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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
40 year old female WITH
urethra stricture under evaluation
CASE HISTORY
A 40 year old female , house wife ,CAME from west bengal WITH
CHEIF COMPLAINTS OF -
dysuria decreased frequency of urination post void urinary retention and slow urine stream since 6 months
burning micturition since 5 months
dysperunia since 4 months
loin and lower back pain since 1 month
HISTORY OF PRESENTING ILLNESS -
patient was apparently asymptomatic 6 month back then developed dysuria which was insidious in onset gradually progressive associated with burning micturation retention of urine and lower abdomen pain and distension the pain in abdomen gets relieved with medication and voiding urine
burning micturition not associated with any fever cough nausea vomiting patient developed dysperunia 4 months back and pain in the flanks and lower back 1 month back
no SIGNIFICANT PAST HISTORY , AND THEN CAME TO KIMS FOR FURTHER EVALUATION
PAST HISTORY -
n/k/c/o htn
6 months back was given medication for dm metformine 500 mg for 4 months later stoped on doctor assuring glucose levels in control and no dm
NOT A KNOWN CASE OF EPILEPSY , ASTHMA , TB
No previous surgical history apart from lscs for 2 childs 21 year back and 19 year back
PERSONAL HISTORY :
DIET - MIXED ,APPETITE -normal appetite ,BOWEL MOVEMENT - REGULAR , BLADDER MOVEMENTS - irREGULAR , ADDICTIONS(no ALCOHOL AND SMOKING) - but consumes pan and bettle nut 5 times a day
FAMILY HISTORY -
Not significant
ON EXAMINATION -
PATIENT IS CONCIOUS , orientation to time place person
mild PALLOR, no ICTERUS , CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA)
VITALS -
TEMPERATURE - AFEBRILE
PULSE RATE - 79BPM
BLOOD PRESSURE - 100 /80 MM OF HG
RESPIRATORY RATE - 12
SPO2 - 99% AT ROOM AIR
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM :
normal
P/a on inspection distended and tender on palpation dull note on percussion
obs history
age of menarche 16 years
age of marriage 18 years
1st became Gravid at 19 years age pregnancy aborted at 5 months product of consumption removed in medical facility
2 nd pregnancy at 20 years still birth at 8 months of gestation
3 Rd pregnancy child delivered by lscs live child age 20 years male
4 th pregnancy delivered by lscs present age 18 years male
menstruation cycles 30/5 cycles
lmp - 5 /1/22
INVESTIGATION -
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