Case 2

Hi, I am R. Ramya Keerthana , 3rd semester medical student.This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

Case Scenario
A 45  year old man came to OPD on 11th August with chief complaints of low back pain and dribbling of urine. 

Chief complaints 
- Low back pain gradual in onset and radiating to right lower limb with tingling sensation and numbness since 7 months.
- burning micturition and dribbling of urine since 7 months
- indigestion and bloating since 7 months.

History of present illness
No epigastric pain
No nausea and vomiting
No loose motions
No fever
No pyuria
No abnormal frequency of micturition

History of past illness
No diabetes, hypertension, asthma, CAD, tuberculosis, cancer.
K/c/o epilepsy

Personal History
Married
Occupation: shop owner
Appetite: normal
Mixed diet
Bowels: regular
Chronic smoker for 15 years, smokes 18-20 cigarettes per day.

Family History
Not significant

Physical examination
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema, malnutrition, dehydration.

Vitals
BP: 120/80 mm Hg
Pulse: 82 bpm
Respiratory rate: 16 bpm
Temperature: 98.6°F
SPO2: 98% RA
GRBS: 102 mg/dl

Systemic examination
CVS
No thrills
No cardiac murmurs
S1 S2 heard

Respiratory system
No dsypnoea and wheezing
Vesicular breathing sounds
Trachea in central position

Abdomen
Scaphoid shape
No tenderness, palpable masses, free fluid, bruits, bowel sounds
Liver and spleen not palpable
Normal hernial orifices

CNS
Conscious, normal speech, no neck stiffness and kerning's sign is negative
Cranial nerves, motor system and sensory system normal
All reflexes normal
Cerebellar coordination normal
Gait is normal


Investigations
RFT
Blood urea: 38
Serum creatine: 1.0

LFT
Total bilirubin: 1.87
Direct bilirubin: 0.67
SGOT: 36
SGPT: 39
ALP: 153
Total protein: 7.6
Albumin: 4.63

RBS: 146 mg/dl

Serum electrolytes
Sodium: 140
Potassium: 3.9
Chlorine: 102

Ultrasound abdomen
Nothing significant

Upper GI Endoscopy
- extrinsic impressions in upper esophagus
- erosive fundal gastritis

MRI
L5-S1 spondylolisthesis

2D Echo

ECG
Medication Chart



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