56 years male with bilateral loin pain.

Medical elog book

60 year old male with bilateral loin pain
January 21, 2022
A 56 year old male came to casuality on 13th January with complaints of :

 Chief complaints:

Pain abdomen bilateral and lower back pain since 20 days

Decreased urine output since 15 days

HOPI:

Patient was apparently asymptomatic 2 years ago then he developed burning micturiturition intermittently. 2 month later he developed pain abdomen and bilateral loin pain. Pain was dragging type, no aggravating or relieving factors. 

He then went to a hospital in khammam and was diagnosed with renal stones and was prescribed medication. He didnot use any medication and continued to have loin pain and burning micturiturition. 

He developed vomitings and nausea 1year ago immediately after eating and it was foul smelling.

He had 3 episodes of blood in urine on the same day 3 months ago and it disappeared from next day

2 months ago he developed urinary incontinence 

20 days back he developed abdominal pain 

15 days back he developed fever and decreased urine output 



He doesn't have any chronic illness 

His appetite decreased since 2 years and he takes less quantity of food than before and sometimes feels nauseous after eating and vomits sometimes

He lost 12 kgs in 2years from 44kgs to 32 kgs

He takes mixed diet

His sleep is disturbed due to pain

He regularly drinks alcohol and toddy since 50 years

Smoking since 40 years

No allergies 

GENERAL EXAMINATION :

Patient is moderately built and poorly nourished;conscious,coherent ,cooperative and examined in a well lit room after taking informed consent 

Pallor is present 

No signs of Icterus, cyanosis, clubbing, lymphadenopathy, edema, Koilonychia 



VITALS:

BP - 140/80

PR - 100 bpm

RR - 20 cpm

Afebrile

SYSTEMIC EXAMINATION :

CVS:  S1, S2 heard, no murmurs

RESPIRATORY SYSTEM :

Normal vesicular breath sounds are heard

ABDOMEN :

Scaphoid in shape,soft and nontender

Bowel sounds heard 

A nephrostomy tube is put on back left side





CNS:  NAD

INVESTIGATIONS:




Ultrasound 

13/01/22


20/01/22


CBP
Hb - 7.9
TLC - 6200

RFT:

Urea - 278

Creatinine - 16.3

Na - 139

K - 6.1

Cl- 104

LFT:

Total bilirubin - 0.99

Direct bilirubin - 0.28

AST - 12

ALT -12

ALP - 174

Tp-6. 2

Albumin - 3.5

CUE:

Albumin +

Pus cells - 3.4

RBC - nil

Sugar - nil

ABG:

pH-7.21

pCO2-14.5

pO2-131

spO2-96

HCO3-5.7



APTT-32secs

PT-16 secs

INR-1. 11

Diagnosis 

Post renal AKI secondary to b/l hydronephrosis with refractory hyperkalemia(secondary to renal calculus)









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