and discontinued in the year 2004; he used to smoke 2 beedi's daily during initial years which progressed to 10 beedi's daily. 

Occasional Alcoholic : started at the age of 26 years; 90ml/day; last binge was 12 days ago(90ml).


GENERAL EXAMINATION:

Patient was conscious and coherent.

Febrile, Temp : 102°F.

PR: 102 bpm; RR: 19 cpm; BP: 110/80mmHg; GRBS: 247 mg/dl.

CVS: S1, S2+; R/S: BAE+, Clear; P/A: Soft, Non tender, BS+, Hypogastric fullness+; CNS: HMF intact, GCS 15/15; NFND.






 

ECG at presentation:


  Chest x ray PA view:


  Radiological studies:









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