38 year old female with burning micturition
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A 38 year old female presented with burning micturition
M.ANURAG ( INTERN )
Roll No: 84
I have 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.
CASE:
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
HOPI:
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
Addictions- H/O chewing pan from 10 years around 8/day
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:
CBP:
Hb - 10.2 gm/dl
TLC - 6500 cells/ cumm
RBC - 3.85 million
PLT - 2.9 lakh
CUE:
Colour- pale yellow
Albumin- negative
Sugars- negative
Pus cells- 2-3 cells
Epithelial cells- 1 to 2 cells/ HPF
RFT:
urea - 24 mg/dl
Creatinine - 0.9 mg/dl
Na - 141 mEq/L
K - 4.3 mEq/L
Cl - 102 mEq/L
LFT :
TB- 0.90 mg/dl
DB- 0.18 mg/dl
ALT - 10 IU/L
AST - 12 IU/L
ALP - 156 IU/L
TP - 7.2
albumin - 3.9 gm/dl
COAGULATION PROFILE:
BT- 2 min
CT- 5 min
PT- 17 sec
APTT- 31 sec
INR- 1.2
STOOL FOR OCCULT BLOOD - POSITIVE
PERIPHERAL SMEAR:
RBC - Microcytic hypochromic
WBC - within normal limits
PLATLET - adequate
URINARY PARAMETERS:
SPOT URINARY PROTEIN: 30
SPOT URINARY CREATININE: 57.9
RATIO: 0.51
24 HR URINARY PROTEIN- 800 mg/day
24 HR URINARY CREATININE- 4.0 gm /day
24 HR URINE VOLUME- 2000 ml
CHEST XRAY:
ECG:
USG ABDOMEN:
URINE C/S:
IVP:
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 14 fr foleys catheterization was done under deep sedation
The retention volume of urine was 1500ml
2 PRBC Transfusions done i/v/o low hemoglobin
COURSE IN THE HOSPITAL :
38 YEAR OLD FEMALE PRESENTED WITH COMPLAINTS OF BURNING MICTURITION,
DISTENSION OF ABDOMEN AND PAIN ABDOMEN SINCE 15 DAYS,EVALUATION WITH
APPROPRIATE CLINICAL EXAMINATION AND INVESTIGATIONS WERE DONE
USG ABDOMEN SHOWED CHRONIC CYSTITIS WITH LEFT HYDROURETERO
NEPHROSIS.UROLOGY OPINION WAS TAKEN I/V/O RECURRENT STRICTURE URETHRA AND
PLANNED FOR FOLEYS CATHETERISATION.AS THE PATIENT WAS NOT COOPERATIVE 20F
URETHRAL DILATATION, 14 F FOLEYS CATHETERISATION WAS DONE UNDER GENERAL
ANAESTHESIA.
AND WAS ADVISED SYP. CITRALKA 10ML PO/BD AND PLAN FOR SINGLE STAGE
URETHROPLASTY UNDER GA.
I/V/O SEVERE IRON DEFICIENCY ANEMIA 2 PRBC TRANSFUSIONS WERE DONE
HEMOGLOBIN LEVELS IMPROVED FROM 7.7GM/DL TO 11.5GM/DLON CT ABDOMEN- DISTAL
URETERIC STRICTURE WAS FOUND AND ON IVP-LEFT MILD HYDROURETERO NEPHROSIS.
CASE WAS SHIFTED TO 9TH FEB TO UROLOGY DEPARMENT, URETHROPLASTY WAS DONE
ON THE NEXT DAY UNDER GENERAL ANESTHESIA.
Surgical Procedure done on 10/02/23:
Pre operative diagnosis : Stricture urethra
Surgery proposed : Single stage urethroplasty under GA
Operative Findings : Urethral stricture of 2cm present
Operative Procedure :
1. Under GA , parts painted and covered
2. An incision of U shaped ( inverted ) in between clitoris and urethra is given and extended towards bladder neck
3. A buccal mucosal graft around 3 x 1 cm placed over the stricture and fixed to cut ends of urethra with 5-0 vicryl
4. Quilting suturing is done, Incision sutured with 5-0 vicryl
5. Hemostasis secured
6. 16F foleys kept
7. Procedure uneventful
POST OPERATIVE MEDICATIONS:
1. NBM TILL FURTHER ORDERS
2. IVF - NS,RL @100ML/HR
3. INJ. MEFANEX FORTE 1.5 MG IV/BD
4. INJ. PAN 20MG IV/OD
5. INJ. PCM 1GM IV/TID
6. INJ. ZOFER 4MG IV/TIF
POD-1 : UNEVENTFUL
TREATMENT:
SOFT DIET
INJ. MEFANEX FORTE 1.5 MG IV/BD
INJ. PAN 20MG IV/OD
INJ. PCM 1GM IV/TID
INJ. ZOFER 4MG IV/TIF
POD-2: UNEVENTFUL
TREATMENT:
NORMAL DIET
INJ. MEFANEX FORTE 1.5 MG IV/BD
INJ. PAN 20MG IV/OD
INJ. PCM 1GM IV/TID
INJ. ZOFER 4MG IV/TIF
POD-3: UNEVENTFUL
TREATMENT:
NORMAL DIET
INJ. MEFANEX FORTE 1.5 MG IV/BD
INJ. PAN 20MG IV/OD
INJ. PCM 1GM IV/TID
INJ. ZOFER 4MG IV/TIF
POD-4: UNEVENTFUL
TREATMENT:
NORMAL DIET
INJ. MEFANEX FORTE 1.5 MG IV/BD
INJ. PAN 20MG IV/OD
INJ. PCM 1GM IV/TID
INJ. ZOFER 4MG IV/TIF
CASE SHIFTED TO GENERAL MEDICINE WARD
THE FOLLOWING TREATMENT WAS GIVEN:
1. NORMAL DIET
2. INJ MAGNUS FORTE 1.5GM IV/BD
3. T. DOLO 650MG PO/TID
4. T PAN 40MG PO/OD
5. T. ZOFER 4MG PO/SOS
6. TAB VIT-C PO/OD
REFERRED TO OBG I/V/O RECURRENT STRICTURE URETHRA.
ADVICE: 1. HIGH VAGINAL SWAB
REFERRED TO ENT I/V/O NASAL INTUBATION FOR URETHROPLASTY.
ADVICE: OTRIVIN NASAL DROPS X 5DAYS BEFORE SURGERY.
Investigation
HEMOGRAM:
14/1/23
HB- 7.7GM/DL
TLC- 5700 CELLS/CU.MM
N/L/E/M- 66/20/4/9
PLATELET COUNT- 1.55 LAKHS/CU.MM
20/1/23:
HB- 8.9GM/DL
TLC- 6900 CELLS/CU.MM
PLATELET COUNT- 1.62 LAKHS/CU.MM
24/1/23:
HB- 11.5GM/DL
TLC- 8400 CELLS/CU.MM
PLATELET COUNT- 2.09 LAKHS/CU.MM
3/2/23:
HB- 10.0GM/DL
TLC- 6700 CELLS/CU.MM
PLATELET COUNT- 2.03 LAKHS/CU.MM
6/2/23:
HB- 10.7GM/DL
TLC- 9300 CELLS/CU.MM
PLATELET COUNT- 2.43 LAKHS/CU.MM
9/2/23:
HB- 11.4GM/DL
TLC: 9300 CELLS/CU.MM
PLATELET COUNT- 2.59LAKHS/CU.MM
INTRAVENOUS PYELOGRAPHY ON 8/2/23
IMPRESSION: LEFT MILD HYDRO URETERO NEPHROSIS.
CT ABDOMEN- IMPRESSION - URETERIC STRICTURE
URINE C/S- MORGANELLA MORGAGNI >10 POWER 5 CFU/ML OF URINE ISOLATION
ECG- NORMAL SINUS RHYTHM
Treatment Given(Enter only Generic Name)
1.INJ MAGNEX FORTE 1.5GM IV BD X 5DAYS
2. INJ PCM 1GM IV TID X 5DAYS
3. TAB PAN 40MG PO OD X 5DAYS
4. TAB ZOFER 4MG PO BD
5.TAB NORFLOXACIN 400MG PO/BD X 13 DAYS
6. TAB OROFER XT PO BD X 13 DAYS
7. TAB MVT PO OD X 13 DAYS
8. TAB VIT-C PO OD X 3DAYS
Advice at Discharge
1. NORMAL DIET
2. TAB ZOFER 4MG PO BD
3. TAB PAN 40MG PO OD
4. TAB DOLO 650MG PO TID
5. TAB MVT PO OD
6. TAB VIT-C PO OD
7.TAB.TAXIM 200MG PO BD FOR 7 DAYS
Follow Up
REVIEW SOS/AFTER 1 MONTH TO GM OPD.
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