58M ERECTILE DYSFUNCTION 1yr with ?UTI

 

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan


Chief complains
Lower back pain since one month

PRESENT HISTORY

Patient was apparently alright 15 years ago then had non healing ulcers in right medial thigh went to local hospital and diagnosed with diabetes, started on OHAs

Since one year patient had complains of Burning Micturition Intermittent accompanied with Dark yellow coloured urine.
Patient also complains of erectile dysfunction 

Since two months patient complains of white discharge, non-foul smelling , non-itching.

Since one month patient complains of lower back pain insidious onset, intermittent, prickling type of patient radiating to loin. No aggreviating and relieving factors 

Since two days patient had complains of cold associated with Dry cough. No sore throat
Occasional low grade fever not associated with chills and rigor , on and off.
Occasional flatus- foul smelling

PAST HISTORY
Known case of DM-2 since 15years 
On tab Glimi M1 po/od
On Tab metformin 500mg po/Od 

Not a known case of HTN/thyroid/cad/Cva/TB

PERSONAL HISTORY

Married
Daily wage labourer, truck driver
Appetite- normal
Diet- non vegetarian 
Bowels- regular
Micturition- abnormal
Allergies- no
Addictions
No alcoholic history
Started smoking 2 beedi/day since two months due to health anxiety 

FAMILY HISTORY

mother is a known case of diabetic and had history of stroke

GENERAL EXAMINATION

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

BP-110/70mmhg
PR - 70bpm
GRBS
Spo2-98% at RA

CVS- s1s2 heard, no murmur
R/S- BAE present, NVBS
P/A- Soft,NT
CNS- NFND





PROVISIONAL DIAGNOSIS

Erectile Dysfunction with ?UTI
Lower Back pain under evaluation- ?Renal calculi
DM2 since 10 years

INVESTIGATION 

ECG


UROLOGY Referal in view of erectile dysfunction






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