A 55 yr old male with lower back pain

​E-LOG GENERAL MEDICINE

Hi, This is Kundana , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

Chief complaints: 
 
Patient complains of shortness of breath , fever and lower back ache .
  • shortness of breath since 10 days
  • Lower back pain simce 10 days 


History of present illness:

 

The patient is apparently asymptomatic one month ago , then he developed shortness of breath 


  • shortness of breath: insidious onset , grade-2 (NYHA) , gradually progressive 
  • History of orthopnea, PND, cough present
  • No history of chest pain , cold 
  • Decreased urine output since one month
  • Thin stream , poor flow, increased frequency, hesitency sensations present, burning micturition present, but no pain during micturition
  • Pain: at lower back , dull boring type, non radiating and non associated with micturition or movements 


History of past illness: 

  • known case of diabetes mellitus since 10 yeras 
  • Known case of hypertension since 3 months 
  • Not a known case of asthma, CAD, TB 
  • Hypoglycemic seizures observed 5 months ago
  • Renal failure from 5 months 


Personal history:

  • diet- mixed 
  • appetite- normal 
  • Bowels- regular 
  • Micturition- abnormal 
  • No allergies 
  • Alcohol intake- occassional 
  • Smoking- few months back (chutta) 


Family history:

 Not significant 


Treatment history: 

  • no allergy to any drugs 
  • Uses medication for diabetes ( inj. HAI , NPH ) and hypertension ( tab.AMLONG) 


GENERAL EXAMINATION


  • Patient is conscious , coherent and cooperative 
  • Moderately built and nourished
  • No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema, malnutrition , dehydration 


Vitals


  • Temperature: afebrile 
  • Pulse rate:80bpm
  • Respiration rate: 12 cpm
  • Bp: 110/80 mm/ hg 


SYSTEMIC EXAMINATION 


CVS:

•No thrills and murmurs

• S1 & S2 heard


Respiratory system

• Dyspnoea ,wheeze absent 

• centrally placed trachea 

• Normal vesicular breath sounds 


Abdomen

• Scaphoid shaped abdomen

• No tenderness

• No palpable mass

• No free fluid

• No bruits

• Non palpable liver

• Non palpable spleen

• Bowel sounds present


Central nervous system 

  • conscious
  • Speech- normal
  • No neck stiffness 
  • No  kernings sign
  • All reflexes present 
  • Cranial nerve intact 
Provisional diagnosis:
 Chronic kidney disease with diabetes and hypertension 

INVESTIGATIONS:




















Treatment: 

Haemodialysis 

Salt restriction

Fluid restriction





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