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CHIEF COMPLAINT:
38 year old female, housewife,came to opd 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
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back , then she developed poor stream of urine
she developed pain during micturition since 15 days which is insidious onset.
Burning micturition since 10 days with no H/O haematuria, retention of urine .
Lower abdominal pain since 10 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 urethral dilatation is being done since 6 months.
MENSTRUAL HISTORY:
AOM - 16 years ,Cycle - 5/30 days , regular ,associated with pain in the lower abdomen.
PAST HISTORY:
Not a k/c/o DM, HTN , TB ,epilepsy, asthma,Thyroid.
PERSONAL HISTORY:
Appetite- Normal
Diet - mixed
Sleep- adequate
Bowel - regular
Bladder - burning micturition, dysuria
Addictions-no
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Pt is conscious, coherent and cooperative
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.
Palpation:
Abdomen is firm in consistency.
Suprapubic bulge 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
INVESTIGATIONS:
ECG :
USG :
X RAY KUB:
PROVISIONAL DIAGNOSIS:
RECURRENT STRICTURE URETHRA WITH IDA
