1601006179 LONG CASE

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

Past History

Pt is a k/c/o Hypertension

No H/oDiabetes 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


4) Random Blood Sugar

   


5) Serum Electrolytes


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
3) Co Amoxiclav 250 mg 8 hourly 3 days


4) Ciprofloxacin 100 mg 12 hourly 3 days



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