15 year old male with fever and burning micturition

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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 our hospital 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:

On day 1 (5-9-22)

             

On day 2 (6-9-22)

Diagnosis:  

IRON DEFICIENCY ANAEMIA(SECONDARY TO ?NUTRITIONAL CAUSE)  UTI(RECOVERED) SECONDARY TO PHIMOSIS 

WITH DELAYED PUBERTY

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

On day 3 (7-9-22)

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

Discharge summery

Date:9-SEP-2022

Ward:MEDICAL WARD

Unit: 1

Diagnosis

IRON DEFICIENCY ANAEMIA(SECONDARY TO ?NUTRITIONAL CAUSE)  UTI(RECOVERED) SECONDARY TO PHIMOSIS 

WITH DELAYED PUBERTY

 

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.

 

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:

Name  Value  Range  Name  Value  Range  COMPLETE URINE EXAMINATION (CUE)   05-09-2022 05:50:PM  COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN Nil  SUGAR Nil  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 2-3  EPITHELIAL CELLS 1-2  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil HBsAg-RAPID   05-09-2022 05:50:PM Negative   Anti HCV Antibodies - RAPID   05-09-2022 05:50:PM Non Reactive    LIVER FUNCTION TEST (LFT)   05-09-2022 05:50:PM  Total Bilurubin 0.69 mg/dl 1-0 mg/dl  Direct Bilurubin 0.10 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 33 IU/L 35-0 IU/L  SGPT(ALT) 15 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 200 IU/L 369-54 IU/L  TOTAL PROTEINS 7.4 gm/dl 8-6 gm/dl  ALBUMIN 3.9 gm/dl 4.5-3.2 gm/dl  A/G RATIO 1.09  RFT   05-09-2022 05:50:PM  UREA 11 mg/dl 42-12 mg/dl  CREATININE 0.5 mg/dl 1-0.5 mg/dl  URIC ACID 3.7 mg/dl 7.2-3.5 mg/dl  CALCIUM 9.7 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 4.4 mg/dl 4.5-2.5 mg/dl  SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 4.6 mEq/L 5.1-3.5 mEq/L  CHLORIDE 98 mEq/L 98-107 mEq/L  COMPLETE URINE EXAMINATION (CUE)   06-09-2022 05:22:PM  COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN Nil  SUGAR Nil  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 2-4  EPITHELIAL CELLS 2-3  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil

Format Name  Value  Range  Name  Value  Range  COMPLETE URINE EXAMINATION (CUE)   05-09-2022 05:50:PM  COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN Nil  SUGAR Nil  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 2-3  EPITHELIAL CELLS 1-2  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil HBsAg-RAPID   05-09-2022 05:50:PM Negative   Anti HCV Antibodies - RAPID   05-09-2022 05:50:PM Non Reactive    LIVER FUNCTION TEST (LFT)   05-09-2022 05:50:PM  Total Bilurubin 0.69 mg/dl 1-0 mg/dl  Direct Bilurubin 0.10 mg/dl 0.2-0.0 mg/dl  SGOT(AST) 33 IU/L 35-0 IU/L  SGPT(ALT) 15 IU/L 45-0 IU/L  ALKALINE PHOSPHATE 200 IU/L 369-54 IU/L  TOTAL PROTEINS 7.4 gm/dl 8-6 gm/dl  ALBUMIN 3.9 gm/dl 4.5-3.2 gm/dl  A/G RATIO 1.09  RFT   05-09-2022 05:50:PM  UREA 11 mg/dl 42-12 mg/dl  CREATININE 0.5 mg/dl 1-0.5 mg/dl  URIC ACID 3.7 mg/dl 7.2-3.5 mg/dl  CALCIUM 9.7 mg/dl 10.2-8.6 mg/dl  PHOSPHOROUS 4.4 mg/dl 4.5-2.5 mg/dl  SODIUM 139 mEq/L 145-136 mEq/L  POTASSIUM 4.6 mEq/L 5.1-3.5 mEq/L  CHLORIDE 98 mEq/L 98-107 mEq/L  COMPLETE URINE EXAMINATION (CUE)   06-09-2022 05:22:PM  COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN Nil  SUGAR Nil  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 2-4  EPITHELIAL CELLS 2-3  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil Treatment Given(Enter only Generic Name) Format Advice at Discharge 1. Tab. OROFERXT twice daily  8am.    8pm  ( before food)   2. Tab. limcee twice daily  8am.   8pm   3. Syp. Dexorange. 10ml thrice daily 8am.   2pm.    8pm Format

Followup:

Review to opd after 15 days with hemoglobin and reticount

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY