80 M with hematuria since 1 week

 This 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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan.

Complaints:

80 year male with c/o hematuria since 1 week.


HOPI:

Patient was apparently asymptomatic till last week,then developed haematuria since Last Friday, in each episode of urine output, which lasted for 4 days.No aggrevating factors, No relieving factors.

H/O decreased urine output since 1 month.

No H/O burning micturition, hesitancy or

urgency

No H/O bleeding manifestations,petechiae,rash,blood in stool(melena),bleeding gums.

No H/O Fever, cough, cold, Pain Abdomen

No H/O chest pain, palpitations, Orthopnea.

No polyphagia,polydypsia,nocturia

polyuria present


PAST HISTORY:

N/k/c/o HTN,DM,Thyroid disorders,Epilepsy 

K/c/o renal calculi 2 years back

H/o dialysis 3 years back(2 sessions)


PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Bowel and bladder-regular

Addictions-chronic Alcoholic since 50 years.90ml/day everyday till 2019.

Now occasionally once a week.

Chronic smoker since 50 years.5-6 beedis per day.


FAMILY HISTORY:

Insignificant


GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 130/70mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98.2F


SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS

P/A: soft, non tender,bowel sounds can be heard 


CLINICAL IMAGES:








INVESTIGATIONS:






















UROLOGY REFERRAL:





Diagnosis:

Dimorphic anaemia(Bicytopenia) with CKD(Stage 4) with 4 sessions of hemodialysis done(2019)



Treatment:

  1. TAB.DOLO 650MG PO SOS
  2.  IVF AT 75ML/HR
  3. T.FOLIC ACID 5MG PO OD
  4. T.LASIX 20MG PO BD
  5. INJ.VITCOFOL 1000MCG IM/OD
  6. TAB.NODOSIS 500MG PO OD
  7. T.SHELCAL 500MG PO OD
  8. T.OROFER XT PO OD
  9. T.TAMSULOSIN 0.4 MG
  10. T.PANTOP 40MG
  11. SYP ALKASTON B6 15ML PO BD WITH WATER

SUMMARY:

Final diagnosis:

Dimorphic anaemia(Bicytopenia) with CKD(Stage 4) with 4 sessions of hemodialysis done(2019)


History:

Complaints:

80  year male with c/o Hematuria since 1 week.


HOPI:

Patient was apparently asymptomatic till last week,then developed haematuria since Last Friday, in each episode of urine output, which lasted for 4 days.No aggrevating factors, No relieving factors.

H/O decreased urine output since 1 month, but increased frequency.

No H/O burning micturition, hesitancy or

urgency

No H/O bleeding manifestations,petechiae,rash,blood in stool(melena),bleeding gums.

No H/O Fever, cough, cold, Pain Abdomen

No H/O chest pain, palpitations, Orthopnea

PND.

No polyphagia,polydypsia,nocturia

polyuria present


PAST HISTORY:

N/k/c/o HTN,DM,Thyroid disorders,Epilepsy 

K/c/o renal calculi 2 years back

H/o dialysis 3 years back(2 sessions)


PERSONAL HISTORY:

Diet-mixed 

Appetite-normal

Bowel and bladder-regular

Addictions-chronic Alcoholic since 50 years.90ml/day everyday till 2019.

Now occasionally once a week.

Chronic smoker since 50 years.5-6 beedis per day.


FAMILY HISTORY:

Insignificant


GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 130/70mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

Temperature -98.2F


SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS

P/A: soft, non tender,bowel sounds can be heard 


COURSE IN THE HOSPITAL:

PATIENT WAS ADMITTED IN VIEW OF HEMATURIA 1 WEEK BACK AND ON FURTHER INVESTIGATIONS:


HB:7.4--6.9-7.8

TLC:4500--3900--5200

PLT:60,000--70,000--60,000


CUE PUS CELLS:6-8

RBC:1-2

EPITHELIAL CELLS: 1-2

BACTERIA:PRESENT


PATIENT HAD NO BLEEDING MANIFESTATIONS,PETECHIA,RASH,NO BLOOD IN STOOL (MELENA).NO BLEEDING GUMS.

UROLOGY REFERRAL TAKEN ON 20/05/23 IN VIEW OF HEMATURIA.


DIAGNOSIS: BPH WITH GRADE 2 RPD CHANGES


ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS

T.PANTOP 40MG X 1 WEEK

SYP ALKASTON B6 15ML PO BD WITH WATER


PATIENT WAS TREATED CONSERVATIVELY AND DISCHARGED IN STABLE CONDITION.


PATIENT WAS EXPLAINED TO LOOK FOR THE BLEEDING MANIFESTATIONS AND REPORT TO HOSPITAL IF ANY


TREATMENT GIVEN:

IVF AT 75ML/HR



  1.  TAB.DOLO 650MG PO SOS
  2. T.FOLIC ACID 5MG PO OD
  3. T.LASIX 20MG PO BD
  4. INJ.VITCOFOL 1000MCG IM/OD
  5. TAB.NODOSIS 500MG PO OD
  6. T.SHELCAL 500MG PO OD
  7. T.OROFER XT PO OD
  8. T.TAMSULOSIN 0.4 MG
  9. T.PANTOP 40MG
  10. SYP ALKASTON B6 15ML PO BD WITH WATER

ADVICE:

T.FOLIC ACID 5MG PO OD

T.LASIX 20MG PO BD

INJ.VITCOFOL 1500MCG REGIMEN OD X 1WEEK, ALTERNATE DAYX 1 WEEK, WEEKLY ONCEX 1 WEEK, MONTHLY ONCEX 3MONTHS.

T.SHELCAL 500MG PO OD

T.OROFER XT PO OD

T.TAMSULOSIN 0.4 MGX2 WEEKS

T.PANTOP 40MGX1 WEEK

SYP .ALKASTON B6 15ML PO BD WITH WATER

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