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 

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