80 yr old male came to opd with chief complaints of burning micturition and pain in umbilicus

Hi, I am Y.N.INDU VAISHNAVI 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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 elog also reflects my patient centered online learning portfolio       

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

80 yr old male, unemployed from nampel came to opd with 

C/o-   

nocturia(5times/day) 

Burning micturition

Pain in abdomen during micturtion

Dysuria since 1 day 

History of presenting illness

Patient was apparently asymptomatic before July 2021

Then he developed nocturia(5times /day), urgency, urgency incontinence, dribbling, poor stream for 2 months (June-sep of 2021). Patient went on acute retention of urine in sep 2021 and was catherized. 

He gives a history of voiding trial given 5 months back and failed and he was advised for surgery but he refused it. 

Hematuria was seen when he collected urine for urine examination. 

Dysuria since 1 day, 2 episodes of vomiting 2 days back. 

Glucose levels raised to 540 yesterday night

No history of fever, loss of appetite, loss of weight, turbiduria

Past history

He is known case of diabetes mellitus

2 yrs back he was diagnosed to have HTN but he refuged to take medications

Not a k/c/o , Asthma, TB, thyroid

Treatment history :

He is on medication for diabetis since 2 and 1/2 yrs

Personal history:

Married, unemployed, normal appetite, mixed diet, normal bowel, burning micturition, no known allergies

Alcoholic but stopped consumption since 2 yrs. 

No significant family history 

Examination :

General Examination :

Patient is conscious, coherent and coperative well built and well nourished.

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

Systemic examination:

PER ABDOMINAL EXAMINATION:

INSPECTION-

Shape of abdomen : flat

Umbilicus : inverted 

All quadrants of abdomen move with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites c, no scar on the abdomen 

PALPATION-

Abdomen soft

No local rise of temperature 

No tenderness

No organomegaly

PERCUSSION:

Resonant note heard over all quadrants.

AUSCULTATION:

Bowel sounds heard  

CVS EXAMINATION:

INSPECTION

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse not visible

PALPATION:

Apex beat localised 

AUSCULTATION:

S1 and S2 heard

No Murmurs

 RS EXAMINATION:

INSPECTION: 

Shape of chest: bilaterally symmetrical

Expansion of chest: Equal on both sides

Position of trachea: Central

No visible scars, sinuses, pulsations

PALPATION:

Inspectory findings confirmed

No tenderness, local rise of temperature

Normal expansion of chest on both sides in all areas

Position of trachea: Central

Vocal fremitus: resonant note felt

PERCUSSION:

Resonant note heard over all areas

AUSCULTATION:

Slight wheezing sound is heard

Vocal resonance: resonant in all areas

CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

Investigations