A 42 years male presenting with burning micturation and with fever & chills

- June 11, 2023

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A 42 year male farmer who is a resident of chennaram admitted in the hospital with chief complains of

burning micturation since 3 days

fever since 3 days

vomiting since 3 days

History of present illness:-

Patient was apparently asymptomatic 2 years ago then he developed lumbar back pain insidious in onset, gradually progressive, persistent pain, increased while waking up from bed. Patient was complaining that pain used to reappear again when he lies down on bed and then he used to change his posture on bed till his pain disappears.

2 months back patient pain was so severe that he went to local hospital along with abdominal discomfort where he was advised MRI and endoscopy. He was diagnosed with L3- L4 mild canal stenosis and antral gastritis and also with diabetes and CKD. For which he was treated and symptoms of antral gastritis got resolved.

3 Days ago then developed fever insidious in onset gradually progressive associated with chills and rigors relieved on medications

1 episode of vomiting watery,non bilious,non projectile ,non blood stained 3 days ago

He also complained about burning micturition with increased frequency and decreased urine output since 3 days

No history of urgency , hesitancy

History of past illness

Know case of hypertension since 4 years and is on irregular medications.

DM since 2 months and is on insulin regularly.

History of similar complaints of burning micturation 3 to 4 times in past 6 months.

Treatment history

T.S AMLO BETA 0.5 Mg

Inj .HAI subcutaneous

Personal history

Appetite -decresed

Died -mixed

Bowel -regular

bladder movements - increased frequency about 1 time in a hour

Sleep -inadequet due to increased frequency of micturation and persistent back pain

No allergies

Addictions

Alcohol -weekly once but he is now sober since past few months

Tobacco - from childhood but now he stopped consuming

Daily routine of patient before complain of back pain:

This was his life 2 years ago. He used to wake up at 7 am. used to have breakfast which was mostly rice. Used to go to work by 10 am. He as a farmer by occupation was farming about 8 acres of land without any problem. he used to have lunch by 1 pm which was rice and dal. he used to get home by 6 pm. his dinner was mostly of chapathi and rice. he goes to sleep by 9 to 10 pm

Daily routine of patient after onset of back pain:

Patient gets up daily in between 7 to 8 am

he eats jawa for breakfast

Goes to work by 10am. Because of back pain he now decreased his working area of farming from 8 acres to 2 acres.

He usually have his lunch by 1 pm which is mostly rice with dal

He returns home by 6 pm

His dinner is chapathi and curry most of the time

He goes to sleep by 9 pm. His sleep is disturbing because of persistent back pain and increased frequency of micturation.

Family history:

None of the family members have similar complaints

General examination:

Patient was conscious, coherent, cooperative and well oriented to time, place and person