45 yr old female with hydroureteronephrosis & uretro canalculii

 


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


45 year old female patient came to OPD with c/o reduced urine output since 1 week,easy fatigabiility from 1 week and sob since 3 days and facial puffiness since 1 week.

 DAILY ROUTINE :

She is a daily wage labourer and she stopped working 3 years back because she would easily get tired. 
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
She didn't undergo hemodialysis or wasn't on any treatment for 1 year due to the COVID pandemic. 
1 week back, patient started experiencing reduced urine output and would easily get tired. She also told us that she noticed facial puffiness 1 week back. She also started feeling dyspneic after walking a few steps since 5 days, though it wasn't associated with any orthopnea, PND, chest pain, palpitations. Also no complaints of cough, wheeze.

PAST  HISTORY :
No h/o htn,dm,Epilepsy, asthma 

FAMILY HISTORY:No significant history 

PERSONAL HISTORY 
Appetite: normal
Sleep :decreased 
Bowel movements: normal
Bladder movements :decreased
No addictions 

HTpN 
General Examination:

Patient was a moderately built individual, with pallor  and facial puffiness 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy.





Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98% 
GRBS -116 mg/dl
 
SYSTEMIC EXAMINATION 

CVS: S1 S2 + heard
RS: B/L AE +
CNS :NAD
P/A: soft nontender non palpable masses 

INVESTIGATIONS 
BGT:positive








Serum creatinine-11.2 mg/dl (0.6-1.1mg/dl)



Serology: negative 
PROVISIONAL DIAGNOSIS 

.B/L GROIN HYDROURETERONEPHROSIS 
.B/L URETERIC CALCULI 
.POST RIGHT SIDED DJ STENTING 

TIME LINE
  ->

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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