A 70 year old man with fever since 2 month

This is a HIPAA de-identified open-online-patient-record with initial information in duty-doctors notes as well as patient's voice, posted here spring 2016after collecting informed patient consent (form downloadable here) by our patient-information-communication-executive from pin-code-area for a discussion

Patient  botanical i.d. - ACACIA464PENNATA

History according to pt.

Knowledge of pt.

Subjective examination
Age- 70/M
Occ.- lobar
Add.-
Vital signs -
B.P. 146/100
Pulse 76
R.r. 24
Temp. 98.4 f°

C/o -
Fever on off since 2 month during cold water bath
And increase frequency of micturition

Personal h/o-
nutrition -good nutrition
No Tobacco, no alcohol, tea- 2/day
Pt. Nature - normal

Past medical history- No any past medical history only continue  current problem treatment

Past clinical images-

Family history- no any medi. Complication

Environment h/o-
Living area -village
Source of earning - 300/ day

Present dr. Notes -

Objective examination 

Nails normal

Posture normal

Gait normal 

Ms.tone grading 4-5 

Joint rang of motion are also normal 

No pain present in the body

Breathing normal

Dygnosis-

Usg- prostata enlargement small renal cyst

Analysis 

Pyrexia,

Planning-

Medications -

Tab. Pcm 

Tab. aciloc 

Tab. Emset