40M with Bilateral loin pain

  Hi, I am Presley C (roll no :96), 5rd semester medical student. This is an online E-log book to discuss our patient’s health data after taking his consent. This also reflects my patient-centered online learning portfolio.

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

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