Personal Data

Name - MR XYZ

Age- 54 YR

Gender- MALE

Religion- HINDU

Nationality- INDIAN

Occupation- RETIERD

Married/Unmarried/Divorced- MARRIED

Contact details-

Address- VADODARA GUJARAT

 

Chief/Presenting Complaints

Location: GUT

Sensation: Pt came with complain of intense burning before, during and after urination since 3-4 days, there is constant urge to urinate, scanty urine passed in drops.

Modalities: <urinating, >cold water

Concomitant: noting specific

 

History of Chief/Present Complaints:  ODP since 3-4 days

Family History: noting specific

Gynecology/Obst History: NA

Physical General

·       Appetite: good

·       Thirst: 1lit/day

·       Craving: not specific

·       Aversion: not specific

·       Addiction: NA

·       Perspiration: moderate

·       Bowel: regular

·       Urine: burning urination

·       Sleep: sound

·       Taste: NS

·       Tongue: NS

·       Thermal: chilly

Mental General: nothing specific

Physical Examination

·       General Appearance: lean and thin

·       Vital Signs (Pulse/B.P./Temp/RR): 78/Min, 110/70mmhg, 96’f, 16/Min

·       Weight and Height

Systemic Examination: NAD

Differential Diagnosis:

 ? UTI

? cystitis

Laboratory Investigations (If any)

Final Diagnosis: UTI

Totality of Symptoms

·       Burning before urination

·       Burning during urination

·       Scanty urine Constant urge to urinate

Repertorial /Non-Repertorial method: non repertorial

 

 

Preion (Rx), Dose, Repetition: CANTHARIS 200 1 DOSE

FOLLOW BY SL 30 BD FOR 3 DAYS

Management (If any): DRINK PLENTY OF WATER

Follow up:

1)    24/1/22 – BETTER IN BURNING PAIN / RX SL 30 BD FOR 3 DAYS

 

2)    26/1/22- NO NEW C/O AND OLD CCC/O ARE BETTER / RX SL 30 BD FOR 3 DAYS

 

 

3)    31/1/22 – ALL C/O ARE BETTER NO NEW C/O / RX SL 30 BD FOR 1 WEE

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