A 45 year old male patient, shopkeeper by occupation presented with lower back pain and burning micturition.

E LOG GENERAL MEDICINE 

Hi, I am P Tejaswini , 3rd Sem Medical Student.This is an 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 patient's 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 the 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 a diagnosis and treatment plan. 

CHIEF COMPLAINT:

Patient came with the complaints of lower back pain, burning micturition, dribbling of urine and indigestion for the past 7 months.

Patient was apparently asymptomatic 7 months back. He developed lower back pain which is gradual in onset and prolonged to right leg.

HISTORY OF PRESENT ILLNESS:

Daily routine of the patient: Patient wakes up at 6:00 AM and completes his daily activities and goes to work.

He has  complaint of numbness and tingling sensation. No aggrevating and reliving factors.

No history of fever and pyuria.

PAST HISTORY:

He had epilepsy

No aasthma

No hypertension

No Diabetes mellitus

No CAD

No tuberculosis

No syphilis 

PRESENT HISTORY:

Patient was married.

Diet: mixed

Appetite: normal

Bowels : regular 

Bladder: regular

Sleep : adequate

Habits: chain smoker 

ALLERGIC HISTORY:

No known allergies.

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Pallor is absent.

Icterus is absent. No cyanosis, clubbing koilonychia, lymphadenopathy.

Pedal oedema absent.

VITALS:

PR: 82 bpm

RR: 16 cycles per minute

BP: 120/80

Temperature:98.6 c

PO2: 98%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills 

No murmur 

Respiratory system:

Dyspnea is absent.

Wheeze: no

Abdomen:

Shape : scaphoid

No tenderness

No palpable mass

CNS:

Conscious

Normal speech

Gait - normal

INVESTIGATIONS

Blood urea- 38 mg/dl

Serum creatinine: 1 mg/dl

Random blood sugar -146 mg/dl

Total bilirubin:1.87 mg/dl

Direct bilirubin: 0.67 mg/dl

SGOT: 36 IU

SGPT :39 IU

ALP: 153 IU

Total protein:7.6 g/dl

Albumin:4.63 g/dl

2D echo

Ultrasound:

UGIE report:

ECG: