A 30 years old male with acute urinary retention

 This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

CASE:

 A 30 years old male with urinary retention since five days came to OPD.

CHIEF COMPLAINTS:

  1.  HIGH GRADE FEVER since 10 days.
  2.  COUGH with blood tinged sputum since 5 days.
  3. UNABLE TO PASS URINE since 5days.

HOPI:

Patient was apparently asymptomatic 10 days ago when he developed,

High grade fever with evening rise of temperature no chills and rigor  since 10 days and cough with blood tinged sputum since 5 days.

Since 5days patient could feel the fullness of bladder but could not void for which he was taken a local hospital and Foley's catheter was put and removed the next day but the patient could not pass the urine and the Foley's catheter was replaced.

Patient was diagnosed sputum POSITIVE for Tuberculosis and is on medication since then (01/11/2021) , weight loss since 10 days.

PAST HISTORY:

When patient was 10 years old, he had a trauma to his right leg and then after developed a sinus with pus and discharge and eventually pus stopped. 

3 years ago he met with a RTA and fractured his right tibia and implant was placed.

2 years ago he has another RTA and injured the right leg and had superficial injuries.

1year ago small vesicles on his left leg over the shin of tibia which increased in size and the whole leg was swollen, blackish discolouration;  later multiple large vesicles developed in the left leg, patient visited a doctor where the vesicles were punctured; since then he developed ulcers over the punctured areas for which debridement was done; since then the patient can walk and do his daily activities but cannot work in farm.
Ulcer on left leg and dressing done daily.








Not a k/c/o DM, HTN, Epilepsy, Asthma and CVA.

PERSONAL HISTORY:

  1. Diet- Mixed
  2. Appetite- decreased
  3. Bowel and bladder movements- Regular bowel, burning micturition and unable to pass urine.
  4. Sleep- Adequate
  5. Addictions- H/o alcohol consumption 180ml / day since 15years; smoking cigarettes one packet/ day since 15 years.
  6. Surgical history-No h/o previous surgeries.

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.
He is conscious, coherent, cooperative, well oriented to time, place and person.

He is well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

VITALS
  1. Temp-98.4 °F
  2. BP-120/70 mmHg
  3. PR-78 bpm
  4. RR-18cpm
  5. SpO2-97%

SYSTEMIC EXAMINATION:

  1. CVS: S1 S2 Heard
  2. P/A: soft,non tender, slightly distended,No guarding or rigidity.
  3. RS:  BAE+; NVBS+
  4. CNS:NFD

INVESTIGATIONS:


COMPLETE BLOOD PICTURE


RENAL FUNCTION TEST


LIVER FUNCTION TEST


COMPLETE URINE EXAMINATION


HEMOGRAM


ECG


FASTING BLOOD SUGAR


POST LUNCH BLOOD SUGAR


COLOUR DOPPLER 2D ECHO


CHEST XRAY


PELVIS XRAY with both the hip joints and right femur

X-ray of Rt. FEMUR, KNEE JOINT


X-ray Rt. KNEE lateral view

Orthopedic referal  for stiffness in right knee ?chronic Osteomyelitis

Opinion of orthopedic:

  • Extra articular ankylosis
  • Quadriceps contracture

 X-ray ABDOMEN lateral view


X-ray  ABDOMEN AP view





PROVISIONAL DIAGNOSIS:


Acute urinary retention under evaluation,? Potts spine.
Pulmonary koch's on ATT since 10 days
Multiple ulcers secondary to ?TB vasculitis/?berger's disease

TREATMENT:


9/11/2021

  1. IVF 2 NS,2RL @100 ML/HR
  2. INJ.PAN 40 MG IV/OD
  3. ATT X 4 TABS
  4. INJ.AUGMENTIN 1.2 GM IV/BD
  5. INJ.LASIX 20MG IV/BD
  6. SYP.ASCORYL 10 ML PO/BD
  7. SYP.CREMAFFIN 15 ML PO/BD
  8. BP,PR MONITORING;GRBS 12TH HOURLY
  9. STRICT I/O CHARTING


10/11/2021

  1. IVF 2 NS,2RL @100 ML/HR
  2. INJ.PAN 40 MG IV/OD
  3. ATT X 4 TAB
  4. INJ.AUGMENTIN 1.2 GM IV/BD
  5. SYP.ASCORYL  10ml PO/BD
  6. SYP.CREMAFFIN 15 ml PO/BD
11/11/2021
  1. IVF 2 NS,2RL @100 ML/HR
  2. INJ.PAN 40 MG IV/OD
  3. ATT X 4 TAB
  4. INJ.AUGMENTIN 1.2 GM IV/BD
  5. SYP.ASCORYL 10ml PO/BD
  6. TAB DOLO 650mg PO SOS
  7. SYP. POTKLOR in ONE glass of water 10ml PO/TID








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