A CASE OF HYDRONEPHROSIS PRESENTED IN SUMMER 2023

NOTE: 

• The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 

• Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

• This E-log also reflects my patient's centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom. 

A 67 year old male barber by occupation came to the opd with chief complaints of shortness of breath and fever . 

CHIEF COMPLAINTS 

➤ Shortness of breath since 1 week 

➤ Fever since 4-5 days

HISTORY OF PRESENTING ILLNESS

Pateint was apparently asymptomatic 1 week back.

 Then he developed shortness of breath (grade II- IV) , aggravated on doing work, walking and temporarily relived on medication.

 He also had fever for which he went to local hospital and they gave medication but symptoms were  not relieved and then they went to Miryalaguda hospital for checkup and they referred to our hospital.

He also had fever since 4days, which was of  high grade with evening raise temperature associated with chills and rigors relieved by medication and increased again.

H/O decreased urine output since 6 months

c/o pain abdomen on &off left lumbar region since one week

c/o Vomitings 2 days back 2-3 episodes, watery,non-projectile , non-biliary with food particles as contents

c/o low stools 2-3 episodes 2 days back relieved now , watery , non-mucoid , non blood stained , no foul smelling

c/o decrease in appetite since 1 week 

No c/o of chest pain , palpitations 

PAST HISTORY

➤ k/c/o hypertension since 10 years and on medication 

➤ Not a k/c/o diabetes mellitus,  TB epilepsy , asthma ,CAD , thyroid disorders , CVA. 

➤History of previous surgery : Renal stenting 6 months back.

PERSONAL HISTORY

➤Occupation: Barber 

➤Patient is married .

➤Patient takes a mixed diet and has decreased appetite since 1 month.  

➤Sleep : Regular 

➤Bowel movements are regular ,  decreased urine output with burning micturation since 1 month

➤No known allergies .

➤ Addictions - Tobacco since 30 yrs ,       stopped 1 yr back 

                            Alcohol consumption since 25 yrs , stopped 1 yr back .

FAMILY HISTORY 

Not significant .

GENERAL EXAMINATION

Patient is conscious,coherent , cooperative well known with time, place, person 

He is well built and moderately nourished.

➤Pallor : seen 

➤Icterus : not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : not seen . 

VITALS 

➤ Temperature : 97.2℉

➤PR : 117 beats per minute

➤BP : 120/80 mm Hg

➤RR : 28 cycles per minute

➤SpO2 : 94% in room air

➤ GRBS : 128 mg/dl 

PROVISIONAL DIAGNOSIS: LEFT HYDRONEPHROSIS SECONDARY TO ? LEFT URETERIC OBSTRUCTION ? POST RENAL AKI

TREATMENT:

1. Inj Lasix 40 mg iv stat

2. Neb with duolin stat budecort

 3 .Inj Neomol 1gm IV sos

4. Tab Dolo 650mg PO/BD.

5. Tab Olmesartan- H PO/BD.