62 year old male with urinary symptoms,long case

62 year old male with urinary symptoms.

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Long case.

A 62 year old male came to opd with chief complaints of increased frequency of micturition  since 1 month and burning micturition since 10 days.

History of present illness:

He was apparently asymptomatic 1 month back, then he had increased frequency of urination which is gradually progressing.He empties his bladder 8-10 times per day,then developed burning micturition suddenly , insidious in onset for which he went to a local doctor who prescribed paracetamol which did not relieve his symptoms following which he came to the OPD.

Dysuria present

H/o incontinence and urgency.

H/o suprapubic pain

H/o strangury-intense feeling to void urine after micturition due to severe detrusor spasm.

No h/o dribbling of urine

No h/o loin pain

No h/o of fever

No h/o hematuria

No h/o itching in groin area

Past history:

No history of similar complaints in the past.

Pt is a k/c/o Hypertension

No H/o Diabetes Mellitus, Asthma, Thyroid dysfunction, Epilepsy

No Cardiovascular abnormalities

No known allergies.

Personal history:

Diet : Mixed 

Sleep : Inadequate

Appetite : Reduced

Bladder:burning micturition

Bowel:regular

No known addictions.

Family history:

No history of similar complaints in family.

Drug history:

Patient currently not on any medication.

No known drug allergies.

General examination:

Pt is conscious, coherent and co operative

Well oriented to time and place

Moderately built and nourished

No Pallor, icterus, cyanosis, koilonychia, lymphadenopathy, or pedal edema.

VITALS

Temperature: afebrile 

PR : 80 bpm

BP : 130/80 mm Hg

RR : 16cpm

Systemic examination:

Per abdomen:

INSPECTION

Shape : Elliptical

All Quadrants of abdomen moving in accordance with respiration

Umbilicus central and inverted

No scars sinuses or engorged veins

PALPATION

Inspectory findings are confirmed.

No tenderness

No organomegaly

PERCUSSION

Tympanic

AUSCULTATION

Normal bowel sounds heard.

Respiratory system:

INSPECTION

shape of chest : elliptical and symmetrical

size of chest : Normal

Movement of chest : Symmetrical movement

No engorged veins and sinuses

PALPATION

Shape and size : elliptical and normal

Normal movements corresponding to breathing

No tenderness or pain on palpation

PERCUSSION & AUSCULTATION

Normal resonant note on percussion

Bronchoalevolar sounds heard

Vesicular breath sounds.

Cardiovascular system:

INSPECTION

No engorged veins and sinuses

No visible pulsations

PALPATION

Apical impulse - in left 5th inter costal space,medial to mid clavicular line.

AUSCULTATION

S1 and S2 heard

No murmurs.

Cns:

Higher mental functions : Normal

Cranial nerves : Intact

Sensory System : Normal

Motor System : Normal

Meningeal signs : Absent

Cerebellar signs : Absent.

Investigations:

1.mid catch urine-culture and antibiotic sensitivity.

2.Complete blood picture:

Haemogram.

3.serum creatinine.

4.random blood sugar.

5.serum electrolytes.

6.complete urinary examination.

Provisional diagnosis:

Recurrent urinary tract infection.

Treatment:

1.tablet trimethoprim 200 mg daily three days.

2.nitrofurantoin 50 mg 6 hourly for  three days.

3.co-amoxiclav 250 mg 8 hourly for 3 days.

4.ciprofloxacin 100mg 12 hourly for 3 days.

5.alkanization of urine by citralka syrup.

Syrup citralka 10 ml diluted in glass of water 3 times daily for 2 weeks.

6.urinary analgesics and antispasmodic for detrusor spasm.

Advice:

1.fluid intake of atleast 2L/day

2.regular complete emptying of bladder

3.good personal hygiene

4.cranberry juice may be effective.