Final short case

This is a 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 patients problems through series of inputs from available global community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs .This E log book also reflects my patient centered online learning portfolio and your valuable inputs in comment box is welcome.


38 year old female, housewife, came to opd  on 14/1/23
Chief complaint 
Patient came to opd with chief complaints of : 
    Decreased urine output since 1 month
      Painful urination since 15 days
      Burning micturition since 10 days
      Pain in lower abdomen since 10 days
History of present illness:- 
Patient was apparently asymptomatic 1 month back , then she developed decreased urine output Since 1 month. 
she developed pain during micturition since 15 days which is insidious onset. 
Burning micturition since 10 days 

No H/O haematuria, retention of urine 
 Lower abdominal pain since 10 days , spasmodic type , non radiating with no aggrevating and relieving factors

.No H/O fever, vomitings,nausea

Patient had H/O urinary retention , poor stream of urine and burning micturition when she was diagnosed with urethral stricture 1 year ago and underwent urethrotomy 1 year ago and urethral dilatation is being done 
Past history :
Not a k/c/o DM, HTN , TB ,epilepsy, asthma,Thyroid.
Personal history:
Appetite- Normal
Diet - mixed 
Bowel - regular 
Bladder - burning micturition, dysuria MENSTRUAL HISTORY
AOM - 16 years ,Cycle - 5/30 days , regular ,associated with pain in the lower abdomen.

FAMILY HISTORY:

no significant family history 

General examination :
Pt is Coherent cooperative and concious. 
Pallor is present .
No icterus, cyanosis, clubbing, lymphadenopathy , pedal edema 
Vitals - 
Temp -98.6F
PR - 74bpm
BP - 120/70 mmhg
RR - 18cpm
Systemic examination:
Abdomen:Inspection :  Umbilicus is central and inverted
      All quadrants are moving equally with respiration 

      Suprapubic transverse scar is present

      No  sinuses , engorged veins, visible pulsations. 

Palpitation :

       Abdomen is firm in consistency    Tenderness in hypogastrium.

    Hard mass is present at hypogastric region

Percussion :

         Tympanic note heard over the abdomen.

Auscultation:

          Bowel sounds are heard.

Cardiovascular system:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills 

Auscultation :

        S1 and S2 heard. 

Respiratory system  :

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

Central  nervous system:

Conscious,coherent and cooperative 

Speech- normal

Cranial nerves- intact

Sensory system- normal 




INVESTIGATIONS:





ECG
USG

X ray  KUB
Bacterial  culture and sensitivity:

PROVISIONAL DIAGNOSIS:

RECURRENT STRICTURE URETHRA WITH iron deficiency anemia? 
Treatment  :

Comments

Post a Comment

Popular posts from this blog

A 45 yr old female patient complains of loss of appetite burning micturation and inadequate sleep

Image
This is an 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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box. CHIEF COMPLAINT: A 45 yr old female patient  came to the causality with a complaint of loss of appetite , burning micturation  and inadequate  sleep since 2months HISTORY OF PRESENT ILLNESS:   A 45 yr old female patient who agricultural  labour  by occupation  was apparently asymptomatic since two months then she noticed loss of appetite burning micturation and inadequate sleep  Firstly she visited near by local hospital   HISTORY OF PAST ILLNESS: 4yrs back she had undergone( right
Read more

A 40 yr old female patient with a fever

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.  CHEIF COMPLAINT : 40yr old female patient came to causality with complaint of fever since 4 days   nausea since 3days, generalized weakness nd loose stools since a day HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 5days back  and then she noticed fever, generalized weakness associated with cough went to  local hospital for hypotension started on fluids and discharged.she had vomitings w on food intake, history of loose stool   episodes watery, foul smelling with  HISTORY OF PAST ILLNESS: N/k/o HTN,TB,epilepsy,asthma,thyroid. H/o of dust allergy  PERSONAL HISTORY: Appetite: decreased Diet:
Read more