Anemia under evaluationAssociated with phimosisUTI secondary to phimosis?
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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.
Following is the view of my case :
Date of admission : 5-9-2022
Chief complaints :
A 15-year-old-male patient came to the casualty with the cheif complaints of fever 5 days back
Burning micturition since 4-5 days
Difficulty in micturition since 4-5 dayz
History of present illness : patient was apparently asymtomatic 10 days back ,then developed
H/o Fever-
Onset - insidious
Duration- for 3 days
Type - intermittant ,low grade
It was relieving on taking medications .
Not Associated with chills and rigors.
Not Associated with generalised body aches and weakness
Diurnal variation absent
No increased temperature at night
After his fever got subsided, he had
H/0 burning micturition - since 4-5 days
H/0 pain while urinating , and poor stream.
10 days back, he went to a local hospital at nalgonda for fever ,he got treated for it and his fever subsided.
He got his reports done which showed,
Widal test- positive
...later
him came to KIMS because his parents didnt like that hospital.
Daily routine- wakes up at 8:00 am
Drinks milk at 9:00 am
Goes to college-he is studying intermediate
Lunch at 12:00 pm
Returns from college at 4:00 pm
Takes rest, goes to roam with his friends .
Sleeps at 10:00 pm
History of past illness :
Not a known case of,
diabetes, epilepsy, CAD, asthma, thyroid.
Personal history :
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements -burning micturition
Addictions - no
No known allergies
Drug history :
No significant drug history
Family history :
No significant family history
General examination :
Patient is conscious ,coherent ,cooperative and was well oriented to time ,place and person
at the time of examination
SHe is examined in a well lit room, with consent taken.
SHe is moderately built and well nourished.
Pallor - present
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent
Systemic examination :
CVS : S1 and S2 heart sounds heard
NO murmurs and thrills
RESPIRATORY SYSTEM : Bilateral air entry present
position of trachea - centrall
Vesicular breathsounds heard
CNS : intact
ABDOMEN :
Soft non tender
Splenomegaly present
Bowel sounds heard
Investigations :
Anemia under evaluation
Associated with phimosis
UTI secondary to phimosis?
Treatment:
On day 1 (5-9-22)
1.Tab DOLO 650mg PO SOS
2.Tab. Zincovit PO OD
On day 2 (6-9-22)
1. Tab. DOLO 650 mg PO SOS
2. INJ. Optineuron 1amp in 100ml NS/ IV/OD
3.SYP. Citralka 15ml in glass of water PO/TID
Tab. DOLO 650 mg PO SOS
2. INJ. Optineuron 1amp in 100ml NS/ IV/OD
3.SYP. Citralka 15ml in glass of water PO/TID
On day 4 (8-9-22)
Tab. DOLO 650 mg PO SOS
2. INJ. Optineuron 1amp in 100ml NS/ IV/OD
3.SYP. Citralka 15a ml in glass of water PO/TID
