surgery database DMSF

DATE: dec/03/2023
name: Pothana Boyina Venkata Sai Vara Prasad
roll: 26
IMD 22
Identifying data:

Name: GCQ
Age: 29
Sex: male
Civil status: Single
Occupation: Custodian
Religion: Roman Catholic
Source of history: patient
Reliability: 90%

Chief complaint : blood while urination

History of present illness:

1 day PTA patient felt pain in his genital area. the patient decided to ease
the pain by drinking water, but the patient caused the patient to urinate more. the
patient stopped drinking water due unusual feeling but felt the need to urinated
repeatedly until there was blood spill found on the bowel of the CR. patient
decided to seek consultation to a doctor and was prescribed levoflaxacin 50 mg 1
tab * 14 days. the patient was on foley catheter.
on the day of admission the patient was discharged as he was on OPD. so
he decided to seek consultation in another hospital. hence the admission

Past medical history

patient had acute kidney injury in 2022

Family history
no familial history of hypertension, DM or cancer

Personal and social history

patient does not consume alcohol
patient does not smoke
no pets in home
Review of systems

General - (-) weight loss (-) fatigue

Skin - (-) lesions, (-) rashes (-) itching
EENT: (-) Headache, (-) loss of vision, (-) throat pain
Respiratory - (-) dyspnea, (-) cough
Cardiovascular - (-) chest pain (-) palpitations
Gastrointestinal - (-) constipation, (-) diarrhea
Urinary - (+) hematuria, (-) dysuria (-) polyuria
Musculoskeletal - (-) myalgia, (-) arthralgia, (-) stiffness
Neurologic - (-) loss of consciousness, (-) numbness
Psychologic - (-) anxiety, (-) depression, (-) nervousness
Hematologic - (-) easy bruising, (-) anemia
Endocrine- (-) heat/cold intolerance

Physical examination
VITAL SIGNS:
HR: 91
RR: 21
BP: 100/70 mm/hg
Temp: 36.6
WEIGHT: 63 kg
HEIGHT: 164 cm

GENERAL: Awake, Alert and Not in respiratory distress.

SKIN: Warm to touch. No rashes, no petechiae

HEENT: Anicteric sclera, pale palpebral conjunctiva, no nasal discharge, no

nasal septum deviation

NECK: No palpable cervical lymphadenopathy.

CHEST & LUNGS:

Inspection: equal chest expansion noted, Symmetrical rising of chest
Palpation: Equal Tactile fremitus Noted
Percussion: Resonant sounds upon Percussion noted
Auscultation: Clear breath sounds upon auscultation

CARDIOVASCULAR:
Inspection: Adynamic Precordium noted, PMI at left 5th ICS
Auscultation: Regular Cardiac rate and Rhythm, Prominent S1 and S2 heart
sounds noted

ABDOMEN:
Inspection: No scar, redness or herniation noted
Auscultation: Clicks and gurgles heard upon auscultation
Percussion: Liver dullness noted upon Right upper quadrant. Tympanic sounds
noted on the other quadrants upon Percussion
Palpation: soft non tender abdomen

EXTREMITIES:
CRT<2seconds noted,

NEUROLOGICAL SYSTEM:
LEVEL OF CONSCIOUSNESS: GCS 15
ORIENTATION: orientated to time, place, person
MEMORY:intact memory
CRANIAL NERVES:
CN 2 - Normal pupillary response to light
CN 3,4,6 - Extraocular movements were normal
CN 7 - Normal and symmetrical facial movements noted
CN 8 - Normal hearing upon both sides noted
CN 9 - able to swallow,
CN 11 - Neck and shoulder were symmetrical upon rest and
movements
CN 12 - no deviation of tongue noted

MOTOR STRENGTH: 5/5; 5/5; 5/5; 5/5

REFLEXES: (-) babinski

Diagnostic labs:
HEMATOLOGY:
TEST RESULT UNIT REFERENCE RANGE

blood type "A" Rh positive

complete blood count

hemoglobin 155 g/L 135-175

hematocrit 0.44 % 0.40-0.52

red blood cells 5.18 *10^12/L 4.2-6.1

 TEST RESULT UNIT REFERENCE RANGE

white blood cells (H) 16.4 *10^9/L 4.0-11.0

MCV 86 fL 79-92

MCH 29.90 pg 25.7-33.2

MCHC 35 g/L 32.3-36.5

RDW-CV (L) 11.7 % 11.8-14.5

RDW-SD 36.8 fL

di erential count

segmenters (H) 0.82 % 0.44-0.68

lymphocytes (L) 0.1 % 0.20-0.40

monocytes 0.06 % 0.02-0.04

eosinophil 0.02 % 0.01-0.06

basophil 0.00 % 0.00-0.01

platelet count 303 *10^9/L 150-400

SERUM ELECTROLYTES:

test name result unit reference range

SODIUM 138.30 mmol/L 135.00-145.00

POTASSIUM 3.95 mmol/L 3.50-5.10

IONIZED CALCIUM 1.177 mmol/L 1.120-1.320

MAGNESIUM (L) 0.67 mmol/L 0.74-1.00

CREATININE 100.0 umol/L 71-115

CHEST X-RAY:
impression: unremarkable chest ndings

ULTRASOUND:
impression: cystitis with in ammatory debris considered
onographically normal kidneys, ureters, and prostate glands
ff
fl
fi
Working impression:
acute urinary retention secondary to complicated UTI with hemorrhagic
cystitis

Plans:
started on cefuroxime + salbactum 1.5g iv q12; FC removed voiding freely
POS MGH