Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent.This also reflects my patient centered online learning portfolio.
A 45 year old male patient came to the OPD with chief complaint of lower back pain and dribbling of urine on 11th August 2022
Chief Complaint
- dribbling of urine since 7 months
- indigestion since 7 months
- lower back pain which is gradual in onset and progressed to right lower limb
- numbness and tingling sensation in right limb which relieves on walking
- burning micturition
History of present illness:
- no epigastric pain
- no nausea
- no vomiting
- no loose motions
- no aggravating or reliving factors of pain
- no fever
- no pyuria
- no abnormal frequency of micturition
Personal History:
- married
- mixed diet
- bowel : regular
- micturition: normal
- no known allergies
- no addictions
Family History
- no diabetes mellitus
- no hypertension
- no heart disease
- no stroke
- no cancer
- no tuberculosis
- no asthma
- no other hereditary diseases
Physical Examination
- height: not taken
- weight: not taken
- BMI: not taken
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no edema of feet
- no malnutrition
- no dehydration
Vitals:
- temperature: 98.6 F
- pulse rate : 82 bpm
- BP : 120/80 mm Hg
- SPO2: 98%
-GRBS: 102 mg%
Systemic Examination
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System:
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- PV examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
- gait: normal
Investigations:
- Renal Function Test:
blood urea = 38
serum creatine = 1.0
- Liver Function Test:
Total Bilirubin = 1.87
Direct Bilirubin = 0.67
SGOT = 36
SGPT = 39
ALP = 153
Total Protein = 7.6
Albumin = 4.63
- Random Blood Sugar = 146 mg/dL
- Serum electrolytes
Sodium = 140
Potassium = 3.9
Chlorine = 102
- Ultrasound Abdomen: no significant findings
-Upper GI Endoscopy:
extrinsic impression in upper esophagus
erosive fundal gastritis
erythema in antrum
- ECG:
Aorta = 1.5cm
Aortic valve = sclerotic, thickened
Left atrium = 3.5cm
Left ventricle = concentric LVH, no RWMA
Inferior vena cava size = 1.10 cm
good left ventricle systolic function, diastolic dysfunction
-MRI:
L4 to S5 spondylolithesis
Treatment:
Napoxy 250 mg tablets
Pantop 40 mg tablets
Prabatin HP tablets
Pregebatin HB tablets