64M with pain in right loin
Hello all this is G Jagadeesh,a fifth semester student.This E Log depicts the patient centered approach to learning.
This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Date of admission:22/7/22
Chief complaint
A 64 year old male patient came to medical OPD with chief complaints of pain in right loin since 1 month and vomiting since 1 month and burning micturition Since 1 month .
History of presentings illness
Patient was apparently asymptomatic 10 years back and then developed pain in the right loin for which he was diagnosed to have kidney stones and operated for it . Then 3 years later again he have experienced Bilateral loin pain and diagnosed with Bilateral kidney stones and then underwent for surgery for kidney stones . Then 4 years back he have developed a swelling in front and middle of abdomen for which he was diagnosed as having hernia and Operated for it. 4years back he developed abdominal pain and diagnosed as having intestinal ulcer for which he treated .And at the same time he was diagnosed to be having Diabetes and Hypertension.Then 1 year back he went to the hospital with complaints of generalised weakness and SOB on exertion this was due to reduced Hemoglobin.Then he has experiencing right loin pain and vomiting since 1month.
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
personel 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
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
Renal stones
Investigation
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
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