General medicine 

                                      125 Afrin 

                                      (3rd sem)

                 

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings,investigations,and come up with a diagnosis and treatment plan.

Overview :

    patient came to hospital on 8th October 2021 when he came to know he has B/L renal calculi in USG abdomen &pelvis for which he underwent nephrostomy on 13/10/21 &left URSL with DJ stenting on 20/10/21 and then discharged and suggested to follow Up next month. 

         After discharge there is no improvement in his condition, so they suggested with 3 sessions of dialysis &Right URSL after a month but due to failure of dialysis through IJV on third session he was still in the hospital. 

* 38 year old male came to casualty with loss of appetite ,decreased sleep, nausea since 10 days and shortness of breath ,loin pain since 6 days.

Chief complaints : 

   Patient has decreased appetite, nausea, fever (on and off)  , decreased urine output 6 months back. 

Fever( on &off)  - low grade intermittent not associated with chills and rigor.

Burning micturation.

History of present illness : 

Patient came for follow up to urology on 3rd November. 

   Cr-3.2 ,urea -111, Hb -8.5 ,TC-20000cc/mm3 , platelet count -3.17 l 

Right sided kidney mild hydronephrosis ,lower pole calculus 4-5mm . 

Left mild hydronephrosis. 

History of past illness : 

* USG - abdomen &pelvis  revealed:  right kidney with gross hydronephrosis and left kidney with moderate hydronephrosis, B/L uretric calculi Right -13mm,Left -23mm .

* 9/10/21 :   cr: 9.6 , urea -158 , suggested with 3 sessions of dialysis this is done through right IJV.  

* At the time of discharge serum creatinine -2.1,Hb -8.1 , TC -8500cc/mm3 , platelet count -3.5 l .

Treatment history : 

Surgical history :

 13/10/21 - bilaterally nephrostomy  decreased LA 

20/10/21 - left URSL ( ureteroscopic lithotripsy)  with DJ stenting decreased SA. 

 Personal history  : 

 Decreased appetite since 10 days. 

Mixed diet 

Bowel and bladder movements are regular 

Burning micturation 

No know allergies 

Addiction occasionally -drinking &one bd per day 

( last  consumed 3 months back) 

No k/c/o DM, HTN, CVD, TB. 

General examination : 

Pallor -present 

No icterus

No cyanosis 

No clubbing of fingers or toes 

No lymphadenopathy 

No edema 

No malnutrition 

No dehydration 

Afebrile temperature 

Pulse rate - 86b/m

Respiration rate - 12 cpm 

Bp - 80/50 mm Hg 

Spo2 -99%

GRBS -124mg%

Systemic examination : 

Cardiovascular system :

S1,S2- heard 

No added sounds 

Respiratory system: 

Normal vesicular breath sounds heard. 

Trachea centrally present 

Abdomen : 

Tenderness -diffuse(mild )

Shape of abdomen -scaphoid 

Central nervous system : 

Conscious coherent cooerative

Investigations : 

8/11/21 

Hemogram :

Serum creatinine:

Serum electrolytes :

Complete urine examination : 

Blood urea: 

11/11/21

  

RFT : 

Hemogram : 

14/11/21

Hemogram : 

RFT :

ECG : 

Provisional diagnosis : 

AKI on CKD secondary to post renal obstruction with B/L ureteric calculi with B/L hydronephrosis. 

S/P - Left URSL with DJ stenting done. 

Treatment : 

IVF - NS.  - UO +30m / hr

       - RL 

Inj. OPTINEURON 1Amp IN 100 ml

Inj.  PANTOP 40mg IV/OD 

Inj. BUSCOPAN 2cc IV/ STAT 

TAB. NODOSIS 550mg PO/ TID

TAB. OROFERXT  PO/ OD 

TAB. SHELCAL -CT. PO/OD 

TAB. PCM 500mg PO/ SOS

MONITOR VITALS -4TH HRLY 

STRICT I/O CHARTING 

INJ. PIPTAZ 4.5 mg IV/ STAT 

INJ. PIPTAZ 2.25mg IV/ TID.