A 75yr old man came to hospital with fever,cough,lower back ache 10days ago

 Hi, I am N.Rohith (Roll no:79) 3rd sem medical student. this is an online elog book to discuss our patients health data after taking their consent.This also reflects my patient centered online learning portfolio.


A 75yr old man came to hospital with fever,cough,lower back ache,sweating 10days ago


Chief complaints 

The patient came to the hospital 7days back with chief complaints of high grade fever since 10 days and dry cough since 2 days.Also suffering from irregular micturation.Lower back and pelvic pain

History of present illness

Patient is suffering from this kind of fever since 10 years occasionally and dribbling of urine

History of past illness

Had a lower back spine surgery 10 years back.

After 2 years of surgery he got hypertension and diabetes

Renal canaliculi 5 years back

Personal history 

Married

Occupation: daily labourer

Diet:mixed

Bowels :constipation

Appetite:lost

Sleep:normal

No known allergies 

General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

No pedal odema 




SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - No

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid No 

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

Investigation 







Treatment 

 









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