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)









Comments

Post a Comment

Popular posts from this blog

15 years old school student with chest pain.

Image
This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed  I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency I reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. Long case  Stimita Maity  H.tno 1701006178 Chief complaints  A 15 years old male presented  with the complaints of chest pain and heaviness in the left side of the chest since 3 months.  History of
Read more

17 years old male with altered sensorium and vomiting after binge of alcohol.

Image
This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."                                          " I’ve 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 diagnosis and treatment plan " Unit posting (Intern 2017) Medical Ward  GM II  Dr Nikitha Dr Haripriya Dr Govardhini Dr Stimita 17 years old male with altered sensorium and vomiting after
Read more

37 year male with SOB, decreased urine output, abdominal distension

Image
37 year male with SOB, decreased urine output, abdominal distension and facial puffiness, pedal edema This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."                                          " I’ve 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 diagnosis and treatment plan " Unit posting (Intern 2017) Medical Ward  GM II  Dr Nik
Read more