33 year old male patient

33 year old male patient 


GM Blog: 33 year old male patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 29-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of burning and painful micturition since 2 years.

C/o  Dyspareunia ( painful intercourse) since 2 years.
C/o  Bilateral Decreased hearing since 2 years
C/o indigestion and pain abdomen since 5 years

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 5 years back then he developed pain abdomen and epigastric burning sensation episodically for which he went to the local hospital 
The pain was located in the left flank and sometimes radiating to the whole abdomen.
Relieving factor - medication
Aggravating factor- non vegetarian food like chicken, mutton and fish
He had few episodes of vomiting during the indigestion. Vomitus mostly included food particles.
following which he developed papules in the leg which lead to blisters and hyperpigmentation of the skin of both the limbs. It is non tender.
Later he developed burning, painful micturition and inability to retract prepuce since 2 years.


PAST HISTORY:

Known case of Diabetes mellitus since 7 yrs 
Whitish ear discharge in both ears since childhood, progressive, non foul smelling for which he visited many hospitals and clinics. He underwent an ear surgeries in the year 2009 and 2015 .
He had no complaints of tinnitus and vertigo.
He met an accident 15 years back during which he injuried his left leg.
No history of coronary artery disease, epilepsy, asthma, kidney diseases , tuberculosis,  fits or any other chronic illness 

PERSONAL HISTORY:
Married 
Obese 
Diet: mixed. ( Non vegetarian)
Sleep- reduced 
Appetite - normal 
Bladder movement- painful and burning 
Bowel movements- normal 
Allergy- dust allergy 
Addiction- alcohol occasionally. ( Stopped since last 3 months ) 


FAMILY HISTORY:
Father and mother known case of diabetes mellitus

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
Obese 
Pallor - absent 
icterus absent
No cyanosis
No clubbing
No edema 
No Lymphadenopathy  


Vitals 
Temperature: 98.6 F 
Pulse rate : 86 beats /min
Respiratory rate: 18/ min
Blood pressure: 110/ 70 mmHg 
Spo2-98%
Random blood sugar: 126 mg /dl

Systemic examination 

Cardiovascular system
S1, S2 heard
No murmurs 

Respiratory system

Wheeze and dyspnea absent 
Position of trachea: central
Breath sounds: Vesicular
Adventitious sound: absent 

Abdomen
Shape of abdomen: scaphoid
Non tender
No palpable mass
No free fluids
Spleen and liver not palpable

Central nervous system
Conscious
Speech: normal
Neck stiffness - no

ENT examination
Bilateral Decreased hearing 
































Investigations

















Gastroenterology 





Treatment: 

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