70/M with body pains, reduced appetite and shortness of breath
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70 year old male has come to the opd with chief complaints of :
Body pains since 10 days
Reduced appetite since 10 days
Shortness of breath since 10 days
History of presenting illness :
Patient was apparently alright 8 years back, then he complained of stomachache. He was diagnosed with cholelithiasis and chronic kidney disease. Surgery was done for cholelithiasis. CKD was managed conservatively.
H/o recurrent episodes of fever and vomiting 7 months back. He was advised hemodialysis for progressive chronic kidney disease.
He was started on MHD since 2 months.
Since 10 days, the patient is complaining of body pains especially lower backache and neck.
H/o reduced appetite since 10 days
Decreased range of movements +
Inability to stand from sitting position +
Swelling of joints + aggravates on active movements with no relieving factors
SOB grade 2 +
No h/o cough, palpitations
No h/o reduced urine output, Hematuria, pyuria,
H/o chronic NSAID abuse +
No h/o orthopnea , PND
Past history :
No h/o similar complaints in the past
K/c/o DM since 20 years and is on HAI 10 IU TID
K/C/O HTN since 8 years and is on Telmi 40
Denovo hypothyroidism
N/k/C/o epilepsy, asthma, CAD.
Personal history :
Sleep : adequate
Diet : mixed
Appetite : reduced
Bowel and bladder : regular
Addictions : none
General examination:
Pt is c/c/c
No pallor , icterus , cyanosis, clubbing, lympadenopathy, edema
Vitals :
PR: 83 bpm
RR: 20 cpm
BP: 150/90 mmHg
GRBS : 106 mg/dl
Systemic examination :
CVS : S1 s2 heard no murmurs
RS : BAE NVBS heard.
P/A : soft non tender
No free fluid.
CNS : No FND
Investigations :
X-Ray :
ECG:
2D echo :
Treatment :
Tab NODOSIS 500 Mg PO/BD
Tab LASIX 40 Mg PO/BD
Tab OROFER PO/BD
Tab SHELCAL PO/BD
Tab THYRONOM 12.5 mcg PO/OD
Cap BIO D3 PO once a week
Tab TELMI 40 PO/OD
Tab CHYMEROL FORTE PO/TID
Tab CLINIDIPINE 10 Mg PO/BD
Tab FEBUXOSTAT 40 Mg PO/BD
Tab AUGMENTIN 625 Mg PO/BD
Tab ECOSPIRIN AV PO/HS
Inj HAI SC according to grbs
Dialysis was done on 3/7/23
Blood transfusion was done on 3/7/23
Orthopaedic Referral :
Diagnosis :
C5-C6 disc space narrowing with degenerative changes.
Advice :
MRI spine and neck :
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