A 64 year old male with vomitings and right flank pain

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

02/08/2022

Blog by Janhavi Virani 

Roll no 58

A 64 year old male resident of Chotuppal came with chief complaints of 

1. Vomiting since 15 days 

2. Burning micturition since 15 days 

3. Right flank pain since 15 days 

HOPI -

Patient was apparently asymptomatic 15 yrs back.Then he developed pain in the right loin and was diagnosed with renal calculi(bladder) and was operated and then 3 yrs later again he developed bilateral loin pain and was diagnosed with bilateral renal calculi (ureters) and was operated with a gap of one month.

Then 3 yrs later he developed a midline swelling approx 3 cm below umbilicus and diagnosed with abdominal hernia and a mesh was placed.

Then 1 yr later he developed abdominal pain and endoscopy was done and diagnosed with ulcer and was managed conservatively During this he was diagnosed with diabetes and hypertension

Then 2 yrs back he developed generalized weakness and went to hospital and was told that haemoglobin (6 g/dl)was low and was given iron injections.For which he went to Hyderabad orange hospitals and because of financial crisis he came to KIMS Narketpally . 

Patient presented to KIMS opd 12 days back . 

Since 15 days patient has complaints of vomitings 3-4 times per day containing of food contents in it . Non bilious , non projectile. Not associated with fever , malaise , headache . 

Right sided lower flank pain which dull aching type of pain radiating to the front in the lower right quadrant ( loin ) associated with  Burning micturition and slight pain since 15 days . History of reduced urine output . 

DAILY ROUTINE:

Patient wakes up at 5  am and takes breakfast at 7 and lunch around 12pm and dinner at 8pm and rest of the time spends time with grandchildren. His daily routine is not disturbed even after having illness.

PAST HISTORY- 

History of similar complaints in the past . 

DM and Hypertension since 7 years . 

No history of asthma , epilepsy, CAD , TB 

FAMILY HISTORY - no significant family history 

DRUG HISTORY- no history of drug allergy 

PERSONAL HISTORY- 

Diet- mixed

Appetite- decreased 

Sleep- adequate 

Bowel and bladder- burning micturition and decreased urine output 

Addictions- alcohol occasionally 

GENERAL EXAMINATION- 

Patient is conscious, coherent and cooperative 

Moderately built and nourished 

Pallor - absent 

Icterus- absent 

Cyanosis- absent 

Clubbing- absent 

Lymphadenopathy- absent 

Edema- absent 

VITALS - 

Temperature- a febrile 

Pulse rate - 86 bpm

Respiratory rate - 17 cpm

BP - 90/60 mm of hg

SYSTEMIC EXAMINATION- 

Cardiovascular system  

JVP - not raised 

Visible pulsations: absent 

Apical impulse : left 5th intercostal space in midclavicular line.

Thrills -absent 

S1, S2 - heart sounds heard 

Pericardial rub - absent

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrically reduced

Trachea is central in position.

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 5th ICS, 

Chest movements bilaterally symmetrical 

AUSCULTATION 

BAE+,  NVBS

Abdomen examination:

INSPECTION

Shape : normal 

Scar : Absent 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PALPATION 

Tenderness: presented in lower right quadrant ( right flank pain radiating to loin )  

PERCUSSION- tympanic

AUSCULTATION :bowel sounds heard

CNS : 

Higher mental functions intact 

No focal neurological deficit’s present 

PROVISIONAL DIAGNOSIS- 

Obstructive Uropathy 

INVESTIGATIONS- 

TREATMENT- 

T.lasix 40mg oral BD

T.Nodosis 500mg oral VD

T.Shelcal 500mg oral BD

T.Orafer xt oral BD

T.NICARDIA 20mg

28/7/22

Same treatment

29/7/22

Same treatment.

30/7/22

Same treatment 

2/08/22

Dialysis was done - 4 times since he came .