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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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:
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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