GM case 13. 20/09/2023 75 year male with burning micturation
Hi, I am P.Kathyayani, 5th sem medical student. 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 patients 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 comment box is welcome.
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.
Chief Complaint:
75 year old male came to OPD with chief complaints of burning micturation since 15 days
History of Present Illness:
Patient was apparently asymptomatic 15 days ago and then he developed burning micturation.
h/o frequency, incontinence,dubbling of urine present
h/o fever high grade, intermittent associated with chills and rigors since 15 days and relieved on medication
h/o generalized weakness since 5 days
h/o hematuria since 2 days
No h/o trauma
Daily Routine:
Before he got sick, he used to wake up at 5am every morning, take a bath at 6.30am, eat breakfast of rice and curry and leave for work by 8.30am. He is a daily wage laborer by occupation and he used to pack lunch which was the same rice and curry as breakfast and eat it at her workplace. He used to reach home by 7 or 8pm after which he eat and sleep by 11pm.
After he got sick, he stopped going to work and stayed at home, following which he was admitted into the hospital.
Past History:
h/o similar complaints in the past( 2014) diagnosed with carcinoma bladder underwent surgery and on medication.
Not a k/c/o DM, HTN, Asthma, Epilepsy,CAD, TB, epilepsy.
No h/o pain abdomen
No h/o pedal edema,facial puffiness
Surgical history:
Operated for carcinoma bladder in 2014.
Personal History:
- married
- decreased appetite
- mixed diet
- regular bowels
- micturition -burning micturation since 15 days,frequency ,incontinence present
- no known allergies
- addictions: occasionally takes alcohol but stopped 6 months ago
Family History: not significant
Drug History:
Nitrofurantoin 100mg
General Examination:
I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis
-no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- Temperature: afebrile
- Pulse: 80 beats/min
- RR: 18 cycles/min
- BP:140/60 mm Hg
- Spo2:100%
Fluid Intake and Urine Output
Total Input: ml
Total Output: ml
Systemic Examination:
Respiratory System
- upper respiratory tract : oral cavity, nose & oropharynx appear normal
- chest is bilaterally symmetrical
- respiratory movements appear equal on both sides and of thoracoabdominal type
- position of trachea : central
- vesicular breath sounds : present
- no wheeze
Cardiovascular System:
Inspection :
- shape of chest : elliptical
- no engorged veins, scars, visible pulsations
Palpation :
-Apex beat can be palpable in 5th intercostal space
- no cardiac thrills
Auscultation :
- S1,S2 are heard
- no murmurs
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: right scrotum enlarged, Right sided hydrocele
- speculum examination :normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
USG
2D ECHO
ECG:
Provisional Diagnosis:
1.Carcinoma bladder Recurrence
2.UTI
Treatment:
1.I.v fluids
2.Inj.PCM 1g/I.v
3.TAB.NITROFURANTOIN 100mg
4.TAB.PAN 40 mg
5.TAB.Tranexa 500 mg
6.TAB.pcm 650 mg
7.Capsule LOBUN FORTE
8.Inj.Zofer 4 mg/I.v
