Case history -8

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

A 45 year old female patient who is a daily wage labourer came to OPD with chief complaints of pedal edema,low back pain and shortness of breath since 6months.

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

The patient wakes up by 6AM daily and she used to have her lunch by 1/2 PM (rice & curry ) and goes for work and returns home by 6.30/7 in the evening. Then she used to have her dinner (rice again) and sleeps by 9 PM.

 The patient was apparently asymptomatic two years back and then she developed low back pain which was radiating front for which she visited a local doctor and got diagnosed with hypertension however low back pain didn’t get subsided even on medication. 

The pain got aggravated 6 months back along with pedal edema and shortness of breath.

History of past illness :

The patient is a known case of hypertension since 2 years.

The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma.


Personal history : 

- The patient has loss of appetite

- She takes mixed diet

- No sleep disturbances

-No addictions 

Family history :

- There are no similar complaints in the family members


Treatment history :

- He is not a known case of drug allergy.


General examination :


- Patient is conscious, coherent, cooperative at the time of joining

- No Pallor 

- Icterus present

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- pedal edema is present




 

VITALS - temperature:98.5F

-pulse rate:99bpm

-respiration rate:18/min

-bp:110/80

-spo2-99%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is non tender

- bowel and bladder sounds heard

- no palpable mass or free fluid present

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Investigatons:










Final diagnosis: CKD on mhd 
Treatment:
Salt restriction <2.4gms/day
Fluid restriction <1lit/day
Tab lasix 40mg
Tab nodosis 550mg
Tab shelcal 500mg
Tab oroferx 
Inj erythropoietin 4000IV
Inj iroj sucrose 1amp

What are the causes of low back pain ?



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