General Medicine E-log: A 30 year old male patient with cough, fever, acute urinary retention and ulcers on the leg

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients’ clinical problems with collective current best evidence-based inputs.

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I’ve 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 30 year old male,farmer by occupation and resident of Nalgonda came to OPD with the cheif complaints of

Ulcers on the foot since 1 year.

Cough since 10 days

Fever since 10 days

Retention of urine since 5 days

History of presenting illness:

The patient was apparently asymptotic 1 year back when he developed a small vesicles on his left leg. It gradually increased in size and was associated with itching. Later several vesicles were seen. It was also associated with swelling of the whole limb and black discolouration of the limb.

He was then taken to a local hospital where the vesicles were punctured and he was operated and debridement was done.

-He gives history of cough with sputum

Since 10 days. The sputum was scanty and had blood tinge and not associated with any foul smell. It didn’t show any positional variation.

he also gives history of fever since 10 days. The fever was low grade fever and showed diurnal variation
He has had acute retention of urine 5 days ago,he was able to feel fullness and want to void but couldn't,was put on Foley's outside after which it was removed the next day but he couldn't pass urine and Foley's was replaced

Past history:

-H/o RTA 3 Years ago after which he got implant in right tibia.

-H/o RTA 2 years ago, Injury to the same leg and sustained a superficial wound.

-patient was diagnosed to be sputum + TB and was started on ATT

Personal history

Appetite: normal

diet: mixed

bowel: regular

Bladder: retention since 10 days. He is put on foleys Cather yet.

Addictions: alcohol daily 180 ml since 15 years

smokes 1 pack/day since 15 years.

GENERAL EXAMINATION:

The patient is conscious, coherent, cooperative.

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema are seen

Vitals:

Temp-98.4 degrees F

BP-120/70 mm hg

PR-78 bpm

RR-18cpm

Spo2:97%

Respiratory system examination:

Inspection:

shape of chest: elliptical

Bilaterally symmetrical

Expansion of chest is decreased on both sides.

Trachea is central

Apex beat is not seen

No drooping of shoulders.

No crowding of ribs.

No scars are sinuses on the chest.

Palpation :

All the inspectory findings were correlated. Apical impulse was felt at the in the 5th intercostal space medial to the mid-clavicular line.

Percussion:

Dullness was noted on the suprasinous, supraclavicular infraclavicular and mammary areas on the right side.

Other areas were resonant.

Auscultation:

Decreased breath sounds on the right supraspinous and supraclavicular infraclavicular and mammary areas.Other areas had normal vesicular sounds.

Examination of the ulcer over the left limb:

There are two ulcers which were noticed on the left limb

Ulcer on the foot: it vertically oval measuring 4*2 cms approximately. The floor of the ulcer shows pus and pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation.

Ulcer on the leg: it vertically oval measuring 10*3cms approximately. The floor of the ulcer shows pale granulation tissue. The edges are undermined. The skin surrounding the ulcer is dry and shows hyperpigmentation.