GENERAL MEDICINE E-LOG

A 33 YEAR OLD FEMALE WITH BURNING MICTURITION AND EXCESSIVE HUNGER AND THIRST


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 .

ARUSHI KUMARI
151

A 33 year old female came to OPD with chief complain of 
- Lowe back pain
- burning micturition since 5 months 
- 2 episodes of blood in urine 
- excessive hunger and thirst 
- tingling and burning sensation in UL and LL ( more in UL )

HOPI
- Patient was apparently asymptomatic 1 and half year back when she started experiencing increased frequency of micturition with burning sensation .
- She also observed very minute , black stones in urine associated with pain .
- After observing for 3-4 days continuously she consulted a gynecologist .
- The gynecologist asked her to consult nephrologist .
The nephrologist after conducting CUE and X-ray KUB diagnosed that she is having stones in urinary tract ( ?? Urolithiasis ?? ) 
- She was put on medication which she took for 1 month and then CT scan was done which showed that her stone has been resolved . 
- After about 1-2 months she started experiencing fatigability , shivering ( cold intolerance ) , easily getting tired in doing any work which was relieved by taking rest.
- She also has history of severe backache since 4 years 

- H/O anxiety and insomnia since 1 year ( increased in the last 2 months )
- loss of taste since 2 months 
- hair loss since 2 months
- burning sensation in eyes ( due to inadequate sleep )
- irritation and black spots after scratching in the gluteal region ( pruritus ?? )
- burning and tingling sensation in the Upper limb and Lower limb ( needle and pins sensation ) - more in the upper limb
- history of pain in plantar surface of foot in the early morning

# She was on physiotherapy along with medication for 2 weeks 
( She went to orthopedic with her lower back pain complain )
-  excessive thirst and hunger from last 2 months but decreased appetite but not able to eat properly due to pain in throat while swallowing 

PAST HISTORY
- known case of HTN( On irregular medication )
- She was diagnosed with B/L PCOD 
- skin lesion over both  buttocks since 3 years 
* She was on irregular ointment for the same ( on and off ) 
On examination few well defined , polysized , scaly , hyperpigmented plaques were noted over the buttocks along with diffuse dryness of skin 
- diagnosed to be TINEA CORPORIS ET CRURIS 
- history of hair fall from scalp since 2 months 

MENSTRUAL HISTORY
 - Attended menarche at the age of 13 years 
- Irregular and delayed cycle associated with pain 
- 35-40 days cycle 
- 6-7 days bleeding period 
* Once in college life at the age of 22 years her bleeding lasted 9 days with severe pain for which she consulted local doctor and gave medication which relived her symptoms 

MARITAL AND OBSTETRICS HISTORY
- married in the year 2013 
- conceived after 1 year of marriage 
- 1 st child in the year 2014 
- delivered by C- section 

** She was on medication for her PCOD .

DRUG HISTORY 
- she was on medication for her irregular periods 
Tab. DEVIRY 10 mg 
Tab. NOVELON 
-Tab. AMIXIDE H 
Tab. URIFAST
- she also used Medicine for her urinary tract stone for 1 month  

REPORT : 

            KUB AP View 09/09/2020

          USG lower abdomen 04/12/21 

                          02/12/21 
                         02/12/21 
                         02/12/21 

                        02/12/21 
                        02/12/21

Daily updates 

18/12/21 ( 2nd day of admission )
- Consulted psychiatrist for her anxiety disorder who diagnosed as ADJUSTMENT DISORDER
- Consulted dermatologist for her skin lesion and was diagnosed with TINEA CORPORIS ET CRURIS .

                          18/12/21

                           18/12/21 

19/12/21 ( 3rd day of admission )
Started taking Tab. CLONAZEPAM 0.25mg






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