A 27 YR OLD MALE CAME WITH LOWER BACK PAIN

 This is an online e log book to discuss our patient 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 evident based input.








This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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.


A 27 OLD MALE PATIENT CAME TO OPD WITH 
CHEIF COMPLAINTS : 
Lower back pain since -10 Days 

HOPI - 
Patient was apparently asymptomatic 3 months back and then he developed fever which is sudden in onset ,no diurnal variations for whicb patient got treated from a local RMP and After That he again got fever and swelling in legs and went to district hospital Where he was diagnosed with less haemoglobin and high blood pressure
 For which he took Nifedipine and Clonidine hydrochloride 
After 2months he found to have altered Renal parameters and was advised for hemo dialysis 
No h/o haematuria 
No h/0 Shortness of breath 
No h/o Palpitations ,sweating ,Giddiness 
No h/o oliguria 



PAST HISTORY : 
No history of similar complaints in the past 
Not a known case of DM ,Asthama ,TB ,Epilepsy 



FAMILY HISTORY: 
Not significant 



PERSONAL HISTORY : 
Diet -Normal 
Apettite -Normal 
Bowel and Bladder -Regular 
Sleep - Adequate 
Addictions - No addictions 



Treatment History : 
Nifidipine 
Clonidine hydrochloride for hypertension 



GENERAL EXAMINATION : 
Patinet is consious , coherent , co operative 

And well orineted with time  and place 

Pallor - absent 

 Icterus -Absent 

clubbing -absent 

Cyanosis - Absent 

Lymphadenopathy-Absent 

Pedal Edema - Absent 

VITALS : 
Temp -Afebrile 

PR - 83 bpm 

Bp - 140/100 mm of hg 

RR - 17 cycles /min 






SYSTEMIC EXAMINATION : 

Respiratory examination : 

INSPECTION- 

 Shape of chest : elliptical 
Trachea -Midlined 
No drooping of shoulders 
No winging of scapula 
No crowding of ribs 
No scars , sinus ,swellings on the chest 
No supraclavicular fullness or hallowing 
Chest moves with respirations

PALPATION : 

All the inspectorg findings are confirmed by palpation 
No local rise oc temperature 
Trachea -Central 
Movements of the chest -Normal 
No crowding of ribs 
No tenderness 
No apical impulse is seen 
vocal fremitus -normal 

PERCUSION : 
All the regions of chest are resonant ( Normal ) 

AUSCULTATION: 
Non vesicular breath sounds are heard 




ABDOMINAL EXAMINATION : 
Soft and non tender 
Liver and spleen Are not palpable 
No swellings 
No dialated veins 


CVS : 
S1 and s2 heard 
No murmurs 

CNS : 

HMF -intact 

REFLEXES :        RT.       LT.  
Biceps ————- +.           + 
Triceps ———— +.             + 
Supinator ———-+.           + 
Knee jerk———-+.             + 
Ankle jerk ———+.            + 


CRANIAL NERVES - intact 

MOTOR SYSTEM - intact 

SENSORY SYSTEM - normal 

CEREBELLAR SIGNS -normal 





INVESTIGATIONS : 





PROVISIONAL DIAGNOSIS : 
CHRONIC KIDNEY DISEASE UNDER HAEMO DIALYSIS 


















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