A 45yr old female patient came to OPD with cheif complaints of reduced urine output and difficulty in breathing since 3 days.

45 yr old female with B/L groin hydroureteronephrosis,B/L ureteric calculi ,Post right sided DJ stenting






February 17-2022

This is an online elog book to discuss our patient's deidentified health data shared after taking her or guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

This Elog also reflects my patient centre's online learning portfolio and valuable inputs on the comment box is welcome. 

Case-
45 year old female patient came to OPD with c/o reduced urine output since 3days and difficulty in breathing since 3 days.

HOPI-
Patient was apparently asymptomatic before a year then she had no urine output since 3days.

Sob- which is grade-IV, gradually in onset,gradually in progression,no positional variations and no aggregating and relieving factors.

Vomitings- 3 to 4 episodes a day, which is sometime after taking food, greenish in colour.

H/o loin pain and nausea is seen.
No h/o fever,body pains and joint pains.

Past history-

1 year back she experienced severe right loin pain along with reduced urine output and generalized anasarca. 
She underwent right DJ stenting and also 3 sessions of hemodialysis.
Then on improvement she stopped dialysis.

She not a known case of diabetes,HTN,TB, epilepsy,asthma.

Family history- not significant.

Personal history-
Appetite-reduced
Diet-mixed
Bowel- not regular and decreased
Bladder- no urine pass out
No allergies
Sleep- adequate

General examination-

Patient is examined with informed consent , moderately nourished and moderatly built , patient is conscious coherent and cooperative well orientated to Time place person.

Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98% 
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .

Investigation:

BGT: B positive 
Serology: negative

Diagnosis:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

Clinical images :


Plan of treatment :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. Tab NODOSIS 500 mg PO BD
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. MONITOR VITALS

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