URINARY RETENTION

30 years old male with urinary retention since 5 days

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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.

D.shreeya,roll no-39 

7th Semester 

chief complaints :

A 30 years old male , farmmer by occupation  came to OPD with a cheif of

Decreased Urine out put since 5 days

fever since 10 days

cough with expectoration since 5 days

History of presenting illness .

The patient was apparantly asymptomatic 10 days back and developed Acute urinary retention and went to Near by RMP Hospital and the patient was put on foley's catheter and then removed next day But the patient couldn't Pass urine and foley's replaced.

Patient developed fever 10 days back which was high grade and associated with chills. the fever subsides on medication

Then patient developed cough with Blood stained sputum since 5 days. 

Past History:

3 years ago Patient meet with an accident (RTA) - had a Right tibia fracture and was operated and implant was placed

2 yrs ago patient again meet with an accident (RTA) and had a superficial injury in the Right leg

Then year ago patient developed a small vesicle over the left Shin of tibia which was increased in size with Swelling of whole leg , Blackish discoloration of skin later multiple large sized v esicles are developed over left lower limb then he visited Near by doctor Where they have punctured vesicles later they developed ulcers over puncture site

Since then He stopped going to farm But he was able to do His routine work

10 day Back He developed cough with Blood in sputum want to RMP doctor and was test Positive for TB and was started on ATT drugs regimen

No H/O OF DM

NO H/0 of HTN

NO H/o of asthama

NO H/O of epilepsy

Treatment H/ O

There is a History of treatment for TB (ATT)

personal History:

loss of appetite

Mixed diet

Normal Bowel movements

difficulty in mitcuration

NO allergies

addictions -

          Alcohol - regular (daily 8O ml ) Since 15 yrs

          Tobacco - smoking 1 pack Per day since 15 yrs 

Family History:

NO History of TB in his family

General examination

The patient was consious ,coherrent and co-operative

moderatey Built and moderately nourished

NO pallor

NO ictherus

No clubbing 

NO cyanosis

NO pedal edema

No lymphadenopathy 

Mild dehydration

Temp- febrile

pulse rate - 76

Respiratory rate - 14

BP- 120 /80

SP02 - 97

Random Blood glucose _ 150mg %

systemic examination

B . cardiovascular

cardiac sounds- S 1, S2 ± 1 No murmurs

C. Respiratory system

NO dyspnoea

No wheeze

position of trachea-center

Breath sounds- vesicular

D. Abdomen

Normal Shape of abdomen

No tenderness

No palpable masses

NO Free fluids

Liver is not palpable

spleen is not palpable

Bowel sounds are heard

Investigations :

chest x ray 

ultra sound 

Gallbladder -distended 

Pancreas - Normal

NO ascitis

NO lymphadenopathy 

Liver Normal

urinary bladder - distended with foley's Bulb

pelvies cant be assesed

Hemogram

complete   urine examination

Doppler 2D Echo

All are normal

liver function test 

RFT

fasting blood sugar- 89 mg / dl

post lunch Blood sugar- 100 mg / dl

Blood urea- 15mg / dl

serum creatinine- 0. 6 mg/ dl

serum electrolytes

      Na - 136

      k- 2. 9 

      CI - 90

ESR- 130 nm / ist hr

C- Reactive protein - positive - 1.2mg / dl

SARS - COV - 2 PCR _   Negative

urinary chloride - 218 mmol / L

spot urine potassium - 7-2

spot urine sodium _ 201

NCCT- KUB (Plain)

Bacterial culture and sensitivity test

     sample collected - urine

      Zn Staining - NO acid fast bacilli

provisional diagnosis

Acute urinary retention - potts spine

Multiple lower limb ulcer - TB vasculitis

Hypokalaemia

upper lobe of Right lung cavition .

Treatment

Inj Augmentin 1.2g m/ Iv / BD

Inj PAN 40mg IV / OD

ATT 4 tabs pO OD according to body weight

Tab. DOLO 650mg DO SOS

Syp. CREMAFFFIN 20m 1

SyP . Ascoryl 10 ml

oint . Megaheal for L/A

Stri ct I/ O Chasting 

GRBS monitoring 6 hourly

Temp Charting 10 hourly

moniter vitals