CASE OF A 70 YEAR OLD FEMALE WITH COMPLAINTS OF DECREASED URINE OUTPUT AND BURNING MICTURATION

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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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.


CHIEF COMPLAINTS
 
A 70 year old female, labourer by occupation presented with chief complaints of : 
  • Decreased urine output since 20 days. 
  • Burning Micturation since 20 days. 
  • Urgency in micturation since 20 days.

HOPI

The patient was apparantly asymptomatic 20 days back when she developed decreased urine output, burning micturation and urgency in micturation for which she visited the local hospital. 
She denies any history of Fever, Hematuria, Lower Back Pain or Loin Pain.

PAST HISTORY
 
   She has undergone a Hysterectomy for a Uterine Fibroid. 
   She is not a known case of DM, HTN, TB, Asthma and Epilepsy.

PERSONAL HISTORY 
 
  • Diet - Mixed
  • Appetite - Normal 
  • Sleep - Adequate
  • Bowel Movements - Normal 
  • Addictions - Alcohol (Occasionally)

GENERAL EXAMIMATION 
 
   The patient was conscious, coherent and cooperative.
   PR -
   RR -
   BP -
   Temp - Afebrile

Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent

SYSTEMIC EXAMINATION
 
  CVS - S1, S2 are heard, no murmurs 
  RS - Normal B/L Vesicular Breath Sounds 
  CNS - No focal neurological deficits. 
  P/A - Palpable Mass in the suprapubic region,Skin - Smooth, Surface - Smooth, Firm consistency, Tenderness present.

INVESTIGATIONS
HEMOGRAM
CUE 
LFT
BLOOD UREA
SERUM CREATNINE
SERUM ELECTROLYTES
URINE CULTURE AND SENSITIVITY

PROVISIONAL DIAGNOSIS


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