64 M With Vomiting and Burning Micturition

Elog 

25/07/2022

This is online E log book to discuss our patients health data shared after taking his guardians informed consent form.

I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings

 investigations and come with a diagnosis and treatment plan. 

  

Date of Admission:22/07/2022

A 64 yr old male resident of jaikaisaram choutuppal farmer by occupation came to OPD with chief complaints of pain in right loin vomiting burning micturition since 1month.

History of present illness:

Patient was apparently asymptomatic 10yrs back then developed pain in the right loin for which he was diagnosed to having renal stone and was operated for it later after 3 yrs he developed bilateral loin pain and was diagnosed having bilateral renal stones and at was operated after a gap of 1 month.and later after 3 yrs and 4yrs back He developed midline swelling later which is diagnosed as hernia and mesh was placed later after 1 yr developed diffuse abdominal pain which he went to an Hospital,endoscopy was Done and diagnosed as intestinal ulcers and managed it conservatively this time he was diagnosed with Diabetes and hypertension.And 1 yr back he had Generalised weakness and Sob on exertion for which he went Hospital and diagnosed with having low Hb and using Iron Injections and Now 1month Back following Chief complaints are Present.

History of past illness

K/c / o DM and Hypertension

for Hypertension he was not using any medication

Not a K/c/o TB, asthma,epilepsy

Treatment history

He was on Diabetic Medication

NO history of use of any other medication

Family history

There is no significant family historys

personal history

Mixed diet

Normal Appetite

Bowel and B ladder movements are Normal

NO known allergies

Adequate sleep

Habits

Occasionally consumes alcohol

cigarette Smoking 20 years back 1 pack per day for 2 yrs 

Daily routine

He generally wakes up at 5 o clock in the morning and does daily work of home.At 7 o clock he has his Breakfast and after some time he goes into the village and Chit chat with neighbours .At 1 o clock he take his lunch and take nap for atleast 2-3 hours.He do not have any habit of drinking tea in the evening.At last he will take his dinner at 8 o clock and then goes to bed. 

General Examination

on Examination patient is conscious,coherent,co - operative and well Oriented to time,place and person.

There are no signs of

Icterus,cyanosis,clubbing,Lymphadenopathy and oedema

There is presence of mild pallor

Vitals 

Temp:99:6 F

pulse rate:88 bpm

Bp:160/70 mm Hg

Resp rate:16 / min

systemic examination

C VS: No thrills

S1 and S2 +

NO murmurs

Respiratory system

NO Dyspnoea

NOWheeze

Trachea is centrally located

Abdomen

soft and non tender

NO palpable Mass

Liver and Spleen are not palpable

CNS

No abnormality detected

Provisional diagnosis:

Renal stones

Investigations:

USG

Right moderate hydrouretero nephrosis

NCCT

Right kidney is enlarged,there is dilatation of pelvicalceal System

Left kidney normal.

Right mid ureteric calaulus causing proximal hydroureteroneprosis.

Diagnosis:

Obstructive uropathy with Acute kidney injury

Treatment

T. Lasix

T Nodosis

T shelcal 

T. orofer 

T Nicardia

on 22/7/22

BP:160/80 mmHg

PR: 82 bpm

C V S: SI and S2 + 

Resp rate: 14 cpm

CNS: NAD 

Treatment Continued

on 23/7/22 

BP: 110/70 mm Hg

PR: 84 bpm

CVS: SI and S2 + 

CNS: NAD 

P/A . Distended

on 24/7 /22 

BP: 100/70 mmHg 

PR:: 82 bpm 

CVS:SI and S2 + 

CNS: NAD 

Resp rate: Normal

on 26/7/22

BP: 140/80 mm Hg 

PR: 80 bpm

cvs:S1 and S2 + 

CNS: NAD 

P/A:soft and nontender