GENERAL MEDICINE E-LOG

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT: 

A male patient aged 85 years came to the opd with the chief complaints of 

  • Decreased urine output and dribbling of urine since 1 week 
  • Abdominal distension 
HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 7 years back, then the patient was diagnosed with DM type II for which he is on medication.

10 days back, patient 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 

TREATMENT HISTORY: 

No relevant treatment history 

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 EXMINATION:

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: 
                 

ECG 

ULTRASOUND REPORT 
REVIEW USG 




2D ECHO REPORT 






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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