A 36 Old Male, Cement factory worker by occupation with C/O of Abdominal pain,Right loin pain,Vomitings
A Case of 36 Old Male, Cement factory worker by occupation with C/O of Abdominal pain,Right loin pain,Vomitings
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This is the case I have been given :-
A 36 Old Male Cement factory worker by occupation came to the opd with chief complaints of
Abdominal pain since 5days
Right loin pain since 5 days
Vomitings since 5 days
Patient was apparently asymptomatic one year ago then he developed pain in abdomen, later he went to the local hospital and was diagnosed to have right renal calculi for which he took treatment and got cured.
Then he developed pain in abdomen 5days ago, which is sudden in onset, gradually progressive, aggrevated on performing daily activities for which he went to local RMP for treatment and got cured (Not documented)
The next day patient developed Right loin pain which is colicky type, sudden in onset, gradually progressive , radiating to right groin
Right loin pain was associated with Vomitings 2-3episodes / day , Non bilious, Content -food particles, Non projectile
Loose stools , 3times / day , Gray colored, non foul smelling , Reduced urine output less than 200ml /day and abdominal distension
Shortness of breath grade 3 since 5 days
No h/o fever, Itching, facial puffiness, burning micurituon, painful micurition, Orthopnea , pleuritic chest pain , PND , Cough, cold
PAST HISTORY -
Not a known case of Hytertension , diabetes , asthma ,CAD,TB, Epilepsy
FAMILY HISTORY
NOT significant
PERSONAL HISTORY
Complaints of loss of appetite since 5days
He is an alcoholic, consumes toddy, whiskey 3times /week , 90ml , content increases during family festivals and gatherings , non smoker
Bowel and bladder movements are irregular
GENERAL EXAMINATION
Patient is conscious, coherent and co operative
Well oriented to time,place,person
VITALS
BP 120/90mm hg
PR 76bpm
RR 28cpm
Spo298% Room air
GRBS 120mg%
Icterus present
No pallor, cyanosis , clubbing lymphadenopathy
SYSTEMIC EXAMINATION:
P/A -Abdominal distension present
No visible veins,Sinuses
Soft, tenderness present
Murphys punch positive on right side
CVS
S1, S2heard , no murmurs
Respiratory system:
BAE + B/L infrascapular Crepts +
CNS NAD
INVESTIGATIONS
USG ABDOMEN 17th June 2022
Impression :
Right distal ureteric calculus causing hydro nephro sis
Right simple renal cortical cyst
Right grade 1RPD Changes
Bilateral pleural effusion
Minimal ascitis
PROVISIONAL DIAGNOSIS -
? POST RENAL AKI SECONDARY TO URETERIC CALCULI WITH UROSEPSIS WITH MODS
TREATMENT GIVEN
1) INJ PIPTAZ 4.5gm/IV/STAT
2)IVF DNS @70ml/ hr
3) INJ PAN 40mg IV/OD
4)TAB UDILIV 300mg/PO/BD
5)SYRUP LACTULOSE 15ml/PO/HS
6)INJ VITk IV/OD
7)INJ BUSCOPAN IV/SOS
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