38 y old F with urinary retention.

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CHIEF COMPLAINT:

38 year old female, home maker came to hospital 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 in onset. 
Burning micturition since 10 days.
 Lower abdominal pain since 10 days which is of  spasmodic type , non radiating .
no H/O haematuria.
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 then she was diagnosed with urethral stricture 1 year ago also 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:

Patient is conscious, coherent and cooperative 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy , pedal edema 

Vitals - 

Temp -98.6F
PR - 74bpm
BP - 120/70 mmhg
RR - 18cpm


SYSTEMIC EXAMINATION :

 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.
Hard mass is present in hypogastric region

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.
Palpation: 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:

USG:


Urine culture and sensitivity:

X-ray KUB



PROVISIONAL DIAGNOSIS:

RECURRENT STRICTURE URETHRA WITH IDA

Treatment 
Tab. TAXIM 200 mg PO/BD
T. Dolo 650  PO/BD 
T. MVT PO/OD
T.ULTRACET PO/QID - ½ Tablet.









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