42 yr old male


This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Pt is a 30 yr old male who is a resident of west bengal and a shopkeeper by occupation 
Who has come with chief complaints of left Flank pain since past 15 days.

HOPI
Pt was apparently asymptomatic 10yrs back then he developed pain in the lower abdomen and lower back for which he went to local doctor, was investigated and was found to have renal calculi for which he underwent surgery 10 yrs ago.

 5 yrs later - devloped left flank pain, burning micrurition for which he came to kamineni hospital and used medication for 4y

5 months back - had similar complaints and was treated at local hospital 

15 days back
Pain in left flank Which is intermittent, is of dragging type and increases on exertion and relived on consumption of medication, rest.
Pain is associated with nausea, vomiting and reduced urine output.
 he also has complaints of burning micrurition since past 15 days 


Past history
he is not k/c/o of DM HTN TB asthma and epilepsy.

Appetite:reduced 
Diet: mixed 
Bowel and bladder:regular 
Sleep: reduced 
No significant family history
No addictions 


On admission.
Patient is conscious coherent cooperative 
BP: 110/80mmhg
PR:86
RR: 20 cpm
Temp: afebrile 
CVS:S1 S2+
RS: BAE+ 
CNS: NAD
Speech normal 
REFLEXES-
                        RT. LFT
BICEPS- ++. ++
TRICEPS-. ++. ++
SUPINATOR-. ++. ++
ANKLE. -. ++. ++
KNEE-. ++ ++


Investigations



CT kub 


Radioisotope renogram 

Surgery was done on 27th
As Patient shifted to OT he was catheterised . Immediately 300ml of PUS drained into urobag. Then started with incision. Intra op they found few adhesions and pus in the kidney. So did nephrectomy and now patient is stable. 

2 units of blood given intraoperatively.
Stone sent for analysis

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