A Case of 28 Year Female with SOB and left groin pain and burning micturition

A 28 yr old female, a resident of Kolkata,came to OPD with

Chief Complaints:

- Pain in the left groin since 4 months

- Burning micturition since 4 months

- 2 episodes of hematuria

- Shortness of breath since 4 years and she came for the regular checkup to know the state of her condition

History of present illness:

- Patient was apparently asymptomatic 15years back (i.e..,in 2007 she was diagnosed with TB at the age of 13 yrs when she started experiencing easy fatigability even on doing minor forms of any physical activity resulting in shortness of breath)

For which she was on ATT and after partial relieving of symptoms she discontinued it and from the past 4 years there was re-presentation of shortness of breath

- Later there were episodes of pain radiating from iliac to inguinal region from the lockdown 2020, last episode was from past 4 months 

-she also mentioned minute quantities of blood passed in urine during the span of 4 months

Past History:

Patient has h/o TB but not of hypertension, diabetes, asthma, epilepsy or CAD

Family History:

Currently her daughter has similar complaints of pain in groin and she wasn't diagnosed with TB

Personal History:

Appetite: Decreased

Diet - mixed

Bowel and bladder - Regular

Sleep- adequate

Addictions - None

No known food allergies

GENERAL EXAMINATION

The patient is conscious, cooperative, coherent, and well oriented to time, place, and person.

She is thin built and nourished

She has no pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, pedal edema

Vitals

Pulse : 92 beats per min

Blood pressure : 110/70 mmHg

Respiratory Rate : 18 cycles per min 

SPO2 : 98%

Temperature : 98 F

SYSTEMIC EXAMINATION

Abdominal system:

No scars, sinuses, or any engorged veins

Tenderness present in Left iliac fossa and hypogastric region

No enlargement of liver, kidneys, or spleen

No ascites

Bowel sounds were normal

Cardiovascular system:

s1 and s2 heard

Respiratory system:

No chest wall deformity 

Trachea central

Breath sounds decreased in Right upper infra clavicular area, no wheeze or crackles heard

Central nervous system:

No focal abnormality detected

Investigations:









 

Findings: Right upper lobe fibrosis 

Provisional Diagnosis:

Right upper lobe fibrosis secondary to old pulmonary TB

Treatment receiving:

DRINK PLENTY OF ORAL FLUIDS

TAB. MVT PO/OD

TAB ULTRACET 1/2 TAB QID







Comments

Post a Comment

Popular posts from this blog

55 F WITH LOW BACK ACHE SINCE 15 YEARS

Image
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."  CHIEF COMPLAINTS  55 year old female from Assam came with the CHIEF COMPLAINTS of lower back ache since 15 years . HISTORY OF  PRESENTING ILLNESS  Patient is a resident of Assam married at the age of 18 years ,started working in farms 4 years after her marriage ,her work many consisted of  ploughing and sowing ,transplanting the sampling requiring her to bend forward and lean for several hours (5-10hrs/day) She gave birth to her first child 2 years after marriage
Read more

49 yrs old male with HF and CKD

Image
 Chief complaints Right lower limb swelling since 10 days, fever since 5 days History of presenting illness Patient was apparently asymptomatic 10 years back then he developed progressive swelling of right lower limb and diagnosed with filariasis for which he was prescribed medicines by a local doctor 10 year back he was diagnosed with diabetes mellitus and hypertension and since then using antihypertensives( nifedipine) and anti diabetics( glizide) - 3 years back he developed pedal oedema and went for further evaluation and diagnosed to have chronic renal failure ? - 2 years back he suffered from COVID-19 following which he had shortness of breath at rest (grade 4) and chest pain for which he went to co-operate hospital in Hyderabad and diagnosed to have inferior wall myocardial infarction, So he was treated with streptokinase. At that time coronary angiogram was not done in the view of high serum creatinine levels - After 1 month coronary angiogram was done to recanalized the right c
Read more

39 year old male patient presents to casualty with complaints of shortness of breath

Image
A 39 year old male came to the casualty around 10 pm with  Chief complaints of sob since 3 days.  Fever since 10 days Cough since 10 days Chest pain since 10 days Pain abdomen since 10 days HOPI :  Patient was apparently asymptomatic 10 days back, then he developed fever associated with chills and body pains, headache, sore throat. Patient had cough which was productive with white coloured sputum. Then patient got tested positive for Widal after 4 days of onset of fever. He used symptomatic medication for a week. Then, he developed SOB since 3 days for which he got admitted in Nalgonda. SOB was insidious in onset, gradually progressed from grade 2 to grade 4 since past 10 days, SOB was more in sitting position and relieved on lying down, as his SOB aggravated, patient got shifted from that hospital and presented to our casualty. Patient also used to complain of intermittent chest pain, pain abdomen since 15 days Past History : Admitted to a hospital for pain abdomen for 4 days Not a k/
Read more