40M with Bilateral loin pain

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve 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 and come up with diagnosis and treatment plan.

Chief Complaints:

Bilateral loin pain since 3days.

History Of Presenting Illness:

Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically. 

C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down.

C/O low grade fever,Nausea and vomiting,bloating.

N/C/O Burning Micturation,decreased or increased urine output.

N/C/O cough,cold,body aches,chest pain.

Past History:

N/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions: chronic alcoholic since 20years.

Tobacco smoking since 20years.

Family History:

Not significant 

General physical examination:

Patient is conscious ,coherent,cooperative and well oriented to time, place and person.

Well built and nourished.

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

Vitals:

Temperature - 98*F

PR :- 98beats per minute 

BP :- 130/100mm Hg

RR:-18 cycles per minute

SpO2-98%

Systemic examination:

Per Abdomen:

Shape of abdomen-distended

Umbilicus -inverted

Abdomen moves accordingly with respiration.

 No sinuses/scars

Swelling in left lumber region

Abdomen is soft,tenderness in bilateral loin region.

Lipoma measuring 6x4x3cm associated with pain.

No free fluid

Hernial orifices-Normal

No organomegaly

Bowel sounds- present 

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

Measurements 

AP diameter-16cms

Transverse -26cms 

Tactile vocal

Fremitus                   Right              Left

Supraclavicular          N                  N

Infraclavicular           N                   N

Mammary                   N                   N

Inframammary          N                   N

Axillary                        N                   N

Infraaxillary               N                    N

Suprascapular           N                    N

Infrascapular            N                     N

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary               NVBS             NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary            NVBS              NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

Conscious

Cranial nervers -normal

Tone                 Rt                  Lf 

UL                     N                   N

LL                      N                   N

Power               Rt                  Lf

UL                    5/5                 5/5

LL                     5/5                 5/5

Fine touch       Rt                  Lf 

UL                     N                   N

LL                      N                   N

Reflexes.          Rt.                 Lt

Biceps               ++                 ++

Triceps             ++                  ++

Supinator        ++                  ++

Knee                 ++                  ++

Ankle                ++                  ++

Investigations:

Liver Finction test:

Total bilirubin-0.69mg/dl

Direct bilirubin-0.16mg/dl

SGOT-18IU/L

SGPT-25IU/L

Alkaline phosphate-234

Total proteins-7.3g/dl

Hemogram:

Hemoglobin-14.8gm/dl

Total count-15000cells/m3

Platelets:2.5L

CT:2min 30sec

BT:4min 30sec

Renal function test:

Urea-68mg/dl

Creatinine-3.4mg/dl

Chloride-108

Sodium-137

Potassium-4.8

CUE:

Albumin-nil

Sugars-nil

Pus cells-2-4

Rbc- nil

Epithelial cells-2-3

Rbs-94mg/dl

USG ABDOMEN:

Right renal cyst.

https://youtube.com/shorts/OTFTWR5EK4I?si=6Dyfc2qnpWKSP_-Y

Provisional diagnosis:

Acute kidney injury with h/o snake bite.

Treatment:

Inj Optineuron 1ampoule in 1500ml NS IV/OD

Inj Zofer 4mg IV/SOS

Inj Tramadol 100mg in 100ml NS IV/SOS

IV Fluids @NS 75ml/hr