A Case of Gross Bilateral Hydroureteronephrosis
Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centred online learning portfolio.
I will be looking forward to some feedback and valuable inputs through the comments box provided below.
I have been given this case 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, diagnosis and treatment plan.
CASE:-
A 45 year old female came to the OPD with complaints of reduced urine output from 1 week, easy fatiguability from one week and shortness of breath grade-IV from 3 days. She also had vomitings and pain in the lower back bilaterally.
HISTORY OF PRESENT ILLNESS:-
Before the illness, she was a daily wage labourer and also tended to duties at home like cooking, sweeping, doing the dishes, etc. She used to mostly dig dirt at work and lift heavy bags.
5 months back, she stopped working because it became increasingly difficult for her to work and she couldn't deal with the workload.
10 days ago, she started to feel pain in her kidney area and also had vomiting. This made her come to the hospital.
On 18th Feb, she underwent dialysis and, according to her husband, she became very breathless and the doctors had to attend to her immediately.
The patient's vomiting has reduced after staying in the hospital. Her appetite has reduced greatly and is mainly eating and talking only when her daughters and granddaughters come to visit her.
HISTORY OF PAST ILLNESS:-
History of undergoing haemodialysis for 3 sessions 1 year back. No history of diabetes mellitus, hypertension, tuberculosis, epilepsy, CVA.
TREATMENT HISTORY:-
No significant treatment history
PERSONAL HISTORY:-
Appetite: decreased
Diet: non-vegetarian
Bowels: regular
Micturition: normal
Habits: No habits/addictions
FAMILY HISTORY:-
No family history of diabetes, hypertension, heart disease, stroke, cancer, tuberculosis, asthma
PHYSICAL EXAMINATION:-
No pallor, icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy, pedal oedema
VITALS:-
Temperature: afebrile
Respiratory rate: 22/min
Pulse rate: 92/min
BP: 160/100mm Hg
SpO2: 99%
SYSTEMIC EXAMINATIONS:-
CVS: S1, S2 sounds heard
Respiratory system: BAE+
Abdomen: Shape is scaphoid, bowel sounds heard
CNS: The patient was conscious and alert with normal speech
DIAGNOSIS:-
CKD on MHD
B/L groin hydroureteronephrosis
B/L ureteric calculi
Post right sided DJ stenting
INVESTIGATIONS:-
15/2/2022
TREATMENT:-
CROSS CONSULTATION NOTES:-
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