60 yr old male with burning micturition.

 Hello! This is Siddhartha Yelagandula of eighth semester MBBS.  This is an 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 patient's 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 the comment. 

A 60 year old male person, resident of narketpally, came to General Medicine OPD with Complaints of:

Burning micturition on and off since 2-3months

Burning sensation near  heart since 5 days.

Bilateral pedal edema since 5 days.

Shortness of breath since 5 days.

HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 4 years back.

Then he developed lower back pain which was sudden in onset and gradually progressive with no aggravating and relieving factors.

Then he was admitted in a hospital where they diagnosed him having a kidney failure and was prescribed medication.

5 days back, he complained of

Pedal edema: since 5 days, insidious in onset and gradually progressive with no aggravating or relieving factors.

Shortness of breath: since 5 days, and is of grade 3 SOB, insidious in onset and gradually progressive and aggravated on walking and relieved on rest.

Burning sensation near chest: since 5 days and is sudden in onset.

Burning Micturition: since 2-3 months and is not associated with decreased frequency, fever, urgency, hesitancy.

No history of PND, orthopnea, nausea, vomiting, giddiness, generalized weakness.

History of past illness : 

No similar complaints in the past 

Known case of diabetes since 8 years.

Known case of hypertension since 6 months.

No history of  TB, asthma, CHD, CVD, epilepsy.

No drug allergies.

Family history : not significant.

Personal history : 

Sleep : adequate

Diet : mixed 

Appetite : normal

Bowel and bladder movements : regular

Smoking and alcohol stopped 2 months back.

General examination : 

Patient is conscious, coherent , cooperative and well oriented to time, place and person.

Moderately built and nourished.

Pallor : mild 

Icterus : absent

Cyanosis : absent 

 Bilateral Pedal edema : present grade 1

Lymphadenopathy : absent

Vitals :

BP : 130/80mm of Hg

Pulse : 86 bpm

RR : 15 cpm

System examination :

Respiratory system :

Inspection : 

Position of trachea central

No dropping of right shoulder

No intercostal indrawing

Shape and symmetry of the chest normal.

No dilated veins. 

No visible scars.

accessory muscles of respiration not prominent.

Palpation : 

On three finger test : position of the trachea central.

Respiratory movements are normal

Percussion :

No dull note is observed.

Auscultation :

Normal  vesicular  breath sounds.

 

Bilateral air entry positive.

No crackles heard.

ABDOMEN

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umbilicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gastric peristalsis.

Palpation: 

no tenderness  , no raised temperature

On deep palpation

no free fluid

no bruits

liver and spleen are not palpable.

Percussion :

Resonant note present.

Percussion of Liver for Liver Span : 14cm

 

Auscultation 

Normal bowel sounds heard.

2. Bruit - no renal artery bruit heard.

                no iliac artery bruit heard.

CVS 

Inspection :

Elliptical chest shape

No abnormal pulsations

No visible scars.

No chest deformities.

Mediastinum normal

Trachea central in position.

Palpation :

Mediastinal position : apex beat normal

                                   Position of trachea central.

Percussion :

On percussion No cardiomegaly observed.

Auscultation :S1 and S2 heard. No murmurs heard.

CNS : No focal neurological deficits present

             Cranial nerves, motor, sensory are normal.

INVESTIGATIONS

ECG :

Pedal edema :

Provisional diagnosis : 

Chronic kidney disease associated with Grade 1 Hypertension.

Treatment :

    IV insulin 

   IV calcium gluconate

   Sodium bicarbonate

   Sodium polystyrene sulfonate

Hypertension :

Beta blockers

Calcium channel blockers

Diuretics

ARBs

ACE inhibitors.