A 67 year old male patient with left renal hydronephrosis, left flank pain and grade IV SOB - GM CASE 14

9th June 2023
CASE STUDY 14

Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

CHIEF COMPLAINTS:
c/o 
- continuous fever associated with rigors and chills since 9 days.
- grade IV SOB since 1 week.


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 days ago until he developed a swelling on his left side of middle abdomen i.e left flank which was associated with pain. The pain was squeezing type, continuous, and radiating towards back in nature. 5 years ago he was also diagnosed with renal cysts in his right kidney. 8 months ago, the right kidney was operated, after which he was given fluid therapy for 3 months. He developed mild burning micturition after the surgery. 10 days ago he lost consciousness and was provided with immediate first aid. The following day he developed high grade fever and increased difficulty in breathing even at rest. He was brought to casualty with the same complaints with associated chills and rigors

h/o burning micturition and rediced urine output since 8 months after the renal surgery.
h/o itching around 8 months ago for 2-3 days which healed spontaneously.
h/o 4-5 episodes of vomiting for 3-4 days out of which first episode was bilious, non projectile and the rest were non bilious, non projectile with no traces of blood. 
h/o diarrhea 1 week ago. Had 4 episodes everyday for 3-4 days.
h/o fever since 1 week with associated chills and rigors.
no h/o nausea 
no h/o rash
no h/o constipation 
no h/o cough
no h/o headache, blurring of vision.



ASSOCIATED DISEASES:

———

PAST HISTORY:

h/o HTN since 10 years and is on regular medication (tab. olmesartan)
No K/C/O DM,  Epilepsy, TB, CAD, CKD. 


PERSONAL HISTORY:

Married.
Barber by occupation.
Was on a mixed diet but stopped eating non veg food 8 months back after the renal surgery.
Reduced appetite since 1 week.
Disturbed sleep.
Increased Bowel movements. 
Has no known allergies.



FAMILY HISTORY:


Has N/K/C/O  Diabetes Mellitus, No HTN, No Strokes. No CAD, TB, Asthma or Epilepsy.


DRUG HISTORY:






GENERAL EXAMINATION:

-No palor
-No Icterus
-No cyanosis 
-No lymphadenopathy
-No pedal edema 
-No clubbing of fingers














VITALS:

Temperature: Febrile - 98.9°F

Pulse: 117 beats per minute

Respiratory rate: —28 cycles per minute

Blood pressure: 120/70 mm of Hg

SPO²: 90%

GRBS: 128mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular? yes

Abdomen:

Shape : Obese
Tenderness present on left lumbar area
No palpable mass
non palpable spleen
hernial orifices normal 
Non palpable liver
No free fluid (ascites) present 
No bruits
Bowel sounds: heard




Central Nervous System:

Conscious and Alert 
Speech: Normal

INVESTIGATIONS:
Biochemical investigations:


ECG:


2D-ECHO REPORT:



ULTRASOUND REPORT:




GRAPHIC SHEET :



PROVISIONAL DIAGNOSIS:
———






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