60 year old male with red coloured urine and Generalised weakness

 

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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.

 A 60 year old male, ambulance driver by occupation & resident of appalguda thanda of suryapet district presented to OPD with chief complaints of 

Chief complaints :

Red coloured urine since 2 months

Shortness of breath since 45 days

Generalised weakness since 30 days

Constipation since 6 days 

HOPI :

Patient was apparently asymptomatic 2 months back. Then he noticed red coloured urine, which was insidious in onset, gradually progressive. Increased in frequency of urine, mainly during night time. 

Incontinuity of urine is present, at first patient passes red colour urine for few seconds followed by decreased urinary stream associated with sensation of obstruction and pain, after intense pressure he passes dark coloured clots and then normal stream of red coloured urine.

He also has burning micturition and supra-pubic pain while passing urine.

Patient also has compliants of constipation since 6 days which resolves on taking medication. 

H/o giddiness.

H/o tremors .

No H/O fever, weightloss

No H/O loss of appetite 

No H/O cough and hemoptysis

No H/O nausea,vomiting,loose stools. 

No H/o orthopnea and paroxysmal nocturnal dyspnea.

No H/O abdominal distension, abdominal pain.

Past History: 

History of hydrocele, since 15 years.

He worked as a driver for 20 years.

History of trauma 15 years back, while lifting the lorry back door, he slipped and fell during this. 

After this incident in 1-2 months he noticed a swelling in the right groin which is gradually increased in size, painless. Later he neglected the swelling as there was no pain.

Not a k/c/o HTN, diabetes, asthma, epilepsy, TB.

No H/O any past surgery.

He has a H/O fracture of left humerus at distal end, when he was 20 years old, while cutting a tree. Then he got treated for it with reduction and plaster of Paris. But the treatment resulted in maluni7on.

Personal History:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder: constipation since 6 days 

Addictions:

 Alcohol intake every day  (90ml) from 30 years, stopped 2 months back.

Smoking daily 20 beedi in 1 day from 30 years,stopped 2 months back 

Family history:

No significant history.

General examination:

Patient is conscious, coherent, and co-operative. Well oriented to time place and person.

He is moderately built and moderately nourished.

Pallor- present

Icterus- absent

Cyanosis- absent

Clubbing- absent

No lymphadenopathy

No edema

Vitals :

Temperature- Afebrile

Blood pressure- 120/80mm hg

Pulse rate- 96bpm

Respiratory rate- 20cpm

Systemic examination:

Per abdomen: 

On inspection:

Shape of abdomen: scaphoid

Umbilicus: inverted

Movements of abdominal wall with respiration

Scars present( due to beliefs that it helps in digestion, done in childhood)

Swelling in scrotum.(hydrocele?)

No visible peristalsis, pulsations, sinuses, engorged veins.

On palpation:

All Inspection findings are confirmed

No local rise of temperature 

Soft and non tender

No palpable masses

Liver is not palpable

Spleen is not palpable

On percussion:

Tympanic note present

On auscultation:

bowels sounds heard

CVS examination:

Inspection:

No raised JVP

Trachea appears to be central

The chest wall is bilaterally symmetrical 

No dilated veins, scars or sinuses are seen

Palpation:

Trachea central in position 

Apex beat is felt in the fifth intercostal space, 1cm medial to the midclavicular line

Auscultation:

S1 S2 heard

No murmurs 

Respiratory examination:

Shape of chest is elliptical, bilaterally symmetrical

B/L airway entry present

Normal vesicular breath sounds

CNS Examination:

Conscious, coherent, cooperative and well oriented

Normal speech.

No neurological deficit found.

 DIAGNOSIS:

Severe Anemia secondary to blood loss (Hematuria) 

? Urothelial malignancy with right sided vaginal hydrocele