GM E-LOG :A 35 YEAR OLD FEMALE WITH SHRUNKEN RIGHT KIDNEY, RENAL CALCULI

 A 35 YEAR OLD FEMALE WITH SHRUNKEN RIGHT KIDNEY, RENAL CALCULI

NOTE
This is an ongoing case and will be updated .
This e log is made under the guidance of Dr. Pallavi.
The reference link (if any) will be mentioned at the bottom.

Date of admission :13 July 2021

CHIEF COMPLAINT :
A 35 yr old woman, who is a housewife in West Bengal, presented with
 Pain in abdomen since 3 years and Lower back pain since 6 months

H/o PRESENT ILLNESS:
  1.  Woman, mother of 3 children was apparently asymptomatic 3 yrs back. 
  2.  She started experiencing pain in the right lumbar region radiating to the back since 3  yrs., and right upper thigh along with burning micturition. 
  3. On visiting a local hospital, was told to have 2 renal calculi in her right kidney for which she had been put on certain medications, which reduced her pain. 
  4.  She has been experiencing intermittent fever. 
  5.  Since the past 6 months, she has been experiencing similar pain after which she visited a hospital and was told to have a small right kidney with 2 calculi. 
  6. She had been on conservative treatment ever since. 
  7.  Since the past 3-4 months, she has also been experiencing intermittent headaches followed by vomiting. 

H/o PAST ILLNESS:
•  Is a k/c/o renal calculi
• Not a k/c/o
            DM, HTN, CAD, asthma, TB 

DRUG HISTORY :
• Had been on conservative treatment for renal calculi since the past 6 months. 
• No treatment history of diabetes, HTN, CAD, asthma, TB, antibiotics, hormones, chemo radiation, blood transfusion, surgeries. 

PERSONAL HISTORY :
•  married with 3 children{1 son and 2 daughters}.
• Her appetite is normal. Follows mixed diet. 
• Her bowel habits and micturition : normal. 
• Has no known allergies , and no addictions. 

FAMILY HISTORY :
• Has no family history of DM, HTN, TB, asthma, CAD, strokes, cancers, heart diseases, . 

OBSTETRIC HISTORY :
• Has 3 children. 
• Has regular menstrual cycles, but with decreased flow since past 5 months. 

PHYSICAL EXAMINATION:
• Pallor - mild
• icterus - absent
• cyanosis - absent
• clubbing of fingers/toes - absent
• dehydration - absent

VITALS : 
• pulse rate - 120/min
• SPO2 - 98%

SYSTEMIC EXAMINATION :

CENTRAL NERVOUS SYSTEM:
• Pt, conscious, coherent and cooperative
• Speech is normal
• no signs of meningeal irritation

CARDIOVASCULAR SYSTEM:
• S1, S2 +

RESPIRATORY SYSTEM:
• lungs clear on auscultation

PER ABDOMINAL EXAMINATION:
• Tenderness in rt. Lumbar region

INVESTIGATIONS :

ECG :


COMPLETE BLOOD PICTURE :


LFT :



RFT :



HEMOGRAM :



COMPLETE URINE EXAMINATION:




BACTERIAL CULTURE AND SENSITIVITY REPORT :





14 JULY 2021








15 JULY 2021









16 JULY 2021


PROVISIONAL DIAGNOSIS : 

 RT. RENAL CALCULI WITH SHRUNKEN RT. KIDNEY and RECURRENT UTI

TREATMENT : 
 13/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

14/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

15/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

16/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

Plan of further management
Surgery -Nephrectomy 

DISCHARGE SUMMARY
CHIEF COMPLAINT :
A 35 yr old woman, who is a housewife in West Bengal, presented with
 Pain in abdomen since 3 years and Lower back pain since 6 months

H/o PRESENT ILLNESS:
  1.  Woman, mother of 3 children was apparently asymptomatic 3 yrs back. 
  2.  She started experiencing pain in the right lumbar region radiating to the back since 3  yrs., and right upper thigh along with burning micturition. 
  3. On visiting a local hospital, was told to have 2 renal calculi in her right kidney for which she had been put on certain medications, which reduced her pain. 
  4.  She has been experiencing intermittent fever. 
  5.  Since the past 6 months, she has been experiencing similar pain after which she visited a hospital and was told to have a small right kidney with 2 calculi. 
  6. She had been on conservative treatment ever since. 
  7.  Since the past 3-4 months, she has also been experiencing intermittent headaches followed by vomiting. 

H/o PAST ILLNESS:
•  Is a k/c/o renal calculi
• Not a k/c/o
            DM, HTN, CAD, asthma, TB 

DRUG HISTORY :
• Had been on conservative treatment for renal calculi since the past 6 months. 
• No treatment history of diabetes, HTN, CAD, asthma, TB, antibiotics, hormones, chemo radiation, blood transfusion, surgeries. 

PERSONAL HISTORY :
•  married with 3 children{1 son and 2 daughters}.
• Her appetite is normal. Follows mixed diet. 
• Her bowel habits and micturition : normal. 
• Has no known allergies , and no addictions. 

FAMILY HISTORY :
• Has no family history of DM, HTN, TB, asthma, CAD, strokes, cancers, heart diseases, . 

OBSTETRIC HISTORY :
• Has 3 children. 
• Has regular menstrual cycles, but with decreased flow since past 5 months. 

PHYSICAL EXAMINATION:
• Pallor - mild
• icterus - absent
• cyanosis - absent
• clubbing of fingers/toes - absent
• dehydration - absent

VITALS : 
• pulse rate - 120/min
• SPO2 - 98%

SYSTEMIC EXAMINATION :

CENTRAL NERVOUS SYSTEM:
• Pt, conscious, coherent and cooperative
• Speech is normal
• no signs of meningeal irritation

CARDIOVASCULAR SYSTEM:
• S1, S2 +

RESPIRATORY SYSTEM:
• lungs clear on auscultation

PER ABDOMINAL EXAMINATION:
• Tenderness in rt. Lumbar region

PROVISIONAL DIAGNOSIS : 

 RT. RENAL CALCULI WITH SHRUNKEN RT. KIDNEY and RECURRENT UTI

TREATMENT : 
 13/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

14/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

15/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

16/07/21
• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

Plan of further management
Surgery -Nephrectomy 

Comments

Post a Comment

Popular posts from this blog

39 year old male patient from West Bengal

Image
This is a case of a 39 year old bus driver who is a resident of West Bengal. CHIEF COMPLAINT : Abdominal distension since 2 months. Swelling in the leg since 2 months. Decreased appetite since 2 months. Decreased urine output since 1 month.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type. After a month his urine output got decreased still he continued his work as a bus driver. His relatives started noticing that his abdomen is getting distended and his appetite is decreased. They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension
Read more

OSCE and Learning points

Image
OSCE AND LEARNING POINTS PREFINAL PRACTICAL EXAMS NAME : VAGISHA RANI ROLL NO: 138 DATE: 4 December '23 Blog link: https://vagisharani.blogspot.com/2023/12/48-year-old-male-patient-from-west.html QUESTIONS  1) West haven criteria clinical grade for hepatic encephalopathy. 2) Wilson's disease and cirrhosis of liver  Wilsons diease is an inborn errors of copper metabolism characterised by increased total body copper. Etiology: Molecular defect within the copper transporting ATPase encoded by gene ( ATP7B) located on chromosome 13 Pathology:  Copper enters the body through the digestive tract with the help of a transporter protein in the cells of the small bowel, copper membrane transporter 1 (Ctr1; SLC31A1).  In response to rising copper levels, an enzyme called ATP7A releases copper into the portal vein to the liver. Liver cells carry the CMT1 protein and metallothionein, and then ATOX1 binds it inside the cell. Once here, ATP7B links the copper to ceruloplasmin and
Read more

59 year old female

Image
This is a case of a 59 year old professor who is a resident of West Bengal. CHIEF COMPLAINT : Case of  Rheumatoid arthritis under medication.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic an year and half ago.  Then she felt pain in her left wrist joint which was insidious in onset and gradually progressive in nature. It slowly progressed to the hands and shoulder on both the sides with an increased intensity causing difficulty in daily activities and sleep. She used painkillers which provided relief for sometime.  She underwent a physiotherapy for a month. She also took steroid injections twice in a local hospital in West Bengal but the pain reappeared later. There is no history of swellings, morning stiffness, malaise, musculoskeletal pain, weight loss,fever or rash. On February 2022, she went to a specialist in Hyderabad, who suggested her some medications but there was no improvement. Later she went to an OPD in Nalgonda and she got relieved from pain within 10
Read more