64 year old male with burning micturition, polyuria and lower backache
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1. COMPLAINTS AND DURATION
64 year old male daily wage labourer from Thirumalagiri came with complaints of
-Pain in the lower back since 3 years.
-Burning micturition since 2 months
- Polyuria since 2 months.
2. HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 2 months back then he developed burning miturition associated with polyuria for which he visited a local hospital and was diagnosed as a denovo case of Diabetes Mellitus Type -2 (for which he was prescribed medication). But his complaints of burning miturition and polyuria didn't get relieved.
Patient also complaints of lower back pain which is non radiating and insidious in onset since 3 years. No H/o trauma or fall.
Patient had a history of occasional tingling and numbness in B/L feet.
He also has h/o occasional SOB(+) on exhaustion. No H/o orthopnea or PND.
No H/O fever, vomitings, cold, cough, loose motions, chest pain, palpitations.
3. HISTORY OF PAST ILLNESS
H/o Diabetes Mellitus Type -2 since 2 months for which he was prescribed medication:
a) Tab. Metformin 500 mg + Glimipiride 2 mg PO/OD
b) Tab. Dapagliflozin 5 mg + Metformin 500 mg PO/OD
H/o CAD- Global hypokinesia with mild LV dysfunction (Ejection Fraction- 40) with moderate pH since 1 year back for which he is on medication:
a) Tab. Atorvastatin 20mg + Clopidogrel 75mg PO/OD
b) Tab. Benfotiamine 100mg PO/OD
c) Tab. Sacubitril 24mg + Valsartan 26 mg PO/OD
d) Tab. Dytor plus PO/OD
Not a known case of TB, HTN, epilepsy, asthma.
4. PERSONAL HISTORY
Patient has a normal appetite, consumes non-vegetarian diet, bowels are regular, burning micturition and polyuria since 2 months, no known allergies.
Patient consumes alcohol (90 ml whiskey) on occasional basis.
Patient used to smoke 4 chutta per day for 10 years but he stopped 1 year ago when he was diagnosed with CAD.
5. GENERAL EXAMINATION
O/E:
Patient is concious, coherent and cooperative
No signs of icterus, clubbing, cyanosis, lymphadenopathy, edema.
Mild pallor (+)
Vitals:
BP: 120/80mmhg
PR: 80bpm
RR: 17 cpm
TEMPERATURE: 98.4 F
GRBS: 202 mg/dl
SPO2: 97% at RA
6. CLINICAL IMAGES:
7. SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM EXAMINATION :
Bilateral air entry +
Normal vesicular breath sounds heard
Trachea central
No added sounds
CVS EXAMINATION :
S1, S2 heard
No murmurs
ABDOMEN EXAMINATION :
Soft, no tenderness
No organomegaly
Bowel sounds - present
CNS EXAMINATION :
Gcs - E4V5M6 (15/15)
Higher mental functions - normal
Cranial nerve examination - normal
Sensory and motor system normal
No signs of meningeal irritation
8. INVESTIGATIONS:
RBS: 110mg/dl
BLOOD GROUP: B POSITIVE
Hemogram:
CUE:
LFT:
RFT:
Chest Radiography PA View:
L Spine Radiography
AP view:
ECG:
9. PROVISIONAL DIAGNOSIS:
64 year old male diagnosed with
-Heart failure with Reduced Ejection Fraction
-Diabetes Mellitus type 2
-Lower backache under evaluation
- ? UTI
10. TREATMENT:
-Tab. Ultracet 1/2 tab PO/TID
-Tab. Metformin 500 mg + Glimipiride 2 mg PO/OD
-Tab. Dapagliflozin 5 mg + Metformin 500 mg PO/OD
-Tab. Atorvastatin 20mg + Clopidogrel 75mg PO/OD
-Tab. Dytor plus PO/OD
-Tab. Benfotiamine 100mg PO/OD
-Syp. Sucralfate 10 ml PO/OD
-Syp. Milk of magnesia agnesia 10 ml in 1 glass water PO/OD
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