Medicine case discussion

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have 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.


CASE

80 year old male came to the opd on 15/6/2021 with chief complaints of

Burning micturition since 4 months
Increase in frequency of urination since 4 months
Thin streaming of urine since 3 months


HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 4 months back, then developed fever with chills which is high grade, continuous and associated with burning micturition and  increased frequency of urination.Fever was relieved on medication but burning micturition and increased frequency of urination was persistent. 
He complaints of lower backache when there is increased frequency of urination. 
Presently there is no complaints of fever, cold, cough. 
No hesitancy of urine
No complaints of abdominal pain, pedal edema, facial puffiness. 

PAST HISTORY

He is not a known case of Hypertension, Diabetes mellitus, Asthma, CAD, TB
No surgeries in the past.

PERSONAL HISTORY

Diet- Mixed
Appetite- normal
Bowel and bladder movements - regular
Sleep - adequate
No allergies
Addictions:occasional toddy drinker

FAMILY HISTORY 

Insignificant

GENERAL EXAMINATION
The patient is examined with informed consent.
Patient is conscious, coherent and cooperative ,is well oriented to time, place and person.
He is moderately built and nourished

Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent

VITALS:
On 15/6/2021
Temperature :98.7F 
Pulse:82 BPM
Respiratory rate :18 cycles/min
BP : 110/60mm HGHG


SYSTEMIC EXAMINATION

 CVS:

S1 and S2 heart sounds heard.

No murmurs heard.

Respiratory system:

Bilateral air entry 

Vesicular breath sound

CNS

Intact oriented to time, place and person


Abdomen

Soft and non-tender.

Bowel sounds were heard.

No organomegaly


INVESTIGATIONS

CBP

CUE

Serum creatinine

RBS

Ultrasound abdomen

Blood culture

Urine culture






PROVISIONAL DIAGNOSIS

Urinary tract infection with grade 2 prostatomegaly

TREATMENT REGIMEN


TAB NITROFURONTOIN 
TAB UROMAX
PLENTY OF ORAL FLUIDS
TEMPERATURE CHARTING EVERY 4TH HOURLY


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