A 67 year old male with fever and burning micturition with decreased urine output

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.


A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of 

Fever x 4days

 burning micturition x4days

decreased urine output x 3days

HOPI :

Patient was apparently asymptomatic 4 days ago and then developed fever which was insidious in onset,intermittent,associated with chills and rigors,burning during micturition and decreased urine output.Relieved on taking medication 

Fever is not associated with cough, vomiting, loose stools,pedal edema

PAST HISTORY:

Urinary complaints of frequency and urgency since 1 yr along with burning micturition.

3months back patient developed fever went to local hospital got medicines ,even after medication symptoms are not relieved

K/c/o hypertension since 10 yrs,using medication

Bilateral knee pain since 5 yr  bcz of which he stopped farming.

PERSONAL HISTORY: 

He wakes up at 6: 30 am and he had a tea and breakfast.At 8:00 am he walks for 1km to reach his work place,work till 1:00pm tand walks back for lunch to home.He has his lunch and takes a nap till 4 pm  . In evening routine he eat snacks of tea and biscuits and watch telivision till 9pm and in dinner he eat rice with dal and vegetable curry and sleeps by 10:00pm

Diet:mixed

Sleep:regular  

Bladder -  burning micturition +

Bowel movements are regular 

Addictions:he started taking chewable tobacco since 30 years 

 Taking alcohol since 25 years 

Family history: No family h/o of diagnosed hypertension in their parents

Parents died of old age 

Younger brother died of HIV

GENERAL EXAMINATION:

Patient is conscious,coherent , cooperative  with time, place, person 

Vitals:

BP-120/80mmhg supine position on right arm.

PR-84 bpm,regular rhythm, normal volume

RR- 24cpm

Jvp - not elevated

Grbs-  120 mg/dl

Poor oral hygiene (Tobacco staining on upper inner teeth) 

 no history of pallour,icterus,lymphadenopathy,cyanosis,

clubbing

+)


No history of pallor,icterus,lymphadenopathy,cyanosis,clubbing








SYSTEMIC EXAMINATION:


RESPIRATORY SYSTEM: 

Patient examined in sitting position

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & barrel shaped.

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 


Upper respiratory tract-  external nose normal,oral cavity- poor oral hygiene,no halitosis,no thrush

Lower respiratory tract- trachea appears central,no scars,dilated veins over chest,apical impulse not visible,chest bilaterally symmetrical and movements equal on both sides

Spinal deformity-Kyphosis

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Tactile Vocal fremitus

Infraclavicular-normal

Mammary- normal

Axillary-normal

Infra mammary-normal

Suprascapular-normal

scapular- normal

Infrascapular-normal

AP diameter- 28cms,transverse diameter- 28cms

Percussion:  resonant-normal.

Auscultation:normal vesicular breath sounds with no added sounds

Vocal resonance normal.



CVS: 

Inspection : 

Shape of chest- barrel

No engorged veins, scars, visible pulsations

Palpation :

Apex beat can be palpable in 5th inter costal space

Auscultation : 

S1,S2 are heard

no murmurs


PER ABDOMEN

**Shape of abdomen-scaphoid

**Tenderness-No

** Palpable mass-No

** Liver- Not palpable

**Spleen - Not palpable

**Bowel sounds - Normal


Provisional Diagnosis: Lower urinary tract infection


Investigations:













Final diagnosis:


Urinary tract infection

Post renal aki secondary to left ureteric obstruction -?mass/strictures

K/c/o htn since 10 years

Kyphosis



Treatment:

1.INJ PIPTAZ 2.25 GM IV TID Day6


Plan of care:-

-Cystoscopy guided biopsy of mass


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