37 yar old female patient with decrease urine output

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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 patient's clinical problems with collective current best evidence based inputs. 


This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."


35 year  old female patient presented with chief complaints 


Decreased urinary frequency since 6 months

Burning mitcuration since 5 months 

Hematuria since 3 months 

Associated with lower back pain since 1 month.



HOPI:

Patient is appearantly asymptomatic and then developed decrease in urine frequency since 6 months which is insidious in onset and gradual in progression


Then she developed pain during mitcuration since 5 months which was burning type.

This was associated with lower back pain since 1 month, which gets aggrevated on urination,and relieved on medication. 

There was history of hematuria since 1 month

There is no association of fever, vomiting, nausea 


Past history:


No similar complaints in the past.

No history of usage of any drugsmetformine 500 mg for 4 months and stopped as per doctor's instructions.

.

No history of asthma diabetesAND HYPERTENSION.

history of increase in sugar levels 3 months back which was relieved on medication in advice of doctor.


Personal history:

Diet :mixed 

Appetite: normal

Bowel habits normal'

Bladder : irregular habits

Addictions: none

But usage of beetel nut leaves once a month.


Menstrual history:


Menarche :at age 13 

No history of white discharge

No history heavy menstrual period , bleeding during coitus.

History of previous 2 surgery LCSC.

Tubectomy after 2 pregnancy.

 

Obg history:

P3L2D1A1 

 Fam history:

No similar complaints

General examination:

Patient is conscious, coherent, non cooperative, moderately nourished well oriented with time and plac

 Pallor:

Mild.

No icterus

No clubbing

No edema





Vitals:


Temperature afebrile

Pulse 86bpm


BP 110/80


RR: 12/min


Systemic examination:

 

Abdominal examination: 







Inspection:

Shape distended

Scars are absent

Prominent veins not seen

Palpation:

Temperature normal 

Tenderness present

Liver and spleen not palpable

Auscultation: bowel sounds Heard 






Investigation;



 























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