A 45 years old man came to hospital with lower back pain and burning micturation
Hi, I am Niteesh Gangina (roll no :81)3rd semester medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
A 45 years old man sweet shopkeeper by occupation came with lower back pain and burning micturation
Chief complaints
The patient came to hospital with lower back pain and with dribbling of urine
History of present illness
Patient is asymptomatic 7 months back and developed lower back pain gradually which radiated to lower right limb.Also developed dribbling of urine with burning micturation.
History of past illness
Patient suffered from epilepsy
Personal history
Diet:mixed
Appetite:normal
Sleep:normal
No known allergies
General examination
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal odema
SYSTEMATIC EXAMINATION:
B. CARDIO VASCULAR SYSTEM
1. Thrills No
2. Cardiac Sounds s1,s2
3. Cardiac murmurs No
C. RESPIRATORY SYSTEM
1. Dyspnoea - No
2. Wheeze - No
3. Position of Trachea - Central
4. Breath Sounds - Vesicular
D. ABDOMEN
1. Shape of abdomen - Scaphoid
2. Tenderness - Not
3. Palpable mass - No
4. Hernial Orifices - Normal
5. Free Fluid - No
6. Bruits No
7. Liver - Not palpable
8. Spleen - Not palpable
9. Bowel sounds - No
E. CENTRAL NERVOUS SYSTEM
1. Level of Consciousness
a) Coriscious
2. Speech - Normal
3. Signs of Meningeal Irritation
a) Neck Stiffness - No
b) Kerning's Sign No
CEREBEILAR SIGNS
Finger - Nose In - Coordination - Yes
Knee - Heel In-coordination - Yes
Probable diagnosis
Lumbar spondyloarthropathy
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