A 55years old women with incomplete void of urine.

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR            PATIENT'S DE - 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

 

55 years old female tea seller by occupation came to the opd with chief complaints of incomplete void of urine and increase frequency of urine since 10years.

History of presenting illness:

Patient was apparently asymptomatic 10years back then she started having incomplete void of urine with increase frequency.

H/o burning micturation since 3years,3-4episodes/month releived in on taking medication and plenty of water.

She wakes up 8-9 times in night times to pass urine.

 

Past history:

No h/o Hypertension ,Diabetes Tuberculosis,epilepsy and Asthma.

Family History:

 

Mother is diabetic.

Personal history:

Diet-mixed

Appetite-normal

Sleep-decreased 

Bowel-regular

Bladder-incomplete  micturation 

Addictions-none.

General examination:

 

Patient is conscious,coherent,cooperative to time, place and person.Well built and well nourished.

Pallor-absent

Icterus-absent

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

Pedal edema-absent

Vitals:

Temperature-98.7F

Blood pressure-130/80mmHg

Respiratory rate-17cpm

Pulse rate-94bpm

Spo2-99%

GRBS-116mg

Systemic examination:

CVS-S1S2heard

RS-BAE+,NAVBS

P/A- soft,non tender

CNS-NAD

Investigations:

CUE

Albumin Sugar Nil

Pus cello 3-4

epithelial cells - 2-3

Casts: nil

Reaction: Acidic

Неmogram:

Hb: 12

TC: 8,200

N-63

L: 31 

PCV-35.8

RBC: 40.5

Pit : 2.92

LFT

TB: 0.59

DB: 0.16

AST: 19

ALT 10

ALP: 262 

TP: 6.9

Albumin 4.0 

A/G- 1.38

RFT:

Urea-29

Creat: 0.7

Uric acid-2.6

Ca : 10.2

Pa -3.5

Na+-141

Cl-:99

K+- 4.4

ECG:

USG:

Provisional diagnosis:

Acute cystitis with urethral stricture.