Renal calculi, shrunken kidney case

General Medicine E-log

A 35 year old female came to the hospital with pain in the abdomen and lower back.

Date of admission: 13/07/21

Chief complaints:

A 35 year old female presented to the OPD with chief complaints of abdominal pain since 3 years and pain in the lower back since 6 months.

History of present illness:

The patient was apparently asymptomatic 3 years ago when she started experiencing pain in the right lumbar region, radiating to the back.

She also had complaints of pain in the right upper thigh region and burning micturition.

On visiting a local hospital, it was found that she had 2 renal calculi in her right kidney. She had recieved medication that reduced her pain.

She has also been experiencing intermittent fever.

For the past 6 months, she has been experiencing the same pain. On visiting a hospital, it was found that she had a small right kidney with 2 renal calculi.

She has been on conservative treatment ever since.

She also complained of experiencing intermittent headaches followed by vomiting since the past 3-4 months.

History of past illness:

She is a known case of renal calculi.

She is not a known case of HTN, DM, CAD, CVA, Epilepsy, TB, Asthma or Thyroid disorders.

Personal history:
She is a resident of west Bengal.

Occupation: housewife

Marital status: married with 3 children (1 son amd 2 daughters)

Appetite: normal

Diet: mixed

Bowel and bladder habits: regular

Drug history:

Patient had been on conservative treatment for renal calculi for the past 6 months.

Family history:

No significant family history.

Obstetric history:

She has 3 children (1 son and 2 daughters)

Her menstrual cycles are normal but with reduced flow since the past 5 months.

General examination:

Patient is conscious, coherent and co-operative.

Mild pallor is present.

No icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy, edema is seen.

Vitals:

PR: 120 bpm

SpO2: 98%

Systemic Examination:

CNS:

Speech: normal
No signs of meningeal irritation
Motor & sensory system: normal
Cranial nerves: intact

CVS:

S1, S2 were heard

No Murmurs
No thrills

Respiratory system:
NVBS heard
No added sounds

Per Abdomen:

Tenderness in right lumbar region.

Investigations:

ECG

13/07/21

CBP

13/07/21

Haemogram

13/07/21

LFT

13/07/21

RFT

13/07/21

CUE

13/07/21

X-Ray scan

Bacterial culture and sensitivity report 

13/07/21

RBS

14/07/21

Bleeding and clotting time

14/07/21

Prothrombin time 

14/07/21

Provisional diagnosis: 

Right renal calculi with shrunken right kidney and recurrent UTI.

Treatment given (present course in the hospital):

13/07/21

1. Tab. MYOSPAS PO/OD

2. Inj. OPTINEURON  NS/IV/OD 

3. BP, PR, RR, Temp monitoring.

14/07/21

1. Tab. MYOSPAS PO/OD

2. Inj. OPTINEURON  NS/IV/OD 

3. BP, PR, RR, Temp monitoring.

15/07/21

1. Tab. MYOSPAS PO/OD

2. Inj. OPTINEURON  NS/IV/OD 

3. BP, PR, RR, Temp monitoring.

16/07/21

1. Tab. MYOSPAS PO/OD

2. Inj. OPTINEURON  NS/IV/OD 

3. BP, PR, RR, Temp monitoring.