68 male acute retension of urine secondary to urethral stricture

A case of a 68 yr old male with decreased urine output and shortness of breath

December 06,2023

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.

A 68 yr old male resident of Ramanpeta a retired accountant came to the OPD with

Cheif complaints - 

Decreased urine output -3 hrs

Breathless -3 hrs

History of presenting illness- 

Patient was apparently asymptomatic to 3 hours ago then he developed decreased urine output which was sudden in onset, associated with urgency and pain.

Associated with shortness of breath which is insidious in onset gradually progressive aggravated on walking and relieved by taking rest.

History of abdominal distention and facial puffiness on and off since 3 months.

No history of fever, chest pain, palpitations, cough and cold.

Past history- 

7 years ago - The patient has undergone hemorrhoidectomy on one side and later he couldn't get hemorrhoidectomy done on the other side as the patient lost follow up with doctor.

1 year ago-

28/10/22 - 

7.00 am -

 The patient woke up and performed his daily routine

9.00 am -

The patient developed severe chest pain and shortness of breath when he was walking in varenda .

9.15 am - 

The patient was taken to nearby primary health care center and an ecg was taken which was abnormal and the doctor insisted to go to a bigger hospital.

4.00 pm - 

The patient was admitted at a tertiary hospital and a 2D echo was done and was planned for percutaneous coronary intervention.

6.00 pm - 

Percutaneous coronary intervention was done .

29/10/22 - 

The patient was discharged and adviced bed rest and proper nutrition.

30/10/22 -

The patient was relieved of symptoms.

K/c/o hypertension - 1 year ago taking medications - ramipril 2.5 mg + metoprolol 25 mg

K/c/o hypothyroid - 6 months T.thyronorm 12.5 mcg.

N/k/c/o - DM, asthma , epilepsy.

PERSONAL HISTORY:

Before illness : 

Diet- mixed

Appetite - normal 

 Sleep -Adequate 

Bowel and bladder movements - regular  No known allergies

After illness : Diet : mixed 

Appetite - decreased 

Sleep - adequate

Bowel and bladder movements-  decreased urine output

He consumed alcohol regularly since 30 years and smoked about 2-3 packs per day before PCI stent placement and stopped afterwards.

FAMILY HISTORY : not significant

GENERAL EXAMINATION : 

Patient was conscious coherent cooperative.

Moderately built 

Moderately nourished.

No pallor, icterus, cyanosis, clubbing and lymphadenopathy.

Vitals : pulse rate : 80 bpm

Respiratory rate : 32 cpm

Temperature : a febrile

Blood pressure : 110/80 mm hg.

Systemic examination: 

Cvs:  S1 ,S2 heard, no murmurs 

Respiratory system :  normal vesicular breath sounds heard, bilateral air entry

CNS: no focal neurological deficit , higher mental functions intact , no signs of meningial irritation.

Tone:          RT.            LT

             Ul. N.               N

             Ll. N.               Reduced

 

Power : RT.          LT

            UL. 5/5   5/5

            LL. 5/5 

Reflex: RT.              LT

            B :+3           +3    

            T:  +3.         +3

            S :+3           +3

            K :+3           not elicited    

            A :+3           not elicited 

Per abdomen : 

Distended , soft , non tender , no ornganomegaly.

Investigations: 

ECG :

On: 3/12/23 

Ultrasound abdomen:  

3/12/23

 

Retrograde urethrogram: 

On 5/12/23

Provisional diagnosis:

Acute retension of urine secondary to structure urethra.

Treatment:

- Inj.ceftraixone 2mg iv bd

- Inj.lasix 29 mg iv /bd

- Tab .Ramipril 2.5 + metoprolol 25 mg od

- T.ecosprin av 75/10 OD

- T. Thyronorm 12.5 mcg OD

- neb. with duolin 8th hourly,budecort 12th hrly