70M BPH DM(4yrs)

 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.

70 YR OLD MALE C/O URINARY RETENTION, URINARY HESITATION, URINARY URGENCY SINCE 1 MONTH

C/O B/L KNEE PAIN SINCE 2013

C/O LEFT EAR HEARING LOSS SINCE 2008

BOTH EYES BLURRING OF VISION SINCE 1 YEAR

 HISTORY OF PRESENTING ILLNESS

PATIENCE WAS APPARENTLY ASYMPTOMATIC 1MONTH AGO AND THEN HE DEVELOPED URINARY RETENTION SINCE ONE MONTH, UNABLE TO URINATR AND SEVERE DISCOMFORT WITH BLADDER FULLNESS AND ASSOCIATED WITH URINARY HESITATION SINCE ONE MONTH AS PATIENT IS UNABLE TO URINATE WITH DIFFICULTY IN STARTING AND MAINTAINING URINARY STREAM ASSOCIATED WITH URGENT URINATION (URINARY URGENCY) SINCE ONE MONTH WITH SUDDEN NEED TI URINATE WITH DISCOMFORT IN BLADDER ASSOCIATED WITH NOCTURIA WITH 3 TO 4 TIMES AT NIGHT ONLY SINCE ONE MONTH

B/L KNEE PAIN SINCE 2013,INSIDIOUS ONSET PROGRESSIVELY INCREASING AND AGGREVATING ON WALKING, CLIMBING STAIRES ASSOCIATED WITH HEARING LOSS LEFT SIDE SINCE 2008 AND BLURRING OF VISION SINCE 1 YR OF BOTH EYES

H/0 SIMILAR COMPLAINTS OF URINARY RETENTION 40 YRS BACK(1972)

K/C/O DM II SINCE 4 YRS AND ON TAB GLIMEPERIDE 1MG +TAB METFORMIN 1000MG PO OD

H/0 OBSESSIVE COMPULSIVE DISORDER AND ON MEDICATION TAB CLOMIPRAMINE hcl

H/0 DEPRESSION AND ON TAB OLANZAPINE 5MG+ FLUOXETINE 20 MG, AND TAB CLOMIPRAMINE HCL

DAILY ROUTINE BEFORE 2008

B/W 6AM TO 6 30 AM :WAKES UP, MAKES TEA, TOILET

6 30AM TO 8 AM :EXERCISE, REST, FRESHUP

8 AM TO 10 AM: BREAKFAST, DAILY CHORES, BUYS GROCERIES

10AM: SHORT MEAL

10am to 11am: travel to school

11 am to 4pm goes to school as he was a school teacher

4pm to 5pm: travel back home

5pm to 5 30pm: lunch

5 30 t0 7  pm: plays volley ball, football, gardening

7 pm to 9pm: reads books and journals

9 pm to 10 pm :dinner

10 pm to 10 45 pm: reads books

11 00pm :sleep off

Daily routine  from 2008 to 2013

9am :wakes up

10 am: breakfast

10 40 am to 4 pm:  goes to school

4pm to 5pm: travel back home

5pm: lunch

5 30pm to 9 45 pm :sleeps

10 pm: dinner

10 30 pm: sleeps off

Daily routine from 2014 to 2018

7am: wakes up

8 am to 10 am:  batch1 tuition

10am to 12 pm: batch 3 tuition

12 30 pm to 5pm :lunch, sleep tv

5 pm to 8 pm: batch 3 tuition

8pm to 10 pm reading books, journal

10 pm to 11pm :dinner

11 pm :disturbed sleep

Daily routine from 2019

9am to 10 am wakeup, drinks tea, breakfast, reads news paper sleep

10am to 1 30 pm sleep

1 30pm to 2 pm lunch watch tv

2 30 pm to 5 pm sleep

5 30pm to 6 pm drinks tea, tv sleeps

6pm to 10 30pm sleep

10 30pm dinner watch tv while eating

11 pm sleep

BIOPSYCHOSOCIAL HISTORY

PT C/O BLASPHEMOUS THOUGHTS SINCE 4 YEARS

BACKGROUND HISTORY

PT WAS DIAGNOSED WITH PSYCHIATRIC ILLNESS IN 2009 USED MEDICATION FOR 4 YEARS AND STOPPED AS PER DOCTORS ADVICE ( REPORTS NOT AVAILABLE) BUT OCCASIONALLY REPETITIVE, INTRUSIVE THOUGHTS WERE STILL PRESENT WITH NO IMPAIRMENT IN PTS SOCIAL AND OCCUPATIONAL FUNCTION

 HISTORY OF PRESENTING ILLNESS

PT WAS APPARENTLY ASYMPTOMATIC TILL 4 YEARS BACK WHEN ALL OF SUDDEN HE LOST HIS WIFE(DUE TO ? HYPOGLYCEMIA) IN 2019,FOLLOWING WHICH PT MENTIONED THAT HE STARTED FEELING LOW ALL THE TIME AND HAD LOST INTEREST IN DOING ANY ACTIVITIES AND SOMETIMES FELT THAT LIFE WAS NOT WORTHY LIVING AND COULD NOT FOCUS ON ANY WORK HE PUTS HIS MIND TO WHICH, ASSOCIATED WITH DISTURBED SLEEP AND DECREASED APPETITE AND PT INFORMS HE FELT LIKE HE HAD NO ENERGY TO DO ANYTHING AND HE SOMETIMES WOULD HEAR SOUNDS THAT NO ONE ELSE COULD HEAR

INFORMANT SAYS PT SMILES TO HIMSELF WITHOUT ANY REASON AT TIMES BUT ONLY WHEN ALONE

PT ALSO INFORMS THAT HE HAD REPETITIVE INTRUSIVE BLASPHEMOUS THOUGHTS WHICH WERE PREVIOUSLY PRESENT BUT AGGRAVATED SINCE THE DEATH OF HIS WIFE WHICH WERE OFTEN TRIGGERED BY EXTERNAL OBJECTS, SOMETIMES THOUGHTS WHICH LED TO HIM EXPERIENCING SIGNIFICANT BLACK MAGIC WAS DONE ON HIM AND THAT IS THE REASON FOR ALL HIS COMPLAINTS

FOR THESE COMPLAINTS PT WAS TAKEN TO PSYCHIATRIST AND IS ON REGULAR FOLLOW UP SINCE 2020.PT AND ATTENDER REPORTS SIGNIFICANT IMPROVEMENT IN SYMPTOMS AND ARE COMFORTABLE WITH THE TREATMENT

CURRENTLY PT REPORTS OCCASIONAL BLASPHEMOUS THOUGHTS BUT NO OTHER COMPLAINTS, ATTENDER REPORTS NEAR TOTAL IMPROVEMENT

SLEEP AND APPETITE NORMAL, SELF CARE AND HYGIENE MAINTAINED, OCCASIONAL ALCOHOL USE, ABSTINENCE FROM CHEWING TOBACCO, NO OTHER SIGNIFICANT PSYCHIATRY HISTORY

PAST HISTORY

1 EPISODE OF SIMILAR C/O IN 2008 FOR WHICH PT WAS ON MEDICATION FOR 4 TO 5 YRS

General examination

Pt is c/c/c

CVS EXAMINATION:

JVP NOT RAISED 

INSPECTION:

SHAPE OF CHEST - ELLIPTICAL

NO VISIBLE PULSATIONS

NO ENGORGED VEINS AND SCARS 

APICAL IMPULSE NOT VISIBLE

PALPATION:

APEX BEAT PRESENT OVER THE LEFT 5TH INTERCOSTAL SPACE 1CM MEDIAL TO MIDCLAVICULAR LINE

NO PARASTERNAL HEAVE

NO PRECORDIAL THRILL

NO DILATED VEINS

AUSCULTATION:

S1 S2 HEARD ,NO MURMURS

RESPIRATORY EXAMINATION:

UPPER RESPIRATORY TRACT - NORMAL

LOWER RESPIRATORY TRACT-

INSPECTION:

CHEST BILATERALLY SYMMETRICAL,

SHAPE- ELLIPTICAL

TRACHEA- CENTRAL

PALPATION:

TRACHEA IS CENTRAL

NORMAL CHEST MOVEMENTS

VOCAL FREMITUS IS NORMAL IN ALL AREAS 

PERCUSSION: IN SITTING POSTION

                                         Rt.                    Lt

Supraclavicular.    N(resonant).           N

Infraclavicular.            N                         N

Mammary region.       N.                       N

Inframammary region.   N.                  N

Axillary region.                N.                   N

Infra axillary region      . N                 . N

Supra scapular region.    N.                  N

Interscapular region.        N                  N.  

Infrascapular region.       N.                  N

AUSCULTATION:

NORMAL VESICULAR BREATH SOUNDS

NO ADDED SOUNDS

VOCAL RESONANCE IS NORMAL IN ALL AREAS.

CNS EXAMINATION:

Higher motor functions - intact

Cranial nerves - intact

Motor system:

            Rt-     UL.     LL.     Lt-   UL.    LL

Bulk -            N        N.               N.       N 

Tone -           N.       N.                N.       N

Power -        5/5.    5/5.              5/5.    5/5

Reflexes:         

                               UL                      LL

Biceps.                    2+                       2+

Triceps.                  2+                       2+

Supinator.             2+                       2+

Knee                       2+.                      2+

Ankle.                    2+                       2+

Sensory system: intact

Co ordination is present 

Gait is normal

No Cerebellar signs 

No signs of meningeal irritation

ABDOMINAL EXAMINATION:

Inspection:

Shape - distended

Umbilicus - inverted

All quadrants moves equally with respiration 

No engorged veins, visible pulsations,scars,sinuses

Palpation:

All inspectory findings are confirmed 

No local rise of temperature

Abdomen is soft and non tender 

spleen and liver -not palpable 

No other palpable masses

Hernial orifice are free

Auscultation:

Bowel sounds heard.

Urology referal done i/v/o urinary Frequency, urgency,incontinence and Nocturia since 2 weeks and adviced for PSA

Surgical profile Sent on 12/1/24

Repeat rft done on 12/1/24

Urine for culture and sensitivity sent as adviced by urologist

Report pending

Chest xray

Ecg

Ortho referal done i/v/0 bilateral knee pain on 10/1/24

Xray knee taken as advised by orthopedic as pt was complaining of bilateral knee pain

Psychiatry referal done i/v/o blasphemous thoughts 

2D echo

Grbs monitoring from day of admission

Pre anaesthesia checkup (PAC) ON 13/1/24

Review PAC ON 16/1/24

Electronical discharge summary