80 year old male with low back ache since 6 months

 Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references

CASE :

A 80 year old male patient came to the op with c/o 

  • low backache since 6 months 
  • shortness of breath since 4 months 
  • body pains since 4months.

HOPI :

---Patient was apparently asymptomatic 6 months ago then he developed low backache which is insidious in onset and gradually progressive in nature and intermittent in nature aggravated on walking and relieved on rest.

---Shortness of breath present since 4 months which is present on ordinary to less than ordinary activities (grade 2-3) relieved on taking rest.

---Patient also have generalised body pains since 4 months.

---No h/o chest pain, orthopnea, pnd, decreased urinary output, pedal edema, facial puffiness.

PAST HISTORY :

---Patient was informed he had Kidney dysfunction 3 years ago when he was admitted in our hospital for left distal tibia fracture, He initially used medication for it (medication not known) and discontinued after using for 1 month.

  • H/o cataract surgery 15 years back.
  • Not a k/c/o HTN, TB, asthma, epilepsy, CAD.
PERSONAL HISTORY :

  • Normal appetite, mixed diet, adequate sleep, reduced urine output.

GENERAL EXAMINATION :

Patient is conscious, coherent, cooperative. 

Mild pallor +

No signs of icterus, koilonykia, edema, lymphadenopathy.





Vitals:

  • Temp - 98.3F
  • PR - 80bpm
  • BP - 110/70mmhg
  • GRBS - 106mg
  • Spo2 - 99% on RA

SYSTEMIC EXAMINATION :

  • CVS - S1, S2 heard, no murmurs.
  • CNS - Absent joint 
  • RS - BAE +
  • PA - Soft, nontender.

PROVISIONAL DIAGNOSIS :

INVESTIGATIONS :

17/7/2023-

Electrolytes:

Sodium:143

Potassium:6

Chloride :98

Calcium:1.18

Blood Urea : 61

Uric acid : 6.9

Serum Creatinine : 1.9

RBS - 70

Serology - negative 








18/7/2023-

Electrolytes:

Sodium:139

Potassium:5.4

Chloride:106


TREATMENT :

Tab. ULTRACET PO/BD

Tab. Pan PO/OD


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