27F with leftside lower back pain, burning micturition with increased frequency of urination ∵4 days

 E LOG GENERAL MEDICINE 

Hi, I am B.Glory Evangeline , 6th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient- centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.

 * This is an ongoing case. I am in the process of updating and editing this ELOG Chief complaints and duration.

Chief complaints:

27F with left lower back pain, burning micturition with increased frequency of urination since 4 days came to opd

Telangana PaJR 

History of presenting illness :

Patient was apparently asymptomatic 4 days back then she developed left lower back pain gradually progressive ,non radiating with no aggregating and relieving factors, associated with burning micturition and increased frequency of urination 

Past history:

History of renal calculi 5 years back 

Similar complaints seen 3 months back for which she underwent treatment

Known case of hypothyroidism since 7 years 

For which medication taken is 

Thyronorm 75 mg 

Not a known case of asthma , tb , epilepsy, CAD, CVD

Family history: irrelevant

Personal history:

Diet : mixed

Appetite: normal

Bladder and bowel movements: regular 

Sleep : adequate

No habits 

Vitals 

Temp: afebrile

Pulse rate : 85 beats/min

Respiratory rate: 17 c/m

BP: 110/80 mmHg 

Gen Examination:

Patient's consent was taken

Patient was examined in a well lit room 

She was conscious, coherent, cooperative 

No pallor

No icterus

No cyanosis

No clubbing

No lymphadenopathy

No pedal edema 

Systemic examination:

Per abdomen: 

soft, non tender , bowel sounds present , no organomegaly

Respiratory system: 

bilateral air entry present , clear

Cvs: 

s1,s2 present , no added sounds 

External genitalia:

 normal ,

No abnormalities detected .