Case of a 33 years old man with balanoposthitis.

November 03, 2022

Case of a 33 years old man with balanoposthitis.

This is an online e log book to discuss our patient's de-identified health data shared after taking his/her/guardians' signed informed consent. This Elog reflects my patient-centred online learning portfolio.

Case of a 33 years old man , resident of West Bengal and owner of a fruit selling business .

CHIEF COMPLAINT

Patient has the chief complaint of

Gas problem from 5 years

Episodes of burning micturition from 2 years

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 years ago , when he started complaining of dyspepsia . He complains of pricking pain in the left hypochondrium , 1-2 hours following consumption of fatty food and non veg foodstuff. He would get relief on taking medication . The pain would not radiate to any other location. The episodes are usually associated with bloating , belching and vomiting ( non bilious , non foul smelling , containing consumed food ) and diarrhoea ( 3-4 times loose stools , not associated with blood or mucus ) . The patient complains of increased number of episodes from the past 3 months . The episodes are not regular.

2 years ago , he started experiencing episodes of burning micturition . He complains of burning sensation during coitus .The patient complained of developing cuts following coitus , which would cause burning sensation during micturition . It would be associated with mild bleeding .He would get relief by using an ointment .

The patient also complains of decreased hearing in both the ears from 2 years . Not associated with any discharge, aural fullness, pain or tinnitus.

Patient also complains of discolouration of both the legs ( hyperpigmentation ) from 1 year . The patient initially had multiple blisters on his legs that burst and were followed by discolouration of the legs . It is not associated with muscle cramps , or pain during walking or standing .

The patient also complains of pain in the temples while trying to open his mouth from 3-4 days.

The patient a known case of diabetes mellitus type 2 from 7 years. He was diagnosed in a routine test done before surgery.

HISTORY OF PAST ILLNESS

When the patient was a child, milk entered his ear during feeding. Since then, he had profuse white coloured non foul smelling doughy discharge from left ear associated with aural fullness , not associated with pain , blood or tinnitus. He underwent a tympanoplasty in 2009 , after which discharge stopped from left ear. Soon after similar discharge started from right ear. He underwent another tympanoplasty in the right ear, following which the discharge stopped.

Known case of diabetes mellitus type 2 from 7 years.

Not a known case of hypertension, asthma, TB, Thyroid condition, CVD, or Epilepsy.

FAMILY HISTORY

Father- known case of DM

Mother- known case of DM

PERSONAL HISTORY

Appetite- Normal

Diet- Mixed

Sleep- disturbed sleep from 3 months due to increased acidity.

Bowel and bladder movements- Regular.

During episodes of indigestion , he would get diarrhoea followed by no bowel movements the following day.

Alcohol- occasional consumption of 1-2 pegs.