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Case Discussion :
I have been given this case to solve in an order to 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.
* FLANK PAIN SINCE 15 DAYS
* BURNING MICTURITION SINCE 15 DAYS
* DECREASED URINE OUTPUT SINCE 15 DAYS
ADMITTED ON 14/09/2022
ADMITTED ON 14/09/2022
HISTORY OF PRESENT ILLNESS:
* Patient was apparently asymptomatic 10 years back then he developed pain in the lower abdomen and lower back, so he went to local Hospital and was investigated and diagnosed to have Renal Calculi for which the surgery was done.
* Then he was asymptomatic for 5 years and since the last 5 years, he had Flank pain which is of of ragging type, present on the left lumbar region, specifically over the scar of the surgery, radiating to the entire abdomen, The pain is insidious in onset and gradually increases in severity over 1-2 hours.and Burning Micturition for which he came to our hospital and used medication for 4 years.
* Had similar complaints since the last 5 months and went to local hospital and was treated symptomatically.
* 15 days back, he had pain in the left flank which is continuous , burning type , aggravated on vomiting and relieved by rest, No diurnal variation and is associated with nausea.
* He also had Burning Micturition, decreased urine output since 15 days.
HISTORY OF PAST ILLNESS:
* He underwent surgery for Renal calculi in 2012.
* History of Similar Complaints in the Past.
* Not a Known Case of Hypertension,DM, Asthma, Epilepsy, Coronary Artery Disease.
PERSONAL HISTORY:
Diet - Mixed
Appetite - DECREASED
Sleep - DISTURBED
Bowel movements - REGULAR
Bladder Movements - DECREASED
Addictions - NONE
TREATMENT HISTORY :
Prescribed 5 years ago
1. TAB.NITROFURANTOIN 100 mg / PO / BD FOR 2 weeks
2. SYP. ASCORYL 10 ml / PO / BD
3. SYP. CITRALKE 10 ml in 400 ml of water
4. TAB. MVT / PO / OD
The patient continued taking this medication for 4 years every time he experienced an episode.
Prescribed 4 months ago
1. TAB. NITROFURANTOIN 100 mg / PO / BD FOR 5 dayS
2. TAB. PANTOP 40 MG / PO / OD for 5 days
3. TAB. DROTIN 1 / SOS
4. SYP. ALKASOL 15 ml for 7 days, with water.
FAMILY HISTORY :
Not significant
PHYSICAL EXAMINATION :
A. General Examination
* Patient is conscious, coherent and co-operative and lying on the bed.
* He is well oriented to time, place and person.
* He is moderately nourished.
Pallor - Absent
Icterus - Absent
Clubbing - Absent
Cyanosis - Absent
Lymphadenopathy - Absent
Edema - Absent
VITALS AT THE TIME OF ADMISSION :
Temperature - AFebrile
Pulse Rate - 82 BPM
Blood Pressure - 110/70 mm Hg
Respiratory Rate - 20 CPM
SPO2 - 99% at Room Air
Random Blood Sugar - 90 mg/dl
Systemic Examination :
CARDIOVASCULAR SYSTEM - S1 and S2 present, No murmurs
RESPIRATORY SYSTEM - BAE +
PER ABDOMEN - Soft and TENDERNESS IN THE LEFT LUMBAR REGION
* Scaphoid shaped abdomen ,
* Scar of previous surgery
* No free fluid or palpable mass present,
* No organomegaly .
CENTRAL NERVOUS SYSTEM - E4V5M6, HMF +
14 / 09 / 2022 :
Provisional Diagnosis:
Renal calculi ( post surgery status 10 years) with ? URINARY TRACT INFECTION
TREATMENT:
1. TAB.NITROFURANTOIN 100 mg / PO / BD
2. TAB. PANTOP 40 MG / PO / OD
3. TAB. ZOFER 4 MG / PO / BD
4. TAB. MVT /PO /OD
5. TAB. ULTRACET /PO /QID ( 1/2 TAB)
15 / 09 / 2022 :
15/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 110/80 mm Hg
PR - 78 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : NEPHROLITHIASIS WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
16 / 09 / 2022 :
ADMITTED ON 14/09/2022
16/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 110/70 mm Hg
PR - 74 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
17 / 09 / 2022 :
ADMITTED ON 14/09/2022
17/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 120/80 mm Hg
PR - 76 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
18 / 09 / 2022 :
18/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 110/70 mm Hg
PR - 96 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
19 / 09 / 2022 :
ADMITTED ON 14/09/2022
19/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 110/80 mm Hg
PR - 92 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
20 / 09 / 2022 :
ADMITTED ON 14/09/2022
20/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 130/90 mm Hg
PR - 74 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
2. 4th HOURLY TEMP MONITORING
21 / 09 / 2022 :
ADMITTED ON 14/09/2022
21/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 130/80 mm Hg
PR - 80 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
2. 4th HOURLY TEMP MONITORING
Plan for NEPHRECTOMY
23 / 09 / 2022 :
23/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 130/80 mm Hg
PR - 80 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
2. 4th HOURLY TEMP MONITORING
24 / 09 / 2022 :
ADMITTED ON 14/09/2022
24/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 110/80 mm Hg
PR - 84 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
2. 4th HOURLY TEMP MONITORING
25 / 09 / 2022 :
ADMITTED ON 14/09/2022
25/09/2022
S: Complaints of Flank pain, decreased urine output and Burning Micturition
O:
Patient is conscious,coherent and cooperative
BP - 120/90 mm Hg
PR - 94 bpm
Temp- afebrile
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S-BAE+,clear
P/A-soft , TENDER IN THE LEFT LUMBAR REGION
CNS-NAD
A : HYDRONEPHROSIS OF LEFT KIDNEY WITH RECURRENT URINARY TRACT INFECTION
P:
1. TAB. ULTRACET 1/2 TAB /PO/QID
2. 4th HOURLY TEMP MONITORING
26 / 09 / 2022 :
28 / 09 / 2022 :
DISCUSSION AROUND THIS PATIENT:
[9/27, 3:05 PM] Rakesh Sir GM: @Dr Deepika Ma'am Med PG Please share the image of the stones and kidney removed today for our current patient with recurrent nephrolithiasis where a 5th semester student contributed his A+ blood
[9/27, 3:06 PM] Rakesh Sir GM: @Dr. Charan Sir Med PG : Please share the outcome of the OT asap
[9/27, 3:37 PM] Dr. Charan Sir Med PG: As Patient shifted to OT he was catheterised sir. Immediately 300ml of PUS drained into urobag. Then started with incision. Intra op they found few adhesions and pus in the kidney. So did nephrectomy and now patient is stable sir.
2 units of blood given intraoperatively
[9/27, 3:46 PM] Rakesh Sir GM: Images? Stone and removed kidney?
[9/27, 4:07 PM] Rakesh Sir GM: We need to give the Stone for analysis if we want to find out the reason for his recurrent stone formation which we missed doing in 2012 because of which we now had to remove his entire kidney.
[9/27, 4:17 PM] Rakesh Sir GM: What is the fluid is it all oil?
[9/27, 4:17 PM] Rakesh Sir GM: What about the stone?
[9/27, 4:22 PM] Dr. Charan Sir Med PG: Sir they resected kidney along with stone sir. Stone is inside the kidney and sending lab sir.
@Dr. Pavan Sir Med PG
@Dr Bharat Sir Med PG please coordinate with pathology team and follow up please
[9/27, 4:26 PM] Rakesh Sir GM: Ask the pathology team if they shall analyse the stones. Ask the biochemistry madam Dr Chandana if she can analyse it for us and if she needs any other equipment we can try to get it
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