A 70 year old male with burning micturition ,pedal edema and fever

July 26,2021


Kundana Kanumilli,MBBS 3rd semester

Roll no:60

Under the guidance of Dr.Arun (intern)

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.  This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 

 

A 70 yr old male came to hospital with cheif compliants of severe burning micturition and fever since 1 month

History of present illness

Patient was apparently asymptomatic 6 months ago  then developed burning micturition from 6 months but is has become worsen since 1 month. He is suffering from fever since 1 month. even he is having pain during micturition. He has decrease urine output.

His appetite is decreased and even severe weight loss is seen. He is even having shortness of breath .

He is having pedal edema bilateral  pitting type upto ankle.

Drug history

He is using paracetamol since one month daily


History of past illness 

He is not a c/o Diabetes mellitus, Hypertension ,asthma, TB, Epilepsy

Personal history

Diet: Mixed

Appetite: decreased since a month

Bowel: Regular 

Micturition: decreased urine output( usg showed BPH)

Allergies:drinks toddy (rarely)


Family history

No history of Diabetes mellitus ,Hypertension ,heart disease or stroke ,tuberculosis ,cancer

General examination
patient was consious ,coherent , cooperative and examined in a well lit room.

VITALS:

Pulse rate: 98 bpm
Respiratory rate: 18/min
BP: 130/80 mmHg
Temperature: 98.4F
GRBS: 131mg%
SPO2: 98% at room air
            
Pallor: absent
Icterus: absent
Clubbing: absent
Cyanosis: absent
Lymphadenopathy : enlarged lymph nodes in the left anterior side of neck (matted)
Edema of feet: present, upto ankle, pitting type.
Malnutrition :present
Dehydration :mild

Systemic examination

CVS
  • S1 and S2 heard
  • No thrills
  • No murmurs
Respiratory System
  • Vesicular breath sounds heard
  • Trachea is in central position
  • No wheezing
  • No Dyspnoea
Abdomen
  • Scaphoid shaped abdomen
  • No tenderness
  • No palpable mass
  • No organomegaly
  • Bowel sounds are heard
CNS
  • Conscious and normal speech
  • Normal gait
  • Cranial nerves normal
  • sensory system normal
  • Motor system normal
  • Kernigs sing absent
INVESTIGATIONS:

 CBP









HEMOGRAM










COMPLETE URINE EXAMINATION











BLOOD PARASITE                                                                                                                                            




ULTRA SOUND                                                                                                                                          













                                                   


             CULTURE                                                                                                                                                        

Urine                                                                                                          



                                                                                                


 
FNAC of lymphnode in neck                                                                                                                 
                                                                               





PROVISIONAL DIAGNOSIS

Obstructive uropathy ?AKI
Post renal Benign prostate hyperplasia
?Adenocarcinoma

TREATMENT 

  • Fluid correction
  • salt restriction with <2g/day ivf 1๏ ns @30ml/HR
  • Inj.Lassix 40mg iv/bd
  • IO CHARTING
  • TAB.Ondansetron MD/PO/TID
  • TAB.Nodosis 500mg/PO/BD
  • Inj.Meropenem 500mg/IV/BD










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