71 yr old male with h/o pyuria since 15days

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 71yr old male came to opd with chief complaint of 

White frothy urine since 15days.


History of presenting illness-

Patient was asymptomatic 15 days back ,then he developed pyuria since 15days which is insidious in onset and gradually progressive in nature and decreased output since 3days ,nocturia present 3/4 times at night. Burning micturation on 3/1/23.

History of constipation since 6 months took medication .

History of facial puffiness since 5 days and pedal edema since 15days







2yrs back had COVID symptoms and got hospitalized for 16days .

1month back had a fall while walking with Walker and had injuries on knees and ankle.


Past history:

No similar complaints in the past.

K/c/o bronchial asthma since 50yrs on inhaler.

No DM, HTN,Thyroid,epilepsy,CVD,cad


Personal history:

Wakes up at 5'0clock and reads 

10'0 clock -breakfast

2'0 clock - lunch

4'0clock - tea

9'0clock- dinner

Diet: vegetarian

Sleep:adequate and drowsy

Appetite-Decreased

Urine output -decreased

Bowel and bladder movements - decreased






Family history:

No significant family history


General examination:

Patient is conscious, not coherent ,not coperative moderately built and moderately nourished.

Vitals:

Temp : afebrile 

PR:        92/min             80.                 86

BP:.        130/80mmhg.  120/80.      120/70

Sp02:.     99%

GRBS:.    182.                 167.              117

No pallor,icterus,cyanosis, clubbing,lymphadenopathy

Bilateral pedal edema is present of pitting type.



Systemic examination:


Cvs: s1 and s2 heard ,no murmurs heard


Respiratory system: normal vesicular breath sounds heard.


Cns: no focal neurological deficit

                           R.               L

      Tone: UL.    N.               N

                LL.      N.              N


Power:

               UL:.     5/5.          5/5

               LL:.      3/5.         3/5

Reflexes:

               B.      T.         K.    A.       P

    R.       +.      ++.        -.     -.        FLEXOR

    L.      +.       ++.       -.    -.         FLEXOR

Gait: not elicited

Dysdidokinesia- absent



Abdominal examination - 


INSPECTION:


Shape – distended-uniform


Flanks – free


Umbilicus – 




Skin – normal


Dilated veins – absent


Movements of the abdominal wall - normal


Hernial Orifices, cough impulse - umbilical hernia ,present


External genitalia - normal


Renal angle - no tenderness




PALPATION:


No tenderness, temperature - normal


Liver - not palpable


Spleen - not palpable


Kidney - not palpable


INVESTIGATIONS:












Treatment:

3/1/23 

Inj piptaz 4.5gm iv tid

Inj.pan 40mg iv od

Inj pcm 1gm iv

Monitor vitals

Syrup citralka B6 10ml tid


4/1/23

Inj piptaz 4.5gm iv tid

Inj.pan 40mg iv od

NS@75ml/hr

Syp potklor 15ml tid

Inj.zofer od

Protein powder with100ml milk

Syp cremaffin 10ml

Nebulizer with budecort and ipratropium


5/1/23

Inj piptaz 4.5gm iv tid

Inj.pan 40mg iv od

NS@75ml/hr

Syp potklor 15ml tid

Syp cremaffin 10ml

Nebulizer with budecort and ipratropium


Differential diagnosis: cystitis? 














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