75 yr old male with dribbling of urine

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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.

D. Shreeya , 8th sem ,roll no 39

PRESENTING COMPLAINTS: 

C/O Dribbling of urine since 10 days.

C/O Fever since 7 days.

C/O Myalgia since 5 days.

C/O Dry cough since 2 days.

HOPI:

A 70 year male, labourer by occupation presented to the casuality with complaints of dribbling of urine since 10 days. 

No history of dysuria/ burning micturition/ hematuria. 

History of high grade Intermittent fever associated with chills releived on taking medication since 7 days. History of myalgia since 5 days and history of dry cough since 2 days.

PAST ILLNESS:

The patient had complaints of severe low back pain, paresthesia in the lower limbs and sough for consultation and underwent L-S spine fixation under GA in 2004, which was uneventful.

He was diagnosed with Diabetes Mellitus on regular health checkup which were conducted in the Health center; and started on Oral hypoglycemic agents since 2010.

History of loin pain radiating to the groin on the right side in the year 2017; Patient soughted for consultation for the same and treated conservatively.

PERSONAL HISTORY:

Mixed diet

Sleep was adequate.

Appetite decreased.

Bowel and bladder are irregular.

Smoker: started at the age of 24 years and discontinued in the year 2004; he used to smoke 2 beedi's daily during initial years which progressed to 10 beedi's daily. 

Occasional Alcoholic : started at the age of 26 years; 90ml/day; last binge was 12 days ago(90ml).

GENERAL EXAMINATION:

Patient was conscious , coherent and cooperative Well built and nourished  well oriented with time ,place and person

Pallor

Ictherus 

Cyanosis

Clubbing

Pedal edema

Lymphadenopathy 

Vitals 

Febrile, Temp : 102°F.

PR: 102 bpm

RR: 19 cpm

BP: 110/80mmHg

GRBS: 247 mg/dl.

Systamic examination 

CVS: S1, S2+

R/S: BAE+

P/A: Soft, Non tender, BS+, Hypogastric fullness+

CNS: NFND.

INVESTIGATIONS 

Hb- 12.9

TLC-10,900

HbA1c-6.8

Blood urea -1.8

fever chat

ECG

X RAY

USG

TREATMENT:

1. IVF NS/RL @75 ML/HOUR.

2. INJ. NEOMOL 100ML /IV/TID.

3. INJ. ZOFER 4MG/IV/ SOS.

4. SYP. ARYSTOZYME 15ML/PO/TID.

5. GRBS 7• PROFILE.

6. VITAL MONITORING 4TH HOURLY.

7. I/O CHARTING