A 60 YEARS OLD FEMALE with LEFT SIDE PLANK PAIN since 12 days

Introduction:  Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 A 60 year old female presented to Casuality with, 

CHIEF COMPLAINTS:

Left Flank pain since 12 days

Fever since 10days

Burning micturition since 10days

Increased frequency of micturition since 10days

Vomitings since 2days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 12days ago, she then developed pain in Left flank since 12days.

-Insidious and gradually progressive, radiating

 from left flank to groin

-Spasmodic and pricking type of pain

Fever since 10days

-High grade

-Associated with chills and rigors

-Relieved with medication

Burning micturition since 10days

Increased frequency of micturition since 10days

Vomitings since 2days

-Content food material

-Non bilious

-Non projectile

-Not blood stained

DAILY ROUTINE: 

Patient is a Fruit seller by occupation. 

She wakes up at 6am, has breakfast at 6:30am, goes to work at 10am, has lunch around 1-2pm, comes back home at 6 pm, has dinner at 9pm and goes to sleep around 10-11pm.

Since 10days she hasn't been able to go to work due to Left flank pain and body pains. 

PAST HISTORY:

Patient is a known case of Diabetes Mellitus type 2 since 25years , on Tab. Glimi -M2  PO/OD

Patient is a known case of Hypertension since 25years, on Tab.Amlong 5mg PO/OD

History of Hysterectomy 23years ago

PERSONAL HISTORY:

Patient complains of body pains and decreased appetite since 10days

Bowel movements are normal

History of pruritis seasonal(summer) 

FAMILY HISTORY:

No similar complaints in the family members. 

GENERAL PHYSICAL EXAMINATION:

Examination has been done in a well lit room in supine and sitting position after taking informed consent and after reassuring the patient. 

-Patient was conscious, coherent, cooperative  and well oriented to time, place and person. 

-Pallor present

No signs of Icterus , Cyanosis, Clubbing,Oedema, Lymphadenopathy, Malnutrition, Dehydration, Generalized lymphadenopathy

SYSTEMIC EXAMINATION:

Central Nervous System : No abnormality detected. 

Per abdomen: Soft, Tenderness in Left Iliac fossa, Left lumbar region. 

Cardiovascular system: S1, S2 heard, No murmurs

Respiratory system: BAE+, NVBS+

VITALS:

BP- 140/90 mm Hg

RR- 18 cpm

PR- 96 bpm

SpO2- 98%

Afebrile

INVESTIGATIONS:

Prorthrombin Time

APTT

Serum Electrolytes

 

Serum Creatinine - #1.3

Liver Function Test

Blood Urea

RBS - # 221

Serum Iron

Reticulocyte count

Hemogram

Blood Urea

BGT

Bleeding &Clotting time

Radiological investigations

PROVISIONAL DIAGNOSIS:

ACUTE PYELONEPHRITIS with TYPE 2 DIABETES MELLITUS &  HYPERTENSION with ANAEMIA

TREATMENT:

1) IV Fluids NS at 80ml/hour

2) Injection Piptaz 2.25gm IV /TID

3) Injection Neomol 1gm IV/SOS

4) Injection Optineuron 1amp in NS at 50ml/hour

5) Check GRBS 7th profile

6) Injection HAI S/C TID

7) Injection NPH S/C BD

8) Tab. Cinod 10mg PO/BD

9) Injection Zofer 4mg IV/SOS

10) Injection Pan 40mg IV/OD

11) Injection Tramadol 1amp in 100ml NS IV/SOS

20/7/23

Abdominal pain decreased

No fever spikes, vomitings

O: patient is c/c/c

Temp: 98.5 F

PR: 74 bpm

Bp: 170/100 mmhg 

RR: 18/min

Spo2 - 92% on RA

CVS: s1 s2 heard 

No murmurs 

Rs: BAE +

NVBS

CNS: NAD

P/A : soft 

Tenderness + in left flank and suprapubic region

Bowel sounds are sluggish 

I/O : 1500/1100ml

GRBS: 112 mg/dl given (4units of HAI and 4 units of NPH)

A: Left acute pyelonephritis 

With AKI(resolved) secondary to left proximal ureteric calculus(?17mm) with type 2  DM and HTN since 25 yrs with anemia

S/p : cystoscope and guide wire placement (pod 2) 

S/P:  DJ STENTING WAS DONE UNDER LA YESTERDAY 

1)IV fluids 

Ns,RL@50ml/hr 

2)Inj.Piptaz 2.25gm IV/TID

3)Inj.Tramadol 1amp in 100 ml NS IV/BD

4)Tab Cinod 10mg po/BD 

5) Tab. Nicardia 10 mg po/sos

6) Tab Dolo 650 mg Po/TID

6)Strict I/o charting 

7) GRBS 7. Profile 

8)Inj. HAI S/C21/7/23

Pain subsided

No fever spikes, vomitings

O: patient is c/c/c

Afebrile

PR: 84 bpm

Bp: 170/80 mmhg 

RR: 18/min

Spo2 - 98% on RA

CVS: S1 S2 heard 

No murmurs 

Rs: BAE +

NVBS

CNS: NAD

P/A : No tenderness

Input : 2400ml

Output:2200ml

GRBS: 124 mg/dl  (6units of HAI and 4 units of NPH given)

A: Left acute pyelonephritis 

With AKI(resolved) secondary to left proximal ureteric calculus(?17mm) with type 2  DM and HTN since 25 yrs with anemia

S/p : Cystoscopy and Guide wire placement under LA(pod 3) 

S/P:  DJ STENTING WAS DONE UNDER LA (Pod 3) 

P:

1)Plenty of oral fluids

2)Inj.Piptaz 2.25gm IV/TID

3)Inj.Tramadol SOS

4)Tab Cinod 10mg po/BD 

5) Tab. Nicardia 20 mg PO/QID

6)SYP.Alkastone B6 15ml in 1/2glass of water PO/BD

7)Strict I/o charting 

8) GRBS 7. Profile 

9)Inj. HAI S/C TID

10)Inj. NPH S/C BD