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


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






Probable diagnosis

Lumbar spondyloarthropathy




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