64yr old male with obstructive uropathy
A 64 yr old male resident of chotuppal came with chief complaints of pain in the right loin, vomiting and burning micturition since one month
HOPI
Patient was apparently asymptomatic 15 yrs back.Then he developed pain in the right loin and was diagnosed with renal calculi and was operated and then 3 yrs later again he developed bilateral loin pain and was diagnosed with bilateral renal calculi 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 ventral hernia and a mesh was placed.
Then 1 yr later he developed abdominal pain and endoscopy was done and diagnosed with intestinal 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 was low and was given iron injections.
Then since 1 month he developed loin pain , vomiting and burning micturition
DAILY ROUTINE
Patient wakes up around 5 am and takes breakfast at 7 and lunch around 12 pm and dinner at 8 pm and sleep around 9 pm.Rest of the time he spend with his grand children
PAST HISTORY
There were similar complaints in the past
History of diabetes and hypertension since 5 yrs
History of surgeries for renal calculi and ventral calculi
PERSONAL HISTORY
Diet :mixed
Appetite: decreased
Sleep: adequate
Bowel: regular
bladder: decreased flow and burning micturition
Addictions :occasionally alcohol
FAMILY HISTORY: No significant family history
DRUG HISTORY: No history of drug allergy
GENERAL EXAMINATION
Patient was conscious coherent and cooperative
Well built and well nourished
No pallor
No icterus
No clubbing
No cyanosis
No edema
Vitals
Temperature Afebrile
PR:60 bpm
BP
RR:16cpm
GRBS
SYSTEMIC EXAMINATION
CVS :s1 S2 heard no murumurs
RS :BAE normal vesicular breath sounds heard
GIT :soft and non tender,bloating and distension.
CNS :No focal neurological deficit
Investigations
DIAGNOSIS
Obstructive uropathy with Acute kidney injury
Treatment-
Treatment on 27/07/2022
Tab.Lasix 40 mg oral BD
Tab.Nodosis 500 mg oral BD
Tab.Shelcal 500 mg oral BD
Tab.Orofer oral OD
Tab.nicardia 20 mg oral BD
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