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02/08/2022
Aruna.J
Roll no.61
A 64 year old male resident of Chotuppal came with chief complaints of
1. Vomiting since 15 days
2. Burning micturition since 15 days
3. Right flank pain since 15 days
HOPI:
Patient was apparently asymptomatic 15 yrs back.Then he developed pain in the right loin and was diagnosed with renal calculi(bladder) and was operated and then 3 yrs later again he developed bilateral loin pain and was diagnosed with bilateral renal calculi (ureters) and was operated with a gap of one month.
Then 3 yrs later he developed a midline swelling approx 3 cm below umbilicus and diagnosed with abdominal hernia and a mesh was placed.
Then 1 yr later he developed abdominal pain and endoscopy was done and diagnosed with ulcer and was managed conservatively During this he was diagnosed with diabetes and hypertension
Then 2 yrs back he developed generalized weakness and went to hospital and was told that haemoglobin (6 g/dl)was low and was given iron injections.For which he went to Hyderabad orange hospitals and because of financial crisis he came to KIMS Narketpally .
Since 15 days patient has complaints of vomitings 3-4 times per day containing of food contents in it . Non bilious , non projectile. Not associated with fever , malaise , headache .
Right sided lower flank pain which dull aching type of pain radiating to the front in the lower right quadrant ( loin ) associated with Burning micturition since 15 days . History of reduced urine output .
DAILY ROUTINE:
Patient wakes up at 5 am and takes breakfast at 7 and lunch around 12pm and dinner at 8pm and rest of the time spends time with grandchildren. His daily routine is not disturbed even after having illness.
PAST HISTORY-
History of similar complaints in the past .
DM and Hypertension since 7 years .
No history of asthma , epilepsy, CAD , TB
Family history- No significant family history
DRUG HISTORY- no history of drug allergy
PERSONAL HISTORY-
Diet- mixed
Appetite- decreased (Anorexia).
Sleep- adequate
Bowel and bladder- burning micturition and decreased urine output
Addictions- alcohol occasionally
GENERAL EXAMINATION-
Patient is conscious, coherent andcooperative
Moderately built and nourished
Pallor - absent
Icterus- absent
Cyanosis- absent
Clubbing -Absent
Lymphadenopathy- absent
Edema- absent
VITALS -
Temperature- a febrile
Pulse rate - 86 bpm
Respiratory rate - 17 cpm
BP - 90/60 mm of hg
SYSTEMIC EXAMINATION-
CVS-
JVP - not raised
Visible pulsations: absent
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent
S1, S2 - heart sounds heard
Pericardial rub - absent
Respiratory system:
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical
AUSCULTATION
BAE+, NVBS.
Abdomen examination:
INSPECTION
Shape : normal
Scar : Absent
Umbilicus:normal
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal
PALPATION
Tenderness: presented in lower right quadrant ( right flank pain radiating to other regions )
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard
CNS :
Higher mental functions intact
No focal neurological deficit’s present
PROVISIONAL DIAGNOSIS-
Obstructive Uropathy with
AKI .
INVESTIGATIONS:
Complete Blood Picture
CUE:
Serum Creatinine:
Blood UreaLiver Function TestsUSG
NCCT-KUB
Treatment:
Tab.Nodosis 500mg/PO/BD
Tab.Orofer-XT PO/BD
Tab.Shelcal 500mg PO/BD
Inj.Tramadol- 1amp.in 100ml NS.
Tab.Ultracet1/2 PO/OD
Neb.Duolin 6thhrly
Inj.Vancomycin 500mg inn10ml NSslow IV/Stat
Inj.NA 2amp in 46ml NSat 10ml/hr rate(to maintain MAP>60mm Hg)
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