General medicine e- log 13/04/2021

GENERAL MEDICINE E-LOG 13/04/ 2021

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 box is welcome.”

I've 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 a diagnosis and treatment plan. 

CASE : 

A 27 year old male farmer by occupation came with chief complaints of low back ache radiating to right lower limb since 11 months

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 year back then he developed pain in the the lower back radiating to right lower limb with associated calf pain which was aggravated on walking and relieved on rest.

Patient has surgery done in March 2020(L5-S1 PSF + Transforaminal interbody fusion L4 L5 fenestration discectomy on left side).

 On 13-04-21 L5-S1 PSF + L4 fenestration L5 right hemi laminectomy + L5 sequestered discectomy.

PAST HISTORY :

Not a k/c/o HTN/DM/TB/CAD/epilepsy.

PERSONAL HISTORY :

APPETITE -normal

Sleep adequate 

Bowel and bladder -regular

Smoking - 6 cigarettes /day

FAMILY HISTORY :

not significant 

Examination :

Patient is c/c/c.

Temp: Afebrile

PR:72bpm

Rr:16cpm

Bp:120/80 mm of Hg

Grbs:162

No pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema

Cvs:S1,S2 heard

Respiratory : BAE present. 

Abdomen:scaphoid,no tenderness, free fluid, palpable mass, hernial orifices, bowel sounds heard. 

CNS :conscious,speech normal, reflexes normal. 

PROVISIONAL DIAGNOSIS :

Recurrent L5 S1 paracentral disc extrusion with discitis with right L4-L5 central disc extrusion with S1 lumburization.

REFFERED TO ORTHO  

INVESTIGATIONS ;

1. ECG;

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

2. HEMOGRAM;

3.SERUM ELECTROLYTES;

SODIUM - 146 mEq/L

POTASSIUM - 5.6 mEq/L

CHLORIDE - 99 mEq/L

4.SERUM CREATININE;

SERUM CREATININE - 0.9 mg/dl 

5. BLOOD UREA;

BLOOD UREA- 24 mg/dl

6. X RAY 

TREATMENT 

☆ INJ Ophreuron pamp m 100ml NS/IV/OD

☆ TAB Vltracet 1/2 tab 

☆ T PREGABALIN 75mg/po/BD

        8AM ND 8PM