Is there more to the story : A case of 28 y/f with burning micturition

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Chief complaints

A 28 yr old female, a resident of Kolkata, presented with 

• c/o Burning micturition since 4 months
• c/o 2 episodes of hematuria
• c/o left groin pain since 4 months
• c/o lower abdominal pain since 4 years
• C/o difficulty in breathing since 4yrs

History of present illness: 

• The patient reportedly contracted TB at the age of 11 yrs in 2001 after which she started experiencing easy fatigability even on doing minor forms of any physical activity resulting in difficulty in breathing and she had to turn to one side and then get up from sleeping posture
• Since then she would occasionally experience paroxysms of cough at night accompanied by severe chest pain and throat pain which spontaneously got cured post-delivery
• Patient reported her first encounter with the left lower abdominal pain, dull aching in nature, sudden in onset, not radiating, in the summer of May 2013 while traveling for long hours without drinking water but felt relief after drinking plenty of water and passing urine
• Her second encounter with the pain was in year 2018 pre covid lockdown when she suddenly complained of severe agonizing pain and had to be rushed to ER at 2 am and was given some IV injections and tablets and returned home in few hours 
• But she continued to experience occasional pains here and there which she would disregard and tried to bear with it
• She then resorted to taking homeopathic medications prescribed for renal calculi which she took for over a period of 2 yrs all the while without ever getting an ultrasound kub or any other form of investigation done to confirm renal calculi
• She stopped consuming homeopathic medicines for her pain abdomen but continues to take them till date for her difficulty in breathing
• patient gave history of burning micturition and groin pain post voiding since past 4 months 
• On 25 May, she passed visible blood in urine  and then again on 6 June she passed minute quantities of blood in urine.

Past history : 

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

Menstrual history 

• Age of menarche - 13 years
• Cycles - 45-60 days/ irregular
• Bleeds for 4-5 days
• Uses 2 pads per day
• Not associated with pain abdomen
• H/o passing clots pea sized 

Obstetrical  history

P2L1A1 

P1L1 - female child delivered through c- section ( Ix - patient request) , 6ys of age,healthy child at birth , no history of NICU admission, achieving all milestones till age

P2A1 - induced abortion@ 2 month (Ix - unwanted pregnancy) by consuming oral pills on 6/11/21 following which she experienced disturbance in her mentrual cycle with increasing frequency for next 2 months ( 6/11/21 ---->16/1/22 --->28/1/22 ---->8/2/22) for which she visited a gynecologist who advised her to get an USG done again not done and took TAB. OVRALL ( LEVONORGESTREL + ETHINYLOSTRADIOL) for 1 month and her cycles reverted back to normal

Family history

 Neither her parents nor her brother have any history of similar complaints, or Htn, dm, ba,tb

Her husband reportedly had similar complaints of lower abdominal pain and was found to have renal calculi for which he received treatment

Currently her daughter is reportedly found to have 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, koilonychia, generalized lymphadenopathy, or pedal edema.

Vitals

• Pulse: 92 beats per min, right radial pulse, regular, normal volume
• Blood pressure: 110/70 mmHg, measured on the right upper arm in supine position
• Respiratory Rate:  18 cycles per min 
• SPO2 at room air : 98%
• Temperature: 98 F

SYSTEMIC EXAMINATION

Abdominal system

• No scars, sinuses, or any engorged veins.
• Hernial orifices intact
• Tenderness present in Left iliac fossa and hypogastric region
• No enlargement of liver, kidneys, or spleen
• No ascites
• Bowel sounds were normal.

Cardiovascular system

• cardiac sounds  s1 and s2 heard normally
• Apex beat located in 5th ICS, medial to the mid-clavicular line.
• No cardiac murmurs
• Thrills absent

Respiratory system 

• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is impaired in rt 2,3,4th ICS
• Breath sounds decreased in Right upper infra clavicular area, no wheeze or crackles heard.
• Vocal resonance normal and symmetrical

central nervous system

• No focal abnormality detected
• Higher mental functions intact 
• Cranial nerves I- XII: No cranial nerve abnormality detected.
• Speech normal

• POWER	RIGHT		LEFT
  	UL	LL	UL	LL
  	5	5	5	5
  TONE	NORMAL	NORMAL	NORMAL	NORMAL
  LIGHT TOUCH	NORMAL	NORMAL	NORMAL	NORMAL
  POSITION	NORMAL	NORMAL	NORMAL	NORMAL
  COORDINATION	NORMAL	NORMAL	NORMAL	NORMAL

Musculoskeletal system

• Gait normal
• No muscle or soft tissue changes.
• No bone or joint deformities.
• No limitation of movements.

INVESTIGATIONS :

A 6 min walk test was performed 

Pre walk vitals

SPO2 -95

BP- 100/70

PR 86

RR- 24

Post walk vitals

Spo2- 98

Bp - 110/70

PR- 101

RR-34

Provisional Diagnosis

?Rt upper lobe fibrosis secondary to old pul TB

? PID

Treatment receiving

• DRINK PLENTY OF ORAL FLUIDS
• TAB. MVT PO/OD 
• TAB ULTRACET 1/2 TAB QID 

Discharge summary

Discharge Date

Date:24/06/2022

Ward:FEMALE MEDICAL WARD

Unit:5

Name of Treating Faculty

DR RAKESH BISWAS (HOD)

DR SRI HARSHA (SR)

DR VAMSI KRISHNA (PG II )

DR BHARATH KUMAR PG (PGI)

Diagnosis

RIGHT UPPER LOBE FIBROSIS SECONDARY TO PULMONARY TUBERCULOSIS

Case History and Clinical Findings

A 28 yr old female, a resident of Kolkata, presented with c/o Burning micturition since 4 monthsc/o 2 episodes of hematuriac/o left groin pain since 4

monthsc/o lower abdominal pain since 4 yearsC/o difficulty in breathing since 4yrsHistory of present

illness:The patient reportedly contracted TB at the age of 11 yrs in 2001 after which she started

experiencing easy fatigability even on doing minor forms of any physical activity resulting in difficulty

in breathing and she had to turn to one side and then get up from sleeping postureSince then she

would occasionally experience paroxysms of cough at night accompanied by severe chest pain and

throat pain which spontaneously got cured post-deliveryPatient reported her first encounter with the

left lower abdominal pain, dull aching in nature, sudden in onset, not radiating, in the summer of May

2013 while traveling for long hours without drinking water but felt relief after drinking plenty of water

and passing urineHer second encounter with the pain was in year 2018 pre covid lockdown when she

suddenly complained of severe agonizing pain and had to be rushed to ER at 2 am and was given

some IV injections and tablets and returned home in few hoursBut she continued to experience

occasional pains here and there which she would disregard and tried to bear with itShe then resorted

to taking homeopathic medications prescribed for renal calculi which she took for over a period of 2

yrs all the while without ever getting an ultrasound kub or any other form of investigation done to

confirm renal calculiShe stopped consuming homeopathic medicines for her pain abdomen but

continues to take them till date for her difficulty in breathingpatient gave history of burning micturition

and groin pain post voiding since past 4 monthsOn 25 May, she passed visible blood in urine and

then again on 6 June she passed minute quantities of blood in urine.Past history :Patient has h/o TB

but not of hypertension, diabetes, asthma, epilepsy or CADMenstrual historyAge of menarche - 13

yearsCycles - 45-60 day

s/ irregularBleeds for 4-5 daysUses 2 pads per dayNot associated with pain abdomenH/o passing

clots pea sizedObstetrical historyP2L1A1P1L1 - female child delivered through c- section ( Ix - patient

request) , 6ys of age,healthy child at birth , no history of NICU admission, achieving all milestones till

ageP2A1 - induced abortion@ 2 month (Ix - unwanted pregnancy) by consuming oral pills on 6/11/21

following which she experienced disturbance in her mentrual cycle with increasing frequency for next

2 months ( 6/11/21 ---->16/1/22 --->28/1/22 ---->8/2/22) for which she visited a gynecologist who

advised her to get an USG done again not done and took TAB. OVRALL ( LEVONORGESTREL +

ETHINYLOSTRADIOL) for 1 month and her cycles reverted back to normalFamily historyNeither her

parents nor her brother have any history of similar complaints, or Htn, dm, ba,tbHer husband

reportedly had similar complaints of lower abdominal pain and was found to have renal calculi for

which he received treatmentCurrently her daughter is reportedly found to have Tb

Personal history :

Appetite- decreasedDiet- mixedBowel and bladder- RegularSleep- adequateAddictions- NoneNo

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, koilonychia, generalized lymphadenopathy, or pedal

edema.

Vitals

Pulse: 92 beats per min, right radial pulse, regular, normal volume

Blood pressure: 110/70 mmHg, measured on the right upper arm in supine position

Respiratory Rate:18 cycles per min

SPO2 at room air :98%

Temperature: 98 F

Investigation

HAEMOGRAM

HB 12.1 mg/dl

TLC 8800

N/L/E/M/B 58 /34/4/4/0

MCV 85

MCH 28

PLC 1.58

LFT

T,BIL 1,4

D.BIL O.28

AST 24

ALT 26

ALP 138

TOTAL PROTIEN 6.8

ALBUMIN 4

RFT

S.CREAT 0.7

B.UREA 29

NA 141 K 4 CL 100

CUE NORMAL

6 MIN WALK TEST NORMAL

URINE CULTURE AND SENSITIVITY NORMAL

PFT SMALL AIRWAY OBSTRUCTION

Treatment Given(Enter only Generic Name)

DRINK PLENTY OF ORAL FLUIDSTAB. MVT PO/ODTAB ULTRACET 1/2 TAB QID

Advice at Discharge

1.DRINK PLENTY OF ORAL FLUIDS2.TAB. MVT PO/OD FOR 20 DAYS3.TAB ULTRACET 1/2 TAB

QID FOR 4 DAYS4.SYP CITRALKA 10ML IN 1 GLASS OF WATER PO/TID

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR

ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case

of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries 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