A 80year old male with pain in hypogastric region

October 05, 2023

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

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

Chief complaints:

A 80 year male came to the opd with complaints of pain in hypogastric region since 1year.

Dribbling of urine since 9months

History of presenting illness:

Patinet was apparently asymptomatic 1year back the he developed pain in hypogastric region which is continuous,pricking type ,non radiating no aggravating and relieving factors.

C/O dribbling of urine associated with burning micturation.

C/O urinary incontinence

No C/O vomiting,nausea,fever,cold,cough.

Past History:

N/K/C/O Hypertension,Diabetes,Tuberculosis,

Asthma,CVD,CAD.

Personal History:

Diet : Mixed

Appetite : Normal

Sleep : Normal

Bowel moments :Regular

Bladder:irregular

Addictions: chronic alcoholic since 60yrs and stopped 2months back.

Family History:

Not significant

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Moderately built and nourished.

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent

Vitals:

Temperature - Afebrile

PR :- 84bpm

BP :- 120/80 mm Hg

RR:- 16cpm

Systemic examination:

CVS : S1S2 heard

RS: BAE +

CNS:No focal neurological deficit.

P/A: soft, tenderness in hypogastric region

Investigations:

Prostate specific antigen-37.034ng/ml

USG Abdomen:(2/10/23)

(impression)

Heterogenously hyperechoic lesion with peripheral calcification seen in right lobe of liver.

B/L grade 1- 2 renal parenchymal changes

Grade 1 prostatomegaly with median lobe hypertrophy into urinary bladder.

MRI PROSTATE WITH CONTRAST(2/10/23)

Moderate prostatomegaly with irregular lobulated contour and median lobe is enlarged compressing and displacing the bladder base.

Multiple cystic changes.

Small hypointense ,minimally enhancing nodule seen in outer peripheral zone on both sides with no ristricted diffusion and showing citrate peaks(PIRADS-2/3)