Preeti Prerna M. Vaswani

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Presentation transcript:

Preeti Prerna M. Vaswani Admitting Conference Preeti Prerna M. Vaswani

General Data F.P. 76 years old Male Married Iglesia ni Cristo Sampaloc, Manila

Chief Complaint Hypogastric Pain

History of Present Illness Frequency, dysuria, turbid urine Hypogastric pain Generalized weakness Loss of appetite 3 days PTA Admission

Past Medical History Polycythemia Vera - 2004 (+) BPH - 2008 (+) PTB – completed treatment in 2009 (-) DM, HPN, asthma, thyroid disease, allergies No previous surgery

Family History (-) HPN (-) DM (-) Asthma (-) Cancer

Personal and Social History Smoker – 2.5 pack years Occasional alcoholic beverage drinker No illicit drug use

Review of Systems General: No weight loss Skin: No itchiness, no jaundice Eyes: No blurring of vision, eye pain or itchiness, no excessive lacrimation, no redness Ear: No deafness, no discharge, no tinnitus Nose: No epistaxis, discharge Throat: No sore throat Mouth: No bleeding gums, no oral sores Neck: No neck stiffness, no masses Cardiac: No chest pain, no palpitations Abdominal: No abdominal pain, no diarrhea, no vomiting Musculoskeletal: No myalgia, arthralgia Endo: (-) polyuria, (-) polyphagia, (-) polydipsia; no heat/cold intolerance Neuro: No seizure, no headache Psychiatric: no depression

Physical Examination Conscious, coherent, ambulatory, not in cardiorespiratory distress BP 100/70 mmHg PR 84, regular RR 20 cpm, T 37.0°C Warm dry skin, no active dermatoses, no jaundice Pink palpebral conjunctiva, anicteric sclerae

Physical Examination No nasoaural discharge, turbinates not congested, moist buccal mucosa, nonhyperemic posterior pharyngeal wall Supple neck, (-) palpable cervical lymph nodes, no masses, no tenderness Symmetrical chest expansion, unimpaired transmission of tactile fremiti, resonant on percussion, clear and equal breath sounds

Physical Examination Adynamic precordium, AB 5th LICS MCL, S1>S2 at apex, S2>S1 at base, no murmurs, no S3 or S4, no heaves, no lifts, no thrills Flabby abdomen, normoactive bowel sounds, palpable liver edge, liver span 17cm R MCL, palpable spleen, 15cm below subcostal area, 2.5 cm past midline, tenderness on palpation of hypogastric area, no CVA tenderness DRE: Prostate enlarged, smooth, no nodules Pulses full and equal, no cyanosis, no clubbing, no edema

Neurologic Examination Awake, alert, follows commands, oriented to person, place, time Pupils 2-3mm, ERTL, (+) direct and consensual reflex intact, EOMs full and equal, no ptosis, V1V2V3 intact, (+) corneal reflex, can clench teeth can raise eyebrows equally, can close eyes against resistance , can smile, can frown, can puff cheeks, no facial asymmetry, intact gross hearing, can shrug shoulders and can turn head side to side against resistance, (+) gag reflex, tongue midline on protrusion Motor: 5/5 on both UE and LE; no tremors, no fasciculations, no atrophy Cerebellar: Can do APST/ FTNT with ease DTRs ++ on both UE and LE No sensory deficit (-) Babinski, (-) nuchal rigidity

Assessment Polycythemia Vera Benign Prostatic Hyperplasia T/c Complicated Urinary Tract Infection

Plans CBC Urinalysis Urine culture and sensitivity Ultrasound KUBP Uric Acid

Plans Ciprofloxacin, 500mg/tab, 1 tab BID for 14 days Hydroxyurea Allopurinol NaHCO3