29 year old with bilateral lower limb pain
I am Soumya 9th semester student .
This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them
CASE SCENARIO
29 yr man from Miryalaguda ,a agriculture coordinator K/C/O CKD came to casualty with cheif complaints of
Bilateral lower limb pain since 20 days
HISTORY OF PRESENT ILLNESS
Patient was apparently normal 3 years ago then developed pain in right lower abdomen diagnosed to have renal stones of size 4mm to 6mm and also raised creatinine upto 6 for which he had medication and both problem of stones and creatinine came down
Then after 6 months he had bilateral ankle pain ,which is pricking type and precipitated by heavy work for which we visited a local doctor where he found rised uric acid levels , also adviced decrease protien rich diet along with medication
also had history of Acyclophenac whenever he had pain in lower limbs
Since 20 days the pain is severe as disturbing sleep and not reliveing on medication when to local hospital , found out increased creatinine level 8.2 ,for which he was referred to our hospital for Dialysis
No H/o headache , giddiness, nausea, burning micturing, fever , significant weight loss
HISTORY OF PAST ILLNESS
3 years ago he had lower abdomen pain diagnosed renal stones of 4 mm size - relieved on medication,
History of Rat poisoning 5 years back
Not known case of HTN, epilepsy, asthma ,CAD ,DM
PERSONAL HISTORY:
Married
Occupation: Agriculture coordinator
Diet: Mixed
Appetite: Normal
Sleep disturbed due to pain
Bowels:
Micturation: normal
Known Allergies: No
Addictions :
Consumes alcohol occasionally
Smoking since 6 days ,stopped 8 months
FAMILY HISTORY
No similar complaints in family history
General Examination.
Patient is conscious ,coherent and coperative
Pallor present
No icterus , cyanosis, clubbing , lymphadenopathy, pedal edema
VITALS:
Temperature - 98 F
BP:-140/80mmHg ,
PR:- 78 bpm,
RR- 14 cpm,
Spo2:-98 %
GRBS:134mg/dl
Systemic examination:
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM
Dyspnoea: No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
ABDOMEN
Shape - Scaphoid , inverted umbilicus, no engorged veins, no scars
No tenderness, no palpable mass, No Fluid
No bruits heard
Liver not palpable
Spleen not palpable or any
CNS Examination
Conscious coherent cooperative
Higher mental functions intact
No signs of meningitis
Cranial nerves, motor system, sensory system Normal.
INVESTIGATIONS :
- Pt - c/c/c
- Temp 98 F
- PR - 78 bpm
- BP - 140/80 mmHg
- RS - Bilateral air entry present
- CVS - S1 & S2 are heard
- GRBS 138 mg/dl
- P/A soft & Non tender no organomegaly
- CNS HMF intact
