67M w/c/o blood clots during micturition

NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 67 yrs old male, a vegetable seller by profession. Stopped working 3 yrs ago.

In 2011, one incident of dysentery (lower abd pain, a lot of bright red blood, mucus laden, non-smelly scanty stool). Pt immediately admitted to the hospital and discharged the next day after treatment.

4-5 yrs ago, c/o painful defecation anal swelling, and 2 subsequent incidents of bleeding pr. Dr. gave medication for a wk, taking which reduced inflammation. No more bleeding pr

For the past 5-7 yrs c/o constipation (2-3 days no motion, 4th-day normal defecation). Also c/o gastric problems (dyspepsia, uneasiness, loss of appetite, diffused abd. pain) once a month.

For the past 1 yr also c/o of occasional back pain(low intensity) 2-3 times/wk, which pt reports reduce after defaecation. Sometimes, this back pain occurs after lifting/carrying heavy objects and goes away on its own after a few hrs of rest.

On 30th Nov 2022, at 8 am pt noted passing urine with a reddish hue. 2-3 hrs later gained passed urine with a reddish hue. At around 2:30 pm went to urinate but only clotted blood came out in good quantity. Immediately went to a Urologist who recommended USG, CT, a blood test, a urine examination, and prescribed medication. A soft tissue mass was detected in the rt kidney and the pt was told it was renal ca. Dr. instructed him to continue the same medications. After this incident, pt has to wake up 3-4 times at night for micturition which disturbs his sleep cycle.

From 3rd Dec, sometimes c/o a slight abd pain in rt side, burning sensation while passing urine and whenever feels a burning sensation, blood clots will be present in urine. Urine color is normal. Pt also sometimes c/o a slight pain in rt side of abd which goes away on its own. If severe pain then more blood clots come out while urinating.

Pt is nondiabetic and denied h/o HTN. Denied any h/o smoking or alc. consumption.

Appetite is normal. Pt feels he may have lost some wt recently.

CHIEF COMPLAINTS AND Pt REQ.: c/o blood clots with urine since the past 1wk.

Constipation for the past 5-7 yrs

FAMILY HISTORY: 

Father - no complaints 

Mother - DM (4-5 yrs)

Sister - no complaints

2 brothers - no complaints






 

                                                             




REPORTS:









PROVISIONAL DIAGNOSIS: RCC





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