UDAY KIRAN ROLL NUM 20
30YR OLD MALE WITH URINARY RETENTION SINCE 5 DAYS
It is an online E log book to discuss our patient's de-identified health 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 those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.
A 30 year old male,farmer by occupation resident of Nalgonda came to op And he has
C/O URINARY RETENTION SINCE 5 DAYS
C/O HIGH GRADE FEVER SINCE 1 DAYS
C/O HEMOPTYSIS SINCE 10 DAYS SPUTUM TB +VE STARTED ON 4 TAB ATT
Patient when he was 10 yr old, had a trauma to his right leg and then after developed a sinus with pus and discharge and eventually pus stopped. From then onwards patient can't flex the right knee and become stiff
H/o RTA 3 Years ago after which he got implant in right tibia.
H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound
H/o urinary frequency, urgency, and nocturia since 2 yrs
1 year ago patient developed a small vesicle over left shin of tibia which increased in size with swelling of whole limb, blackish discoloration later multiple vesicles of large size developed over left lower limb,pt visited doctor where they punctured the vesicles and later he developed ulcers over punctured sites,he was operated and debridement was done,since 1 year he was walking, doing his daily chores but not working in farm.
10 days ago he developed cough with blood tinged sputum(hemoptysis),low grade fever with evening rise of temperature.
H/o acute retention of urine 10 days ago,he was able to feel fullness and want to void but couldn't,was put on Foley's outside after which it was removed the next day but he couldn't pass urine and Foley's was replaced.patient was diagnosed to be sputum+ koch's, started on ATT on 1/11/2021
He has normal appetite,takes mixed diet, regular bowel and bladder movements and takes alcohol daily 180 ml since 15 years,smokes 1 pack/day since 15 years.
On examination patient is conscious, coherent, cooperative.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals:
Temp-98.4 degrees F
BP-120/70 mm hg
PR-78 bpm
RR-18cpm
Spo2:97%
P/A:soft,non tender, slightly distended
No guarding or rigidity.
CVS: S1S2+
RS: bilateral air entry+;clear
CNS:NFD
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
INVESTIGATIONS:
HEMOGRAM:
HB-12.1
TLC-16,200
PTC-4.45 Lakhs
Normocytic, normochromic blood picture with leucocytosis
CUE:
Albumin-nil
Sugar-nil
Pus cells-3-4
Epithelial cells-2-3
Red blood cells-2-3
LFT:
TB-1.00
DB-0.18
AST-36
ALT-20
ALP-129
TP-6.6
Albumin-3.0
A/G-0.83
RFT:
urea-17
Creatinine-0.6
Uric acid-5.2
Ca-10.0
P-3.0
Na-137
K-3.0
Cl-98
PLBS 100
FBS 89
11/11/21
Hb: 10.6 gm/dl
T.C:14,500 cells/mm3
Lymphocytes: 16%
Platelets: 4.2 L/mm3
Urea: 15
Creatinine: 0.6
Na+: 136
K+: 2.9
Cl-: 90
On USG ABDOMEN AND KUB : No wny sononological abnormalities detected
Orthopedic referal taken for stiffness in right knee , chronic Osteomilitis?,
Opinion of orthopedic:
Extra articular ankylosis
Quadriceps contracture
And suggested for SURGICAL CORRECTION OF QUADRICEPS PLASTY FOR FLEXION OF KNEE
Urology referal taken for decreased urine output, adviced for Urine AFB, NCCT KUB, Urine C/S, gramstain,AFB
Urology opinion taken agian after the NCCT , culture reports, and USG
USG done and it says normal prostrate size with normal bladder wall thickening
Urine is not positive for any acid fast bacilli
NCCT is normal
Urology opinion:
T.TAMUSOLIN 0.4mg OD for 2 weeks and review after 2 weeks
DERMATOLOGY opinion was taken for blebs followed by ulcerations on left lower limb since 3 yrs
Dermatology opinion: liquid paraffin local application And skin biopsy taken on 13/11/2021
TREATMENT:
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 CHARTINGTREATMENT:
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
POPULAR POSTS
