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