Long Case General medicine Final practical Exam

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CHIEF COMPLAINTS:

38 year old female Came to OPD with an Chief complient of : Poor stream of urine since 1 month.

 Dysuria (painful urination) since 18 days

 Burning micturition since 13 days

 Pain in lower abdomen since 13 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 18 days. 

Pain in lower abdomen Spasmodic type of pain

non radiating with no aggrevating and relieving factors

Burning micturition since 13 days.

Patient had H/O urinary retention , poor stream of urine and burning micturition 

No H/O fever, vomitings,nausea,increased frequency,loose stools .

MENSTRUAL HISTORY

Cycle - 5/30 days and regular

She had history of 2 abortions 

1st abortion at age of 19Years old

2nd abortion at age of 20Years old

PAST HISTORY:

Not a k/c/o DM, HTN , TB ,epilepsy, asthma,CAD,CVD.

she was diagnosed with urethral stricture 1 year ago and underwent dilitation 1 year ago

PERSONAL HISTORY:

Diet - mixed 

Appetite - Normal

Sleep - adequate 

Bowel - regular 

Bladder - burning micturition, dysuria 

Addictions - She has habit of chewing PAN since 7years

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Patient is concious coherent and cooperative and well oriented to time place and person

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 :

   

   All quadrants are moving equally with respiration 

   No sinuses , engorged veins, visible pulsations .

   Distension of lower abdomen

Palpation :

       Abdomen is Soft

       Tenderness present on right hypogastric region

Percussion :Tympanic note heard over the abdomen

Auscultation:

          Bowel sounds are heard.

CARDIOVASCULAR SYSTEM

Inspection:

        Shape of chest is elliptical.

Palpation: Apex beat - felt at left 5th intercostal space. No thrills and parasternal heaves

Auscultation :

     S1 and S2 heard. 

RESPIRATORY SYSTEM:

On Inspection: 

Shape- elliptical 

B/L symmetrical

Both sides moving equally with respiration

On Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present.

vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

Sensory System - Normal

Motor system - Normal

ORAL EXAMINATION :

Gingival recession is seen

Spacings between the tooth (Malocclusion)

Loss of taste sensation (Atrophy of tongue/papilla)

Xerostomia (decreased saliva production) 

Looks like hypocalcification of ENAMEL

Calculus++

Stains++

Pateint has poor oral hygiene 

Clinical Pictures : 

INVESTIGATIONS

HEMOGRAM

COMPLETE URINE EXAMINATION

BLOOD UREA

SERUM CREATININE 

USG

ECG

XRAY

PROVISIONAL DIAGNOSIS:

RECURRENT STRICTURE URETHRA WITH IDA.

TREATMENT :

Tab Norflox 400

Tab Ascofer-XT

UROLOGY opinion was taken and Adviced for FOLEYS CATHETERIZATION

In view of sever pain during CATHETERIZATION procedure was done 

Retention volume=1500ml urine after catheter was placed

Urologist Adviced need for "URETHROPLASTY" 

As patient was Anemic - Need for correction of HEMOGLOBIN for prior surgery.