1601006041 LONG CASE
A case of 62 Year old patient with burning micturtion
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LONG CASE
A 62 year old Gentleman, came to the OPD with chief complaints of severe burning micturition since 1 month.
History of presenting illness
He was apparently asymptomatic 1 month back, developed burning micturition suddenly , insidious in onset for which he went to a local doctor who prescribed paracetamol which did not relieve his symptoms following which he came to the OPD.
Pt experienced sudden loss of appetite followed by disturbed sleep since 2 weeks.
No h/o loin pain
No h/o of fever
No h/o hematuria
No h/o itching in groin area
No h/o suprapubic pain
No h/o flank pain
Past History
Pt is a k/c/o Hypertension
No H/o Diabetes Mellitus, Asthma, Thyroid dysfunction, Epilepsy
No Cardiovascular abnormalities
No known allergies
Personal History
Diet : Mixed
Sleep : Inadequate
Appetite : Reduced
Bowel and Bladder movements : Irregular
No known addictions
Family History
No similar complaints in the family
Drug History
Pt currently not on any medication
No known drug allergies
GENERAL EXAMINATION
Pt is conscious, coherent and co operative
Well oriented to time and place
Moderately built and nourished
No Pallor, icterus, cyanosis, koilonychia, lymphadenopathy, or pedal edema.
VITALS
Temperature: afebrile
PR : 80 bpm
BP : 127/79 mm Hg
RR : 16cpm
SYSTEMIC EXAMINATION
Respiratory system :
INSPECTION
shape of chest : elliptical and symmetrical
size of chest : Normal
Movement of chest : Symmetrical movement
No engorged veins and sinuses
PALPATION
Shape and size : elliptical and normal
Normal movements corresponding to breathing
No tenderness or pain on palpation
PERCUSSION & AUSCULTATION
Normal resonant note on percussion
Bronchoalevolar sounds heard
Vesicular breath sounds
Cardiovascular System :
INSPECTION
No engorged veins and sinuses
No visible pulsations
PALPATION
Apical impulse - in 5th inter costal space
AUSCULTATION
S1 and S2 heard
No murmurs
Per Abdomen
INSPECTION
Shape : Elliptical
All Quadrants of abdomen moving in accordance with respiration
Umbilicus central and inverted
No scars sinuses or engorged veins
PALPATION
No tenderness
No organomegaly
PERCUSSION
Tympanic
AUSCULTATION
Normal bowel sounds heard
CNS
Higher mental functions : Normal
Cranial nerves : Intact
Sensory System : Normal
Motor System : Normal
Meningeal signs : Absent
Cerebellar signs : Absent
Investigations
1) Mid Catch Urine - Culture and Antibiotic Sensitivity
2) Total Blood Count
3) Serum Creatinine
6) Complete Urine Examination
Provisional Diagnosis
Recurrent Urinary Tract Infection
Treatment
1)Tab. Trimethoprim 200 mg daily Three days
2) Nitrofurantoin 50 mg 6 hourly 3 days
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