This is 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 patients 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 comment box is welcome.
I have 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 diagnosis and treatment plan
Name : D.Santhosh (Internee)
CHEIF COMPLAINTS :- Patient came with the complaints of lower back pain since 1 year.
Complaints of bilateral knee pain since 1 year.
HOPI :
- Patient was apparently asymptomatic 4 years back, then patient developed fever and went to government hospital where he was diagnosed with Diabetes and started on Medication.
- 1 year back, went for routine sugar checkup in Government hospital and there he was diagnosed with Hypertension and started on Medication
- Patient was apparently asymptomatic 1 year ago then he developed lower back ache which is insidious onset, gradually progressive, non radiating, dragging type(SLRT negative) not associated with tingling sensations, paresthesias, numbness.
- He also developed bilateral knee pains which is insidious in onset, gradually progressive , crepitus present. no morning stiffness, tenderness, swelling.
- No aggravating and relieving factors
- C/o polyphagia and burning sensation of both feet(on and off)but no c/o polydypsia
- No c/o chest pain, palpitations, SOB, pedal edema
- No c/o fever,pain abdomen,burning micturition,vomiting,loose stools,cough,cold
PAST HISTORY :
- K/c/o HTN since 1 year(on medication of tab.amlodipine 5mg po/od)
- K/c/o DM since 4 years(on medication of tab.metformin 1000mg po/od and glimiperide 1 mg po/od)
- Not a k/c/o Tb,epilepsy,bronchial asthma,cva,cad
PERSONAL HISTORY :
Takes mixed diet
sleep is normal
stools - hard , regular
Micturition - nocturia (3-4 times/night)
Consumes alcohol occasionally (monthly once)
Not a smoker
FAMILY HISTORY : Insignificant
GENERAL PHYSICAL EXAMINATION
No signs of pallor, icterus, cyanosis clubbing, edema, lymphadenopathy.
Vitals at presentation :
Temp - afebrile
Bp 140/90 mmhg
PR: 86bpm
Grbs: 369 mg/dl(just ate)
GRBS charting
On 17th Feb; 8:00 AM
GRBS - 224 mg/dl
On 18th Feb,
2:00 pm - 314 mg/dl
7:30 pm - 82 mg/dl
10:00 pm - 480 mg/dl
On 19th Feb,
2:00 am - 384 mg/dl
SYSTEMIC EXAMINATION :
CVS: S1 S2 heard, No murmurs
RS: b/l air entry present, NVBS
P/A : soft,non tender
no organomegaly
CNS : Hmf intact, NFND
INVESTIGATIONS
HEMOGRAM
AP VIEW
ULTRASOUND REPORT
TREATMENT- TAB ULTRACET PO/QID(1/2 tab)
- TAB AMLODIPINE 5MG PO/OD
- TAB METFORMIN 1000MG PO/OD
- TAB GLIMIPERIDE PO/BD (2mg morning and 1mg night)
- STRICT DIABETIC DIET.
DIAGNOSIS
- LOWER BACK ACHE UNDER EVALUATION(DEGENRATIVE CHANGES+ LUMBAR SPONDYLOSIS).
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