A 31 YEAR OLD MALE WITH ? B/L RENAL CALCULI, AKI.

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.

A 31 yr old male came to the casualty with c/o pain in the left loin radiating to groin since 3 days.
C/o vomiting since 3 days.
C/o decreased urine output since 3 days.

Pt was apparently asymptomatic 4 days ago, then he had a episode of fever, which relieved on taking medication. 
Then the following day in the night he developed pain in left loin radiating to groin colicky type, no aggravating or relieving factors.
C/o vomiting- non projectile, non bilious, content- food.

C/o decreased urine output which remained same even after treatment .

At the night of onset of pain, he received treatment from a local RMP doctor, which didn't make his symptoms any better, still he had continuous vomiting even if he drank water.
Then the patient went to a ORTHOPEDITIAN thinking it might a back pain due to spine issue, doctor gave necessary treatment bt he didn't get any better.

Next he consulted another doctor, where he was referred to our hospital.

No h/o similar complaints in the past.

No known comorbidities.

On examination:
Temp- afebrile.
PR:70 BPM.
RR: 16 CPM.
Bp: 110/70 mm Hg
Spo2 : 98%
GRBS 120 MG%.

No pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema.

CVS:S1 S2 HEARD, NO MURMURS.

RS: NVBS heard, BAE +, TRACHEA CENTRAL, 
RHONCHI+.

P/A : SOFT, NON TENDER, NON DISTENDED.

CNS: CONSCIOUS, NO SIGNS OF MENINGEAL IRRITATION.

REFLEXES.
                   RT.             LT.
BICEPS.     +                 +
TRICEPS.    +                +
SUPINATOR. +              +
KNEE.              +            +
ANKLE.            +            +
PLANTAR: FLEXOR.

Provisional diagnosis
? B/l RENAL CALCULI
AKI.

INVESTIGATIONS

On 12/8/21


On 13/8/21
On 16 /8/21



TREATMENT
Inj. LASIX 40 MG IV BF (8 am, 4 pm).
Inj.ZOFER 4MG IV TID .
Inj.PAN 40 MG IV OD.
IVF NS,RL @100ML/HR.
STRICT I/O CHARTING.
BP,PR,RR,SPO2 CHARTING 2ND HOURLY.

Day 2.SOAP NOTES

1.SUBJECTIVE -
- B/L loin pain, RT > LT
- Decreased Appetite 
- No passage of stools

2. OBJECTIVE 
- BP : 120/90mmHg
- pulse : 52bpm
- RR : 21cpm

3. ASSESSMENT 
- AKI with B/L Renal calculi

4. PLAN OF CARE
- INJ LASIX 40MG IV OD
              1____X____1
- INJ PAN 40MG 1V OD
- INJ ZOFER 4MG 1V/SOS
- TAB DROTIN /PO/BD
- TAB ULTRACET 
- I/O CHARTING

Day 3 , same as day 2

SOAP NOTES DAY 4

SUBJECTIVE
LOIN PAIN RIGHT AND LEFT( RESOLVED)

OBJECTIVE
TEMP afebrile
BP 110/70mmhg
PR 74 bpm


ASSESSMENT
AKI with B/L RENAL CALCULI.

Plan of care
IVF RL NS @75ml/hr.
Tab.LASIX 30mg po/sos
Tab.TAMSULOSIN 0.4mg/po/HS
SYP.CITRALKA 10ml.in 1 glass of water PO/OD
Tab.DROTIN PO BD
Tab. ULTRACET 1/2 × 4
Tab.ONDANSETRON 4mg PO/ BD
SYP.ARISTROZYME 15 ml po/TID.

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