A 15 year old young male presented to the opd with chief complaints of burning micturation associated with pain and burning sensation


7/9/22 

N. Lavanya 

Roll : 93 

5 th semester 

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identified health data shared after taking

 his/her/guardian’s signed informed consent. 

Here we discuss our individual patient’s problems

 through series of inputs from available global online

 community of experts with an aim to solve those

 patients clinical problems with collective current best

 evidence based inputs.

A 15 year old  young male presented to the

 opd with chief complaints of  burning

 micturation associated with  pain and

 burning sensation 



Chief complaints :

Difficulty in micturition since 5 days. 
Pain and burning sensation during micturation since 5 days.
H/o low grade
Not associated with chills and rigor lasted for 4 days and decreased on medication.
N/H/O SOB, chest pain and palpitations

History of presenting illness :

Patients was apparently asymptomatic 1 week back then he developed low grade fever which lasted for 5 days and on further investigation patient was found to have low Hb levels ,then after 4 days patient had developed difficulty in micturition ,pain and burning sensation during micturation
Pain was sudden in onset, No radiation, relieved on excess in take of water and no aggrevating factors 
Patient mainly mentioned about less intake of water around 1 liter per day. 





HISTORY OF PAST ILLNESS 

N/C/O of DM, HTN, TB ,ASTHMA, CAD

PERSONAL HISTORY:

Mixed diet 
Normal appetite 
Regular bowel  movements 
Adequate sleep 
 No addictions

VITALS 

Bp 130/70 mmHg 
Pulse : 80 BPM
Afebrile temperature.

GENERAL EXAMINATION

Pallor -present 
No Cyanosis ,icterus,clubbing,lymphadenopathy ,edema of feet ,no malnutrition,

CVS

S1,S2 are heard
No thrills and murmurs

RESPIRATORY SYSTEM 

Vesicular breath sound heard 

INVESTIGATIONS:

USG: NO ABNORMALITY DETECTED
CBP: HB: 5.5mg/dl

Ferritin : 3.1ng/ml
Serum iron:38ug/dl

CUE : No abnormality detected
LFT : No abnormality detected





PROVISIONAL DIAGNOSIS

ANEMIA UNDER EVALUATION WITH PHIMOSIS

.

 TREATMENT

5/09/22
1. Tab .DOLO 650 mg 
2. Tab.ZINCOVIT
6/09/22
1. Tab.DOLO 650mg
2.Inj.optineuron 1 amp in 100 ml
3. Syp.CITRALLKA 15 ml in glass of water

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