1601006058 LONG CASE
General medicine practical
LONG CASE
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52year old gentleman, from khammam who is a contractor by occupation, came to the hospital with the
chief complaints of urinary incontinence , nocturnal eneuresis, morning urgency and incomplete emptying of bladder since 3 years.
History of Presenting illness :
The patient was apparently asymptomatic 3 years ago, then:
- he developed incontinence of urine since 3 years which got worse since 1 year.he had thin stream of urine and dribbling while voiding since 3 years.
- he had nocturnal enuresis since 1 year which was progressively getting worse. He also experienced morning urgency which was usually uncontrolled dribbling.
- on symptoms getting worse he got a medical checkup where he was diagnosed with benign prostate hyperplasia.
- 4 weeks ago he got his prostate removed for bladder outflow obstruction.
- he then developed jaundice ,high and uncontrolled blood sugar with raised creatinine and urea.
- he also developed headache , dizziness and breathlessness while walking.
- he had normal urine flow rate and no incontinence after the operation.
- he was diagnosed with hydronephrosis and got referred to this hospital.
- he lost 10kg since the last 3 weeks.
Past history :
-he is a diabetic since 5 years.
Personal history :
- He consumes a mixed diet,
- His appetite is normal,
- His bowel movements are regular.
- His bladder movements are regular.
- He has no addictions.
Family history : is not significant
Treatment history : The patient has been taking metformin with glibenpramid since 5 years for diabetes.
On General Physical Examination :
- The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is normal built and well nourished.BMI: 23kg/m2.
Vitals :
- Temperature = he is afebrile
- Pulse = 78 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
- Blood pressure = 110/70 mm of Hg
- Respiratory rate = 17 cycles per minute.
- JVP is normal
- Pallor is present.
- Mild icterus is present.
- There is no Oedema, Clubbing , cyanosis and Generalized lymphadenopathy.
SYSTEMIC EXAMINATION
ABDOMEN
INSPECTION:
1. Shape – round, generalised fullness
2. Flanks – free
3. Umbilicus – Position: normal, Shape- normal
4. Skin – no scars, visible dialations , smooth , no distention.
5.Movements of the abdominal wall equally on respiration on all quadrants.
6. Renal angle:
PALPATION:
Superficial Palpation – No Tenderness, normal Warmth
1. Liver: non-tender, non-pulsatile, no swelling.
2. Spleen is non tender.
3. Kidney :
There is pain on palpation of both the kidneys
No swelling is felt.
Renal angle tenderness is present on both the sides.
PERCUSSION:anterior abdomen is resonant.
AUSCULTATION:
1. Bowel sounds – 10 to 15/min for small bowel, 3 to 5/min for large bowel
2. Bruit – Aortic, Hepatic, Renal Bruit:
27/3/21
27/3/2021
24/4/2021
GRAPH OF SERUM UREA , CREATININE AND HAEMOGLOBIN
SERIES:
Blue: serum urea
Orange: serum creatinine
Grey: haemoglobin
HORIZONTAL:
1:14/4/21; 2:16/4/21; 3:19/4/21; 4:20/4/21; 5:23/4/21
CARDIOVASCULAR SYSTEM:
Inspection:
apical impulse: not visible
No visible pulsations, dilated veins and pericardial bulge.
Palpation: apex beat at 5th intercostal space medial to mid axillary line.
Auscultation:
S1, S2 heard.
EXAMINATION OF RESPIRATORY SYSTEM
Trachea appears to be central.
Shoulders are at same level.
No pectus excavatum or pectus carinatum.
No visible pulsations,dilated veins and scars.
Normal vesicular Breath sounds heard.
NERVOUS SYSTEM EXAMINATION:
On examination of the Higher Mental Functions :
- He is conscious and well oriented to date, time, season, year, place and person.
- His speech is normal.
- His short term and long term memory (when asked to repeat 3 names of objects and when asked what he had for dinner last night)
- He is able to perform basic calculations such as subtracting 7 from 100 five times (100. 93. 86, 79, 65)
- He is able to follow a 3-stage command.
- He is also able to read and obey a written command on a piece of paper ( "Close your eyes")
On examination of the Motor System :
1. Rigidity
2. Bradykinesia
3. Tremors
4. Gait and Coordination
1. Rigidity :
To elicit rigidity, I performed an activation maneuver by asking the patient to tap his hand on the thigh, while I simultaneously checked for rigidity in the wrist, elbow and the ankle.
No rigidity
3. Tremors :
• Tremors are not present
4. Gait and Coordination :
• Gait = normal with good arm swing.
Right left
1. Muscle bulk poor poor
2. Muscle tone normal normal
Upper limb
Shoulder Normal Normal
Elbow normal normal
Wrist normal normal
Lower limb Normal Normal
3. Muscle Power
Upper Limb
Proximal 4/5 5/5
Distal 5/5 5/5
Lower Limb
Proximal 4/5 5/5
Distal 5/5 5/5
4. Reflexes
Superficial reflexes
Right Left
Corneal + +
Conjunctival + +
Abdominal + +
Plantar Flexor Flexor
Deep tendon reflexes
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 2+ 3+
Ankle 2+ 2+
Clonus Absent Absent
On examination of the Cranial Nerves :
• Cranial Nerve 1 : The patient can perceive the smell of soap
• Cranial Nerve 2 : Counting fingers at 6 meters is normal
• Cranial Nerves 3, 4 and 6 : Movements of the extra-ocular muscles, Pupillary reflex and Accommodation reflex are normal. There is no ptosis or nystagmus.
• Cranial Nerve 5 : Sensory component = Ability to perceive sensation over specific areas on the face is Normal. Motor component = Jaw jerk was elicited and the muscles of mastication are normal.
• Cranial Nerve 7 : No deviation of the angle of the mouth, no loss of nasolabial folds, he is able to puff his cheeks, grin and tightly shut his eyes.
• Cranial Nerve 8 : Rinne's test = AC > BC , Weber's test is centralized.
• Cranial Nerves 9 and 10 : Uvula is centrally placed and Gag reflex is present.
• Cranial Nerve 11 : Patient is able to shrug his shoulders against resistance. Trapezius and Sternocleidomastoid are normal.
• Cranial Nerve 12 : Patient can normally move his tongue in all directions.
On examination of the Sensory System :
Right Left
1. Pain + +
2. Crude touch + +
3. Fine touch + +
4. Vibration sense
Medial malleolus 5.7s 4.6s
Patella 9s 4.3s
Elbow 4.8s 6.4s
Wrist 5s 7s
5. Proprioception Normal Normal
6. Stereognosis Normal Normal
7. Tactile localization Normal Normal
8. Two-point discrimination Normal
TREATMENT:
1. INJ PIPTAZ
2. INJ PAN
3. MAINTAIN FLUID INTAKE>2LT
4. INJ LASIK 20mg/IU/BD
5. T. NODOSIS
6. GRBS 6th hourly pre meal
7. INJ HAI 8/L
According to the symptoms and investigations I am of the opinion that it could be acute renal injury due to benign prostate enlargement and he is in the phase of recovery.
SUMMARY :
A 52yr old male with tender renal angle and high creatinine levels with uncontrolled blood sugars being in the recovery phase of acute kidney injury due to benign prostate hypertrophy.
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