Case 13 - A case of left hydronephrosis due to ureteric obstruction in a 67 year old male patient.

A case of left hydronephrosis due to ureteric obstruction in a 67 year old male patient.


Hi, I am R. Ramya Keerthana, 5th semester medical student. This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.

Case Scenario
A 67 year old man from Miryalaguda came to casualty on 2nd of June with chief complaints of:
- shortness of breath since 1 day
- fever since 1 day.

History of Presenting Illness
- patient was apparently asymptomatic 10 days ago when he suddenly lost consciousness while working
- since then he developed insidious onset of continuous fever associated with chills and rigors
- h/o SOB Grade 4 since 10 days 
- h/o loose stools 10 days ago, 4 episodes per day for 3 days, watery, foul smelling and without any trace of blood 
- h/o vomiting 10 days ago, 3 episodes per day for 3 days, non-projectile, bilious in one episode and the rest were non-bilious
- h/o burning micturition and reduced urine output since 8 months 
- h/o pain in the left lumbar region, which was sudden in onset, continuous, non-progressive, radiating towards groin, of squeezing type, not relieved on medication
- h/o itching 8 months ago for 2-3 days which subsided spontaneously 
- no h/o cough, headache, blurring of vision.

Past History
- k/c/o of Hypertension since 10 years on regular medication 
- he was diagnosed with multiple cysts in the right kidney 5 years ago for which he underwent surgery 8 months ago
- n/k/c/o DM, tuberculosis, CAD, epilepsy, asthma and thyroid disorders 
- no h/o blood transfusions.

Personal History
- married
- barber by occupation 
- mixed diet
- reduced appetite since 10 days 
- adequate sleep 
- irregular bowel movements
- reduced urine output since 8 months 
- no known allergies
- no known addictions

Family History
- Not significant

Drug History

General Examination
- patient was conscious, coherent and cooperative 
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no pedal edema 
- no malnutrition 
- no dehydration 


Vitals
04/06/23
- BP: 120/70 mm Hg
- Pulse rate: 117 bpm
- Respiratory rate: 28 cpm
- Temperature: 98.9°F
- SPO2: 90% at RA, 94% on 4L oxygen 
- GRBS: 128 mg/dL

05/06/23
- BP: 120/80 mm Hg
- Pulse rate: 94 bpm
- Respiratory rate:20  cpm
- Temperature: afebrile 
- SPO2: % at RA
- GRBS: mg/dL

06/06/23
- BP: 110/80 mm Hg
- Pulse rate:84 bpm
- Respiratory rate: 22cpm
- Temperature: afebrile 
- SPO2: % at RA
- GRBS: 110mg/dL

07/06/23
- BP: 110/70 mm Hg
- Pulse rate:76 bpm
- Respiratory rate: 20cpm
- Temperature: 101°F
- SPO2: % at RA
- GRBS: 110mg/dL

08/06/23
- BP: 80/50 mm Hg
- Pulse rate:74 bpm
- Respiratory rate: 20cpm
- Temperature: 99.6°F
- SPO2: % at RA
- GRBS: 120mg/dL

09/06/23
- BP: 110/80 mm Hg
- Pulse rate:78 bpm
- Respiratory rate: 19cpm
- Temperature: 98.1°F
- SPO2: % at RA
- GRBS:125 mg/dL


Fluid Intake and Urine Output
05/06/23
Total Input: 200 ml
Total Output: 200 ml

06/06/23
Total Input: 700ml
Total Output:850  ml


Fever Chart

Systemic Examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
- crepts heard during expiration 

Abdomen
- shape: obese
- no scars, striae, engorged veins
- tenderness present  in left lumbar region 
- bowel sounds heard
- no bruits, rubs
- no shifting of dullness
- no fluid thrill
- no palpable mass
- hernia orifices: normal 
- liver: not palpable 
- spleen : not palpable

Central Nervous System


Investigations

Treatment 

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