45 yr old female with B/L loin pain
GENERAL MEDICINE CASE
"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
G. AISHWARYA
ROLL NO- 35
CHIEF COMPLAINTS:
Decreased urine output since 10 days
Shortness of breath since 1 week
Pain in the loin region
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 years back, she was a daily wage worker and stopped working 3 years back because she used to get tired easily.
1 year back she experienced severe right loin pain associated with reduced urine output, facial puffiness, ededma of lower limbs, she went to hospital ans was diagnosed with renal calculi.She underwent right DJ stenting and also 3 sessions of hemodialysis
After that She didn't undergo hemodialysis or wasn't on any treatment for 1 year due to the COVID pandemic.
Pain in the loin region was present for which she used to take medication.
10 days back , patient started experiencing reduced urine output.
Associated with facial puffiness, no pedal edema.
She has shortness of breath after walking a few steps since 1 week, not associated with any orthopnea, PND, chest pain, palpitations. Also no complaints of cough, wheeze.
PAST HISTORY:
No history of diabetes, hypertension, asthama, tuberculosis, epilepsy.
General Examination:
Pallor - present
No icterus, cyanosis, clubbing, generalized lymphadenopathy.
Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98%
GRBS -116 mg/dl
ABDOMINAL EXAMINATION:
Inspection:
Shape of abdomen: scaphoid
Umbilicus - cental and inverted
No scars, sinuses, visible peristalsis, visible pulsations.
Palpation:
Temperature: no raise of temperature
Tenderness is present in tha right and left lumbar regions.
No organomegaly present
Auscultation:
Bowel sounds were heard
Cardiovascular system: s1 and s2 are heard
Respiratory system: bilateral air entry
Cns: no focal neurological lesions.
Investigations
Diagnosis:
B/L groin hydroureteronephrosis
B/L ureteric calculi
Post right sided DJ stenting
Plan of treatment :
1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. Tab NODOSIS 500 mg PO BD
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. MONITOR VITALS
SOAP NOTES
S:
NIL URINE OUTPUT SINCE LAST HEMODIALYSIS
A:
Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98%
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
A:
B/L groin hydroureteronephrosis
B/L ureteric calculi
Post right sided DJ stenting
P :
1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
19/2/22
GENERALISED WEAKNESS
vomitings 6-8 episodes /day since after dialysis ,
Hypoglycemia post that,
Decreased intake of food
S:
C/O generalised weakness
A:
Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema
Vitals at admission:
PR- 87 bpm
BP- 150/90 mmHg
RR- 22 cpm
SpO2- 98%
GRBS - 166
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
A:
B/L groin hydroureteronephrosis
B/L ureteric calculi
Post right sided DJ stenting
P :
1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. INJ PIPTAZ 2.25 gm IV TID
Comments
Post a Comment