Phimosis case

September 07,2022


Hi I am, P.Rakesh, a medical student . This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read!


A 15 young male presented to the opd with chief complaints of 
Difficulty in micturition associated with burning sensation.

CHIEF COMPLAINTS : 
Difficulty in micturition and burning sensation since 5 days.
H/o low grade fever
Not associated with chills and rigor lasted for4 days and decreased on medication.
N/H/O SOB, chest pain and palpitation.

HISTORY OF PRESENT ILLNESS
Patients was apparently asymptomatic 1 week back then he developed low grade fever which lasted for 5 days and on further investigation patient was found to have low Hb levels then after 4 days patient had developed difficulty in micturition and had burning micturition 

HISTORY OF PAST ILLNESS 
N/C/O of DM, HTN, TB ,ASTHMA, CAD

PERSONAL HISTORY
Normal appetite , Vegetarian ,regular bowel movements , no addictions

VITALS 
Bp 130/70 mmHg 
Pulse : 80 BPM
Afebrile temperature.

GENERAL EXAMINATION
Pallor -present 
No Cyanosis ,icterus,clubbing,lymphadenopathy ,edema of feet ,no malnutrition,dehydration.
CVS
S1,S2 are heard
No thrills and murmurs

RESPIRATORY SYSTEM 
Vesicular breath sound heard 

PROVISIONAL DIAGNOSIS
ANEMIA UNDER EVALUATION WITH PHIMOSIS


 TREATMENT

5/09/22
1. Tab .DOLO 650 mg 
2. Tab.ZINCOVIT
6/09/22
1. Tab.DOLO 650mg
2.Inj.optineuron 1 amp in 100 ml
3. Syp.CITRALLKA 15 ml in glass of water

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