A 65 year old male with lower back ache since 4 yrs.

 This is an online E log to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based inputs.

This E log book also reflects my patients-centered  online learning portfolio and your valuable inputs on the comment box is welcome.

B.Pavithra ,8th semester.

roll no;19

CASE;

Date of admission;24/11/22

This is case of 65 yr old male resident of miryalaguda  came with the cheif complaints of

Lower back pain since 4yrs

HISTORY OF PRESENT ILLNESS;

Patient was apparently assymtomaic 4  years ago and then he developed lower back pain(on either sides of lumber veretebra) which is insidious in onset,non-progressive,continous, non radiating ,dull aching type of pain which is relived partially on taking NSAIDs and complains of lower abdomen pain which is insidious in onset ,gradually progressive ,intermittent ,dull aching type of pain aggrevated on squatting and not radiating.

h/o decreased urine output since 7 months with burning micturation and terminal dribbling of urine. no history of increased or decreased frequency of micturation ,hesitancy,urgency and stress incontinence.No h/o any other urethral discharge.

No h/o of change in colour of urine and hematuria. no h/o nausea ,vomiting and fever.

HISTORY OF itching all over the body(more on back and chest) since 7 months for which he is using some medicine but not subsided completely.

No h/o dyspnea, orthopnea and postural hypotension.

SEQUENCE OF EVENTS;

4 years back he complained of pedal edema,back ache,burning micturation  associated with fever for which he went to hospital and got treated conservatively and diagnosed with the hypertension and also doctors told him he has some  kidney problem.from then he was on anti- hypertensives but not taking regularly.he used to take tablet when he got symptoms if raised bp like blurred vision and dyspnea.

from then he started using pain killers for back pain which got relived partially.whenever pain eaggerates he takes injection for pain(it works for 7 days)he discontinue the tablet for that 7 days and continued till date

7 months back he developed itching(also have back pain) and burning micturation for which he went to hospital where he was diagnosed with CKD 

PAST HISTORY:

Known hypertensive since 4 yrs. no h/o DM,epilepsy ,asthma ,TB, thyroid disorders.no h/o previous surgeries.no h/o blood transfusions.

PERSONAL HISTORY;

DAILY ROUTINE:4 yrs  baclk he used to go for farming now he stays at home.wakes at 6am daily his diet contains rice, vegeables sometimes meat,in the evening he drinks tea and he passes all his time with his neighbours and family and goes to bed by 10 pm

DIET; mixed 

APPETITE;normal

B/B;regular bowel,decresed urine output since 7 months

SLEEP;adequate

ADDICTIONS;he used to smoke and drink now he stopped drinking and smoking from past 15 years.

FAMILY HISTORY;not significant.

TREATMENT HISTORY;

atarax-for itching ;oferol,foxstst for incresed uric acid levels ;aceclofenac for pain

GENERAL EXAMINATION:

Patient is conscious ,coherant,cooperative.moderatly built and moderatly nourished.

pallor-present                   

                                   

                              

                                          

                                          

icters-absent 

                

clubbing -absent

                         

koilonycia -absent

                                             

generalised lymphadenopathy- absent

bilaeral pedal edema- absent

                                        

VITALS:

Temperature ;  afebrile

RR;20cycles/min   

PULSE;80bpm

GRBS;110mg%

Spo2; 100 at room temperature

BP; 160/80 MM OF HG

SYSTEMIC EXAMINATION;

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:

trachea central, all quadrants of chest moves equally with respiration.

Breath sounds- bilateral normal

Vesicular breath sounds are heard.

Central nervous system- Patient was conscious, coherent and cooperative

Speech was normal.

No slurred speech.

abdominal examination :

Inspection:on inspection abdomen is flat, symetrical,and not distended.umbilcus is centre and inverted.no scars,engorged veins are seen.All 9 regions of abdomen are equally moving with respiration.all hernial orfices are clear.

Palpation:on palpation abdomen is soft , mild tenderness in hypogastric region no other palpable organs are felt.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.

percussion:no shifting dullness, no fluid thrills.

auscultation:normal bowel sounds are heard.

INVESTIGATIONS;

Previous hospital investigations;

                

PROVISIONAL DIAGNOSIS;

CKD  secondary to nsaids abuse,htn