38 yr old female
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CHIEF COMPLAINT:
38 year old female, came to hospital with chief complaints of Poor stream of urine since 1 month, Dysuria 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 poor stream of urine.
she developed pain during micturition since 15 days which is insidious in onset.
Burning micturition since 10 days.
Lower abdominal pain since 10 days which is of spasmodic type , non radiating .
no H/O haematuria.
No H/O fever, vomitings,nausea , incontinence, increased frequency,loose stools .
Patient had H/O urinary retention , poor stream of urine and burning micturition then she was diagnosed with urethral stricture 1 year ago also underwent urethrotomy 1 year ago and urethral dilatation is being done since 6 months.
MENSTRUAL HISTORY:
Age of Menarche - 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
Sleep- adequate
Bowel - regular
Bladder - burning micturition, dysuria
Addictions- habit of pan chewing 8 times daily
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
No pallor, 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
No sinuses , engorged veins
Palpation:
Abdomen is firm in consistency.
Tenderness in hypogastrium.
Hard mass is present in 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.
Palpation: 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.
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
CENTRAL NERVOUS SYSTEM:
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Clinical images
INVESTIGATIONS:
Hemogram :
USG:
Urine culture and sensitivity:
CUE :
X-ray
PROVISIONAL DIAGNOSIS:
RECURRENT STRICTURE URETHRA WITH iron deficiency anemia
Treatment
Tab NORFLOXACIN 400mg
Tab. TAXIM 200 mg PO/BD
T. Dolo 650 PO/BD
T. MVT PO/OD
Tab orofer
