67 year old male with hydronephrosis

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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.

UNIT 1

AMC CUBICAL 2

DOA:04/06/23

A 67 year old male barber by occupation,resident of miryalaguda came to the opd with chief complaints of

Fever since 4days

burning micturition since 4days

decreased urine output since 3days

Abdominal pain in the left side:-2days

HOPI :

Patient was apparently asymptomatic 4 days ago and then developed fever which was insidious in onset,intermittent,associated with chills and rigors,burning during micturition and decreased urine output.

From 2days patient is having pain in the left side of abdomen—insidious onset,intermittent,Migrating from loin to groin,colicky type of pain.

Fever is not associated with cough, vomiting, loose stools,pedal edema

PAST HISTORY:

Urinary complaints of frequency and urgency since 1 yr along with burning micturition.

3months back patient developed fever went to local hospital got medicines ,even after taking medication symptoms are not relieved

K/c/o hypertension since 10 yrs,using medication

Bilateral knee pain since 5 yr bcz of which he stopped farming.

PERSONAL HISTORY:

He wakes up at 6: 30 am and he had a tea and breakfast.At 8:00 am he walks for 1km to reach his work place,work till 1:00pm tand walks back for lunch to home.He has his lunch and takes a nap till 4 pm . In evening routine he eat snacks of tea and biscuits and watch telivision till 9pm and in dinner he eat rice with dal and vegetable curry and sleeps by 10:00pm

Diet:mixed

Sleep:regular

Bladder - burning micturition +

Bowel movements are regular

Addictions:he started taking chewable tobacco since 30 years

Taking alcohol since 25 years

Family history:

Parents died of old age

Young brother died of hiv

GENERAL EXAMINATION:

Patient is conscious,coherent , cooperative with time, place, person

Vitals:

BP-120/80mmhg supine position on right arm.

PR-84 bpm,regular rhythm, normal volume

RR- 24cpm

Jvp - not elevated

Grbs- 120 mg/dl

Poor oral hygiene (Tobacco staining on upper inner teeth)

pallour present

No icterus,

No lymphadenopathy,

No cyanosis.

No clubbing

No edema

Pics Borrowed from

@sagi vikas

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Patient examined in sitting position

Inspection:-

Upper respiratory tract- external nose normal,oral cavity- poor oral hygiene,no halitosis,no thrush

Chest appears bilaterally symmetrical & barrel shaped.

Respiratory movements appear equal on both sides and its Abdominothoracic type.

Lower respiratory tract- trachea appears central,no scars,dilated veins over chest,apical impulse not visible,chest bilaterally symmetrical and movements equal on both sides

Spinal deformity- kyphosis

Palpation:-