Prefinal Practical examination

 

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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 resident of miryalaguda occupation by barber came to medicine opd with 

Chief complaints :

Fever since 4days

 burning micturition since 4days 

decreased urine output since 3days

Abdominal pain in the left side:-2days

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.

From 2days patient is having pain in the left side of abdomen—insidious onset,intermittent,Migrating from loin to groin,colicky type of pain.

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 taking 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:

Patient wakes up at 6: 30 am and he drinks tea and take breakfast ( chapati , dosa , idly )  .At 8:30am he walks for 1km to reach his saloon shop work till 1:00pm  and walks back for lunch to home. He has his lunch ( rice , any curry and curd ) takes a rest till 4 pm  . In evening routine he eat snacks of tea and biscuits and watch telivision till 9pm , occasionally drinks alcohol 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 

alcohol since 25 years 

Family history: 

Young brother died with HIV 

no similar complaint 

GENERAL EXAMINATION:

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

Vitals:

BP-120/80mmhg 

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) 

Pallor - present 

No icterus,

No lymphadenopathy,

No cyanosis, 

No clubbing, 

No edema.

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM: 

Patient examined in sitting position

Inspection:-

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

Chest appears  bilaterally symmetrical & barrel shaped.

Respiratory movements appear equal on both sides and its Abdominothoracic type. 

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- 26cms,transverse diameter- 26cms 

Percussion:  resonant-normal.

Auscultation:normal vesicular breath sounds with no added sounds

Vocal resonance normal.

PER ABDOMEN:

Inspection:-

Shape of abdomen-scaphoid

Normal contour

Umbilicus is inverted

No scar,pigmentation, engorged veins ,peristaltic waves

All quadrants are moving equally with respiration 

Hernias orifices normal 

Palpation:-

NO local rise of temperature  and Tenderness

No Palpable mass

Liver- Not palpable

Spleen - Not palpable

Bimanual examination-kidney is not palpable on left and right side

Percussion:-

tympanic resonance is heard

Auscultation:-

Bowel sounds are heard

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

CNS: No focal neurological deficits found 

Level of Consciousness- Conscious 

Speech - Normal

Signs of Meningeal Irritation 

Neck Stiffness - No

Kerning's Sign - No

Cranial Nerve-normal 

Motor System- Normal

Sensory System- normal 

Glasgow Scale- normal

Finger - Nose In - Coordination - No

Knee - Heel In-coordination - No 

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

Normocytic normochromic anemia 

Kyphosis