50 YEAR OLD MALE WITH C/O BACK PAIN

SUDHAMSHI REDDY M

This is online E log book to discuss our patient’s de-identified health data shared after taking   his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis 

A 50 year old male came with chief complaints of 

Back pain and left shoulder pain since 1 month

Burning sensation of hands and feet since 1 month

HOPI:

Patient was apparently normal 1 month back then he developed back pain insidious in onset, gradually progressive aggravated on eating nonveg, relieved on lying down, no tingling sensation present.

Complaints of left shoulder pain since one month dragging type of pain, no aggrevating or relieving factors.  No neck pain, no tingling sensation.

C/o tingling sensation of hands (left more than right)

C/o burning and tingling sensation in both feet 

C/o constipation since 10-15 days

C/o loss of appetite since 10 days

No h/o fever, decreased urine output, sob, palpitations, pain abdomen, chest pain, burning micturition.

PAST HISTORY:

Known case of Hypertension since 6 months on Tab Amplodipine 5mg OD

Known case of Type II Diabetes Mellitus since 1-2 months on Tab Metformin 500mg OD

Not a k/c/o TB, Epilepsy, Thyroid disorders, Asthma, CVA, CAD.

Left femur fracture 2 years back and operated. Since then he is not able to walk normally and requires a stick to walk.

PERSONAL HISTORY:

Diet mixed

Sleep normal

Appetite decreased since 10 days 

Bowel constipated since 10-15 days 

Bladder normal

Occasional alcoholic since 20years

Smoker since 30 years smokes chutta daily

No significant family History

GENERAL EXAMINATION:

O/E 

Patient is conscious coherent cooperative

Afebrile on touch

PR : 84bpm

RR : 16cpm

BP : 140/80 mm of hg

Grbs : 119 mg/dl

SYSTEMIC EXAMINATION:

RS: BAE NVBS no added sounds

CVS : S1 S2 heard no murmurs

P/A : soft , non tender

CNS : higher mental functions intact

Tone normal in all 4 limbs

Power 5/5 in all limbs

All reflexes present

Plantar is Flexor on both sides.

INVESTIGATIONS:

ECG- 

CHEST X RAY- 

X RAY B/L KNEE:

AP VIEW-

LATERAL VIEW-

USG ABDOMEN:

PROVISIONAL DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH HYPERTENSION ( SINCE 6MONTHS) WITH TYPE II DIABETES MELLITUS ( SINCE 1-2MONTHS) WITH B/L OSTEOARTHRITIS OF KNEE.

TREATMENT:

1. INJ HUMAN ACTRAPID INSULIN S/C TID

2.TAB AMLODIPINE 5mg PO/OD

3. TAB SHELCAL 50mg PO/OD

4. TAB LASIX 20mg PO/BD

5. TAB OROFER-XT PO/OD

6. CAP BIO D3 PO/OD

7. SYP CREMAFFIN PLUS 15ml PO/HS

8. FLUID RESTRICTION < 1.5L/DAY.