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.

Cheif complaint: 38 year old female patient came with the cheif complaint of poor stream of  urine  since I month and painful urination since 19 days, burning Micturition since 14 days ,pain in the lower abdomen since 14 days 

History of present illness:
Patient was apparently asymptomatic one month ago then she developed poor stream of urine associated with pain during Micturition since 19 days
Pain in lower abdomen Spasmodic type of pain,non radiating  with no aggrevating and relieving factors
No H/O fever, vomitings,nausea ,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: 
N/k/c/o : diabetes,asthama, tuberculosis, epilepsy 

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

Appetite- Normal
Diet - mixed 
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: 
I have taken the consent of the patient and examined her in a well lit room
Patient is concious,coherent ,coperative moderately built,normal gait ,well nourished ,well oriented to time, date and place
Pallor is present .

No icterus, cyanosis, clubbing, lymphadenopathy , pedal edema 
Vitals - 
Temp -afebrile 
PR - 74bpm
BP - 120/70 mmhg
RR - 18cpm
Systemic examination: 
Abdomen -
Inspection: distended lower abdomen and no engroged veins or visible pulsations
Palpation: soft and tenderness in right hypogastric region
Percussion: tympanic note Heard over the abdomen
Auscultation: bowel sounds are heard

Cvs: S1 and S2 heard , no thrills or murmurs Heard

Respiratory: bilateral air entry present

Oral examination: gingival recession, pigmentation in the mucosa and gingiva 
Stains and calculus present


clinical pictures: 

Investigations : 
PROVISIONAL DIAGNOSIS:
RECURRENT STRICTURE URETHRA WITH IDA.
Treatment:
Tab Norflox 400
Tab Orofer-XT

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