A 30 year old male patient with cough, fever, acute urinary retention and ulcers on the leg
ROHITH SOMANI
MBBS 9th semester
roll no:127
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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 diagnosis and treatment plan.
CASE DISCUSSION:
A 30 year old male,farmer by occupation and resident of Nalgonda came to OPD with the chief complaints of
Ulcers on the leg and foot since 1 year.
Cough since 10 days
Fever since 10 days
Retention of urine since 5 days
DAILY ROUTINE: He use to wake 6AM and use to clean cattle shed and use to feed cattle and use to go for work at farm. Afternoon he use have luch and then return to home by and use to spend some time with children and then he drinks alcohol and goes to sleep.
HOPI:
Patient was apparently asymptomatic 1year back and developed small vesicle in left leg which was round in shape and measured about 1 to 2cm in size which was associated with itching and he gave history that he scratched vesicle which led gradual Swelling of whole limb from which there was watery discharge and he went to doctor at Nalgonda he punctured many areas in limb to reduce edema and that areas turned into after few days and they went to doctor ,he dissected black area.
He gives history of cough with sputum
Since 10 days. The sputum was scanty and had blood tinge and not associated with any foul smell. It didn’t show any positional variation.
- -he also gives history of fever since 10 days. The fever was low grade fever and showed diurnal variation associated with chills.
- -He has had acute retention of urine 5 days ago,he was able to feel fullness and want to void but couldn't,was put on Foley's outside after which it was removed the next day but he couldn't pass urine and Foley's was replaced
Past history:
-H/o RTA 3 Years ago after which he got implant in right tibia.
-H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound.
-patient was diagnosed to be sputum + TB and was started on ATT 10days before admission into our hospital.
Patient has no history of Hypertension, diabetes ,epilepsy,asthma
Personal history
Appetite: normal
diet: mixed
bowel: decreased stool output since 5days
Bladder: retention since 5 days. He is put on foleys Cather yet.
Addictions: alcohol daily 180 ml since 15 years smokes 1 pack/day since 15 years.
GENERAL EXAMINATION:
The patient is conscious, coherent, cooperative.
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema are seen
Vitals:
Temp-99.2degrees F
BP-120/70 mm hg
PR-78 bpm
RR-18cpm
Spo2:97%
Respiratory system examination:
Inspection:
shape of chest: elliptical
Bilaterally symmetrical
Expansion of chest is decreased on both sides.
Trachea is central
Apex beat is not seen
No drooping of shoulders.
No crowding of ribs.
No scars are sinuses on the chest.
Palpation :
All the inspectory findings were correlated. Apical impulse was felt at the in the 5th intercostal space medial to the mid-clavicular line.
Percussion:
Dullness was noted on the supraspinous, supraclavicular infraclavicular and mammary areas on the right side.
Other areas were resonant.
Auscultation:
Decreased breath sounds on the right supraspinous and supraclavicular infraclavicular and mammary areas.Other areas had normal vesicular sounds.
Examination of the ulcer over the left limb:
There are two ulcers which were noticed on the left limb
Ulcer on the foot:
it vertically oval measuring 4*2 cms approximately. The floor of the ulcer shows pus and pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation.
it vertically oval measuring 10*3cms approximately. The floor of the ulcer shows pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation.
Inspection
the shape of the abdomen: scaphoid
Umbilicus - everted
palpation;
Tenderness- not present
- no abnormal mass is palpable
Bowel sounds: not heard
liver and spleen not palpable
CENTRAL NERVOUS SYSTEM:
consciousness- conscious
Speech- normal
Neck stiffness-no
Kernig sign -no
Giat- normal
Sensory system:intact
Motor system:
Upper limb reflexes was exaggerated
Lowe limb reflexes was absent.
Power:
Lower limbs -3/5
Upper limb- 5/5
INVESTIGATIONS:
Serum electrolyte:
Sodium:136mEq/L
Pottasium:2.9mEq/L
Chloride:90mEq/L
Hemogram
Hemoglobin:10.5gm/dl
TLC:15,800cells/mm3
Neutrophils:70%
Lymphocytes:18%
Eosinophils:05%
Monocytes:07%
Basophil:0%
PCV:30vol%
MCV:79.4fL
MCH:27.7pg
MCHC;34.9%
RBC:3.7millions/mm3
Platelet:4.9lakhs/mm3
ESR-130mm/1st hour
CRP:1.2mg/dl
CUE:
Albumin-nil
Sugar-nil
Pus cells-3-4
Epithelial cells-2-3
Red blood cells-2-3
LFT:
TB-1.00
DB-0.18
AST-36
ALT-20
ALP-129
TP-6.6
Albumin-3.0
A/G-0.83
RFT:
urea-17
Creatinine-0.6
Uric acid-5.2
Ca-10.0
P-3.0
Na-137
K-3.0
Cl-98
PLBS 100
FBS 89
X-RAY:
Opinion of orthopedic:
Extra articular ankylosis
Quadriceps contracture
And suggested for SURGICAL CORRECTION OF QUADRICEPS PLASTY FOR FLEXION OF KNEE
Urology referal taken for decreased urine output, adviced for Urine AFB, NCCT KUB, Urine C/S, gramstain,AFB
Urology opinion taken agian after the NCCT , culture reports, and USG
USG done and it says normal prostrate size with normal bladder wall thickening
Urine is not positive for any acid fast bacilli
NCCT is normal
Urology opinion:
T.TAMUSOLIN 0.4mg OD for 2 weeks and review after 2 weeks
DERMATOLOGY opinion was taken for blebs followed by ulcerations on left lower limb since 3 yrs
Dermatology opinion: liquid paraffin local application And skin biopsy taken on 13/11/2021
PROVISIONAL DIAGNOSIS:
Acute urinary retention under evaluation.
Pulmonary koch's on ATT since 10 days
Multiple ulcers secondary to TB?vasculitis?buerger disease
TREATMENT:
1)IVF 2 NS,2RL @100 ML/HR
2)INJ.PAN 40 MG IV/OD
3)ATT X 4 TABS
4)INJ.AUGMENTIN 1.2 GM IV/BD
5)INJ.LASIX 20MG IV/BD
6)SYP.ASCORYL 10 ML PO/BD
7)SYP.CREMAFFIN 15 ML PO/BD
8)BP,PR MONITORING;GRBS 12TH HOURLY
9)STRICT I/O CHARTING
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