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

a 69 yr old male with pedal edema

This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.

Chief complaints:-

Pedal edema(pitting type) since 20 days

Decreased urine out put since 2-3 days

Shortness of breath since morning

Cough with sputum since morning 

History of presenting illness:-

Apparently patient was asymptomatic 20 days ago,developed pedal edema, gradually progressed to the knee(pitting type).Went to local hospital for used some tablets after which he developed anuria but pedal edema did not subside.

Daily routine:-

He usually gets up early in the morning and and eats break fast at 6-7am and goes to field for farming.He comes back at 6pm and and has dinner by 8pm and sleeps.

But 3 years ago he had leg trauma in which his both the hip joints got fractured.Hence rods were inserted.Since then he is not able to stand and walk and is bed ridden.So he stopped working and stays home.

History of past illness:-

Known case of  

Diabetis mellitus type 2 since 15-20 years

Leg trauma causing hip joint fracture 3 yrs       ago.Due to this he is bed ridden.

Shortness of breath since many years               which is associated with cough and   wheezing.

Surgical history:-

He got inserted with two rods in hip joint due to fracture caused by leg trauma.

Drug history:-

For diabetes-

 Tab.Metformin 500mg

For pain in the hip-

 Tab.Aceclofenac and paracetamol-100/325mg

Personal history:-

Diet-mixed

Built-low 

Appetite-decreased

Sleep-decreased 

Bowel movement-normal

Bladder movement-decreased 

Allergies- absent

Addiction-alcohol occasionally

 Bidi-1 pack for 2 days

Family history:- not significant 

General examination:-

Pallor,pedal oedema present

Ictreus,cyanosis,clubbing,lymphadenopathy absent

Vitals-

Temperature-98.9F

Pulse rate-96/min

Resperatory rate-28/min

Bp-140/90

Spo2-50%o2

Grbs-60%mg

Systemic examination:-

CVS

Cardiac sounds S1 and S2 present.

No thrills or murmurs.

Apex beat heard in 6th intercostal space lateral to mid clavicular line

Respiratory system

Chest is symmetrical, barrel shaped on inspection.

No visible deviation of the trachea, supraclavicular hollowing or unilateral sternocleidomastoid prominence.

No drooping of either shoulder.

There appears to be a retraction near the 7th intercoastal space on both sides.

On palpation, inspectory findings were confirmed. Trachea in midline, no intercoastal crowding, no rosary beads appearance at costochondral junctions. Pain is present at the site of retraction in the 7th intercoastal space. No dilated veins. Chest movements were normal, symmetrical. Tactile fremitus was more apparent on the right side.

On percussion, no dullness or abnormality was noted.

On auscultation, Bilateral crepts were present and wheezing was noted.

CNS

The patient is conscious, drowsy.

Speech is normal.

No neck stiffness. Kernig's sign is absent.

Abdomen

Normal shape. No tenderness.

No palpable mass. Liver and spleen not palpable.