GM E-Log J. Mounika .Roll (51)

 

Hello all. This is Mounika , a third semester medical student. 
This an e log depicting patient centred approach of learning. This log has been created after taking consent from the patient and her family. 

A 35 YEAR OLD FEMALE WITH SHRUNKEN RIGHT KIDNEY, RENAL CALCULI

Note : This is an ongoing case and will be updated as and when we find new information. 
         This e log is made under the guidance of Dr. Siddharth. 

Date of admission :13.07.2021

CHIEF COMPLAINT :
A 35 yr old woman, who is a housewife in West Bengal, presented with

• Pain in abdomen since 3 years

• Lower back pain since 6 months

HISTORY OF PRESENT ILLNESS:

• Woman, mother of 3 children was apparently asymptomatic 3 yrs back. 

• She started experiencing pain in the right lumbar region radiating to the back since 3 yrs., and right upper thigh along with burning micturition. 
                  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. 
                 
• She has been experiencing intermittent fever. 

• 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. 
               She had been on conservative treatment ever since. 

• Since the past 3-4 months, she has also been experiencing intermittent headaches followed by vomiting. 

HISTORY OF 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 :

• Is married with 3 children, 1 son and 2 daughters. And a housewife. 

• Her appetite is normal. Follows mixed diet. 

• Her bowel habits and micturition is 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

        RECURRENT UTI

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


TREATMENT : 

• T. MYOSPAS /PO/OD
• MONITOR VITALS -  BO, PR, TEMP
• INJ. OPTINEURON  NS/IV/OD

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