38 year old female with poor stream of urine

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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history , clinical findings , investigations and come up with diagnosis and treatment plan .

38 year old female, housewife,came with chief complaints of :     Poor stream of urine since 1 month.

      Dysuria since 15 days

      Burning micturition since 10 days

      Pain in lower abdomen since 10 days

Patient was apparently asymptomatic 1 month back , then she developed poor stream of urine 

she developed pain during micturition since 15 days. 

Burning micturition since 10 days with no H/O haematuria, retention of urine .

 Lower abdominal pain since 15 days , spasmodic type , non radiating with no aggrevating and relieving factors.No H/O fever, vomitings,nausea , incontinence, increased frequency,loose stools .

H/O dyspareunia on and off since 1 year.

Patient had H/O urinary retention , poor stream of urine and burning micturition when she was diagnosed with urethral stricture 1 year ago and underwent urethrotomy 1 year ago and dilatation with hegars dilators ( size 6/8) is being done since 6 months.

MENSTRUAL HISTORY:

AOM - 16 years ,Cycle - 5/30 days , regular , 6 pads/ day associated with pain in the lower abdomen.

PAST HISTORY:

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

PERSONAL HISTORY:

Appetite- Normal

Diet - mixed 

Bowel - regular 

Bladder - burning micturition, dysuria 

FAMILY HISTORY:

No significant family history 

GENERAL EXAMINATION:

Pt is C,C,C 

Pallor is present .

No icterus, cyanosis, clubbing, lymphadenopathy , pedal edema 

Vitals - 

Temp -98.6F

PR - 74bpm

BP - 120/70 mmhg

RR - 18cpm

SYSTEMIC EXAMINATION :

PER ABDOMEN :

Inspection :

      Umbilicus is central and inverted

      All quadrants are moving equally with respiration 

      Suprapubic transverse scar is present 

      No  sinuses , engorged veins, visible pulsations .

      Hernial orifices are free.

Palpitation :

       Abdomen is firm in consistency.

       Suprapubic bulge till umbilicus is present.

       Tenderness in hypogastrium.

       No organomegaly.

Percussion :

         Tympanic note heard over the abdomen.

Auscultation:

          Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++

INVESTIGATIONS:

ECG :

USG :

X RAY KUB:

URINE C/S:

Urology opinion was taken I/v/o stricture urethra and planned for urethroplasty .

Foleys catheterisation was done under SA

Urethral dilatation was done upto 20 fr, following that 16 fr foleys catheterization was done under deep sedation

The retention volume of urine was 1500ml

PROVISIONAL DIAGNOSIS:

RECURRENT STRICTURE URETHRA WITH ?IDA

TREATMENT:

Tab NORFLOXACIN 400 mg PO/ BD

Tab.ULTRACET 1/2 tab PO/QID

Tab. MVT PO/OD

Tab.OROFER XT PO/OD