GENERAL MEDICINE CASE

B.VAISHNAVI

5th SEMESTER

ROLL NO. 22

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

A 85 year old male patient came to the opd with chief complains of Decreased urine output and dribbling of urine since 1 week and Abdominal distension 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic  back, then he had complaints of decreased urine output ( dribbling, hesitancy were present). 

Patient had complaints of pedal edema since 6 days. 

Patient also had complaints of difficulty in walking since 5 days 

No h/o chest pain, palpitations, shortness of breadth. 

No h/o focal neurological deficit, headache, vomiting, altered sensorium. 

HISTORY OF PAST ILLNESS: 

K/c/o DM since 7 years 

Not a k/c/o HTN, epilepsy, CAD, TB 

H/o TURP surgery 7 years back

PERSONAL HISTORY: 

  • Appetite is normal 
  • Having mixed diet 
  • Bowels regular 
  • Micturition - decreased 
  • Has a habit of drinking since 50 years 
  • No habit of smoking 
  • No other habits/ addictions 

GENERAL EXAMINATION:

Patient is conscious, coherent

Presence of pedal edema since 6 days 

Absence of pallor,

                      icterus, 

                      clubbing, 

                      cyanosis, 

                 lymphadenopathy.

                  


VITALS: 

1.Temperature: 98.3 F 

2.Pulse rate: 104 beats per min

3.Respiratory rate: 18 cycles per min 

4.BP: 130/90mm Hg

5.SpO2: 96% @ Room air 

6.GRBS: 226mg%  

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

  • S1, S2 heard
  • No thrills, No murmurs

RESPIRATORY SYSTEM:

  • Normal vesicular breath sounds
  • Position of trachea is central
  • Dyspnea is absent 
  • No wheeze

EXAMINATION OF ABDOMEN:

  • Shape of abdomen - distended 
  • No tenderness
  • No palpable mass 
  • Normal hernial orifices 
  • No free fluid
  • No Bruits
  • Liver is not palpable
  • spleen is not palpable
  • Bowel sounds heard

                       



CENTRAL NERVOUS SYSTEM

  • Patient is conscious 
  • Speech is normal 
  • No focal neurological defect
  • Difficulty in walking 
PROVISIONAL DIAGNOSIS: 

ACUTE RETENTION OF URINE SECONDARY TO BPH? 

K/c/o DM 

INVESTIGATIONS: 
                 



 











TREATMENT: 

TREATMENT ON 19/6/22: 

IV FLUIDS NL @ 75ml/hr 
                  NS
INJ. MONOCEF 1gm/IV/BD 
INJ. OPTINEURON in 100ml/NS 
               over 30mins
INJ. PAN 40mg IV/OD 
INJ. HAI TIC/ SC 
GRBS check 6th hrly 

TREATMENT ON 20/6/22: 

IV FLUIDS NL @ 75ml/hr 
                  NS
INJ. MONOCEF 1gm/IV/BD 
INJ. OPTINEURON in 100ml/NS 
               over 30mins
INJ. PAN 40mg IV/OD 
INJ. HAI TIC/ SC 
GRBS check 6th hrly 






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