This is an online e log of patient's de-identified health data shared after taking his/her/guardian's 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 elog also reflects my patient centered online learning portfolio       

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

80 yr old male, unemployed from nampel came to opd with 

C/o-   

nocturia(5times/day) 
Burning micturition
Pain in abdomen during micturtion
Dysuria since 1 day 

History of presenting illness

Patient was apparently asymptomatic before July 2021

Then he developed nocturia(5times /day), urgency, urgency incontinence, dribbling, poor stream for 2 months (June-sep of 2021). Patient went on acute retention of urine in sep 2021 and was catherized. 

He gives a history of voiding trial given 5 months back and failed and he was advised for surgery but he refused it. 

Hematuria was seen when he collected urine for urine examination. 

Dysuria since 1 day, 2 episodes of vomiting 2 days back. 

Glucose levels raised to 540 yesterday night

No history of fever, loss of appetite, loss of weight, turbiduria



Past history

He is known case of diabetes mellitus
2 yrs back he was diagnosed to have HTN but he refuged to take medications
Not a k/c/o , Asthma, TB, thyroid


Treatment history :

He is on medication for diabetis since 2 and 1/2 yrs


Personal history:

Married, unemployed, normal appetite, mixed diet, normal bowel, burning micturition, no known allergies
Alcoholic but stopped consumption since 2 yrs. 


No significant family history 



Examination :

General Examination :

Patient is conscious, coherent and coperative well built and well nourished.

No pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, pedal edema

Systemic examination:

PER ABDOMINAL EXAMINATION:

INSPECTION-

Shape of abdomen : flat
Umbilicus : inverted 
All quadrants of abdomen move with respiration 
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites c, no scar on the abdomen 

PALPATION-

Abdomen soft
No local rise of temperature 
No tenderness
No organomegaly


PERCUSSION:

Resonant note heard over all quadrants.

AUSCULTATION:

Bowel sounds heard  

CVS EXAMINATION:

INSPECTION

The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse not visible


PALPATION:

Apex beat localised 

AUSCULTATION:

S1 and S2 heard
No Murmurs

 RS EXAMINATION:

INSPECTION: 

Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations


PALPATION:

Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt



PERCUSSION:

Resonant note heard over all areas


AUSCULTATION:

Slight wheezing sound is heard


Vocal resonance: resonant in all areas


CNS EXAMINATION:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact


Investigations 

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60 yr old male

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  A 60 year male CKD on maintenance hemodialysis with anemia of chronic disease with hypertension. December 03, 2023 This is an a 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. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with   Chief complaints: -Pedal edema since 3 months -shortness of breath since 20 days - decreased 
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