55M lower back pain
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55 years old man , daily wager by occupation presented in the casualty with complaints of shortness of breath and pain in lower back.
CHIEF COMPLAINTS
➤ Shortness of breath since 10 days.
➤ Pain in lower back since 5 days .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1month back , then he developed shortness of breath.
SOB was insidious in onset , Grade II, gradually progressed .
Patient has orthopnea and dyspnea.
He has decreased urine output since 1 month , which is thin stream , poor flow , frothy and has increased frequency , associated with generalised itching .
He also has pain in his lower back which is dull , non radiating and not associated with micturition .
Not associated with cough , cold , fever or chest pain .
HISTORY OF PAST ILLNESS
➤k/c/o diabetes since 10 yrs.
➤k/c/o hypertension since 9 months .
➤k/c/o renal failure since 5 months .
➤Not a known case of bronchial asthma ,epilepsy, tuberculosis.
DRUG HISTORY
➤ Tab Amlong 40mg PO/TID since 1 yr for HTN .
➤ Insulin since 25 yrs for Diabetes .
PERSONAL HISTORY
➤ Occupation : Daily wager
➤Patient is married
➤Patient takes mixed diet but has lost his appetite.
➤Bowel movement is normal and bladder movement is abnormal.
➤Addictions : Alcohol - occasionally
Tobacco - 5 packets/day
➤No allergy
FAMILY HISTORY
➤No significant family history.
GENERAL EXAMINATION
➤Pallor :Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
VITALS
➤Temperature : 98.3℉
➤PR : 102 beats per minute
➤BP : 130/90 mm of Hg
➤RR : 20 cycles per minute
➤SpO2 : 100% in room air
➤Blood Sugar (random) : 97mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all
the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤No tenderness
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
No focal neurological deficits
PROVISIONAL DIAGNOSIS :End stage renal disease
INVESTIGATIONS
TREATMENT
1. Salt restriction (<2g/day)
2. Fluid restriction (<1.5L/day)
3. Tab. Nodosis 500mg/PO
4. Tab. Shelcalc 500mg / PO BD
5. Tab. Bio-D3 PO BD
6. Tab Lasik 40mg PO/BD
7. Tab. Amlong 10mg PO/BD
8. Inj. HAI
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