37 y/o BILATERAL LOIN PAIN AND ABDOMINAL DISTENSION

This is srujana from eight semester.  This is an elog depicting  patients deidentified data centered approach for learning medicine.ll This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them


Cheif complaints -
Bilateral pain in loin since 7days
Abdominal distension since 7 days


HOPI-

The patient was apparently asymptomatic 1 week ago when she developed low grade fever ,which was continuousand was  followed by abdominal distension.
H/o generalised pain in the abdomen 
H/o decreased frequency of urination and decreased intake of food
H/o hematuria (since today mrng 6am)
No h/o pain during micturition,burning during micturition
No h/o vomiting and loose stools

Family history -
Not significant

Past history - dialysis 2 sessions -last week
H/o obstructive uropathy -1 week ago

Personal history -
Diet mixed
Appetite decreased
Sleep decreased 
Bladder bowel movements -bowel normal
Bladder decreased 
No addictions
No known allergies

Surgical history -
Renal calculi 1 month ago


GENERAL EXAMINATION:


•Patient is consious, coherent ,cooperative
•moderately built and nourished
•pallor -present (mild)
•no icterus,cyanosis,clubbing,lymphadenopathy
Mild bilateral pedal edema present



Vitals-

Temperature -afebrile
Pulse rate -80bpm
Respiratory rate -12cpm
Bp-110/80 mmhg


SYSTEMIC EXAMINATION-
CVS: S1, S2 heard
          no thrills
          no murmurs
RESPIRATORY SYSTEM:
          Dyspnoea +
           Crepts + @rt 
           BAE +
          Trachea slightly shifted to right side
          Breath sounds heard
ABDOMEN:
          Distension of abdomen
          tenderness present 
          No palpable masses 
          No free fluid 
          no bruits 
          no organomegaly
          normal hernial orifices
          bowel sounds+
Presence of scars on the right side of the abdomen and chest present (previous injury)
CNS: C/C/C to time, place, person
          No signs of meningeal irritation 
          no focal neural deficit found
          normal speech
          functions of cranial nerves, motor & sensory system are normal

Reflexes:  
       biceps triceps supinator knee ankle
right ++ ++ + ++ ++
left ++ ++ + ++ ++

plantar- flexor




Investigations -




Provisional diagnosis -post renal AKI Secondary to renal calculi 



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