Case of a 30 year old male with urinary retention.

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This is the case of a 30 year old male , who is presently unemployed but used to be a farmer.

CHIEF COMPLAINT

The patient came to the casualty with the complaint of urinary retention since 10 days , blood in sputum since 15 days and fever since 5 days .

HISTORY OF PAST ILLNESS

 When the patient  was 10 yr old,he had a trauma to his right leg , since then he cannot flex his knee . 

H/o RTA 4 years ago - in which he fractured his right leg .He underwent surgery .

H/o abscess 14 months ago on the left leg .14months  ago patient developed a small abscess over left shin of tibia which increased in size with swelling of whole limb, blackish discoloration .The patient visited doctor in another hospital where the abscess was removed surgically. Since 1 year he was walking, doing his daily chores but not working in farm.

H/o urinary frequency, urgency, and nocturia since 2 yrs.

H/o of gastritis .

H/o of cough since 15 days with blood in sputum. 

PERSONAL HISTORY-

He has normal appetite, takes mixed diet, regular bowel and bladder movements and takes alcohol daily 180 ml since 15 years, smokes 1 pack/day since 15 years.

GENERAL EXAMINATION

On examination patient is conscious, coherent, cooperative.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

VITALS:

Temp-98.4 degrees F

BP-120/70 mm hg

PR-78 bpm

RR-18cpm

Spo2:97%

P/A:soft,non tender, slightly distended

No guarding or rigidity.

CVS: S1S2+

RS: bilateral air entry+;clear

CNS:NFD

Provisional diagnosis: 

Acute urinary retention under evaluation,? Potts spine.

Pulmonary koch's on ATT since 10 days

Multiple ulcers secondary to ?TB vasculitis/?berger's disease

INVESTIGATIONS:

HEMOGRAM:

HB-12.1

TLC-16,200

PTC-4.45 Lakhs

Normocytic, normochromic blood picture with leucocytosis

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

11/11/21

Hb: 10.6 gm/dl

T.C:14,500 cells/mm3

Lymphocytes: 16%

Platelets: 4.2 L/mm3

Urea: 15

Creatinine: 0.6

Na+: 136

K+: 2.9

Cl-: 90

On USG ABDOMEN AND KUB : No sonological abnormalities detected

Orthopedic referral taken for stiffness in right knee  , chronic Osteomyelitis?, 

Opinion of orthopedic:

Extra articular ankylosis

Quadriceps contracture

And suggested for SURGICAL CORRECTION OF QUADRICEPS PLASTY FOR FLEXION OF KNEE

Urology referral 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

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 CHARTINGTREATMENT:

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