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 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
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 , increased frequency,loose stools .
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 since 6 months.
MENSTRUAL HISTORY:
AOM - 16 years ,Cycle - 5/30 days , regular ,associated with pain in the lower abdomen.
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
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 :
PER 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.
Suprapubic bulge is present.
Tenderness in hypogastrium.
Hard mass is presend 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 and parasternal heaves
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:
PROVISIONAL DIAGNOSIS:
RECURRENT STRICTURE URETHRA WITH iron deficiency anemia?
