V prasaad

 



Elogs of medicine

General medicine

November 17, 2021

 


 General medicine 

                                      125 Afrin 

                                    131 Durga Sri. (3rd sem)

                 

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


 I have 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 a diagnosis and treatment plan.


Overview :


    patient came to hospital on 8th October 2021 when he came to know he has B/L renal calculi in USG abdomen &pelvis for which he underwent nephrostomy on 13/10/21 &left URSL with DJ stenting on 20/10/21 and then discharged and suggested to follow Up next month. 


         After discharge there is no improvement in his condition, so they suggested with 3 sessions of dialysis &Right URSL after a month but due to failure of dialysis through IJV on third session he was still in the hospital. 




* 38 year old male came to casualty with loss of appetite ,decreased sleep, nausea since 10 days and shortness of breath ,loin pain since 6 days.


Chief complaints : 

   Patient has decreased appetite, nausea, fever (on and off)  , decreased urine output 6 months back. 

Fever( on &off)  - low grade intermittent not associated with chills and rigor.

Burning micturation.


History of present illness : 

Patient came for follow up to urology on 3rd November. 


   Cr-3.2 ,urea -111, Hb -8.5 ,TC-20000cc/mm3 , platelet count -3.17 l 


Right sided kidney mild hydronephrosis ,lower pole calculus 4-5mm . 


Left mild hydronephrosis. 


History of past illness : 

* USG - abdomen &pelvis  revealed:  right kidney with gross hydronephrosis and left kidney with moderate hydronephrosis, B/L uretric calculi Right -13mm,Left -23mm .


* 9/10/21 :   cr: 9.6 , urea -158 , suggested with 3 sessions of dialysis this is done through right IJV.  


* At the time of discharge serum creatinine -2.1,Hb -8.1 , TC -8500cc/mm3 , platelet count -3.5 l .


Treatment history : 

Surgical history :


 13/10/21 - bilaterally nephrostomy  decreased LA 


20/10/21 - left URSL ( ureteroscopic lithotripsy)  with DJ stenting decreased SA. 


 Personal history  : 

 Decreased appetite since 10 days. 


Mixed diet 


Bowel and bladder movements are regular 


Burning micturation 


No know allergies 


Addiction occasionally -drinking &one bd per day 


( last  consumed 3 months back) 


No k/c/o DM, HTN, CVD, TB. 


General examination : 

Pallor -present 


No icterus


No cyanosis 


No clubbing of fingers or toes 


No lymphadenopathy 


No edema 


No malnutrition 


No dehydration 


Afebrile temperature 


Pulse rate - 86b/m


Respiration rate - 12 cpm 


Bp - 80/50 mm Hg 


Spo2 -99%


GRBS -124mg%


Systemic examination : 

Cardiovascular system :

S1,S2- heard 


No added sounds 


Respiratory system: 

Normal vesicular breath sounds heard. 


Trachea centrally present 


Abdomen : 

Tenderness -diffuse(mild )


Shape of abdomen -scaphoid 


Central nervous system : 

Conscious coherent cooerative


Investigations : 

8/11/21 


Hemogram :




Serum creatinine:




Serum electrolytes :




Complete urine examination : 




Blood urea: 




11/11/21

  

RFT : 





Hemogram : 





14/11/21


Hemogram : 




RFT :




ECG : 







Provisional diagnosis : 

AKI on CKD secondary to post renal obstruction with B/L ureteric calculi with B/L hydronephrosis. 


S/P - Left URSL with DJ stenting done. 


Treatment : 

IVF - NS.  - UO +30m / hr


       - RL 


Inj. OPTINEURON 1Amp IN 100 ml


Inj.  PANTOP 40mg IV/OD 


Inj. BUSCOPAN 2cc IV/ STAT 


TAB. NODOSIS 550mg PO/ TID


TAB. OROFERXT  PO/ OD 


TAB. SHELCAL -CT. PO/OD 


TAB. PCM 500mg PO/ SOS


MONITOR VITALS -4TH HRLY 


STRICT I/O CHARTING 


INJ. PIPTAZ 4.5 mg IV/ STAT 


INJ. PIPTAZ 2.25mg IV/ TID.  















Comments

Post a Comment

Popular posts from this blog

Pre final

Image
  This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 83yr old male came with complaints of  shortness of breath since 10 days. chief  complaints:  cough since 14 days Fever since 12 days shortness of breath since 10 days History of Presenting illness: Patient was admitted to ICU 16 days back with  breathlessness. It was insidious in onset and
Read more

OSCE

  PREFINAL OSCE Pathophysiology An uninjured healthy lung contains an intact respiratory epithelial layer and alveolar space patrolled by resident alveolar macrophages. Type I and type II pneumocytes contribute to regulation of alveolar contents, including surfactant, and maintain the integrity of the alveolar-capillary barrier.  Following infection or inj ury, an influx of innate immune cells such as neutrophils and monocytes migrate from the circulation into the interstitial and alveolar spaces,  • During respiratory distress, damage to the epithelial and endothelial layers results in breakdown of the alveolar-capillary barrier and accumulation of edematous fluid and debris in the alveolar spaces. Pro-inflammatory and destructive functions of alveolar macrophages, monocytes, and neutrophils co ntribute to disease pathology.  • The consequence is the loss of alveolar-capillary barrier function. This disruption permits the accumulation of proteinaceous fluid in the alveolar space coupl
Read more

ADRENAL TUMORS [131 durga T]

Image
ADRENAL GLAND TUMORS Adrenal tumors are cancerous or noncancerous growths on the adrenal glands  The adrenal glands are located above the kidneys and have two parts, the adrenal cortex and the adrenal medulla. The adrenal cortex secretes hormones including cortisol and aldosterone. The adrenal medulla produces dopamine, epinephrine and norepinephrine. There are different types of adrenal tumors, and they can be either cancerous or noncancerous (benign). Aside from categorizing them as noncancerous (benign) or cancerous (malignant), they are categorized as functioning or nonfunctioning. Functioning tumors lead to overproduction of one or more of the normal adrenal hormones. CAUSES: The cause of most adrenal tumors is unknown. Some hereditary conditions have been linked to an increased risk of developing an adrenal tumor. The hereditary conditions include: Carney complex Li-Fraumeni syndrome Multiple endocrine neoplasia type 2 Neurofibromatosis type 1 MAJOR PROBLEMS: Adrenal tumors can c
Read more