Case : 30 year old male with c/o abdominal pain.

  Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

 -Ajitesh Racharla   07

-Aswin I  18


 CASE REPORT:

 A 30 year old male worker at a poultry farm by profession , resident of Nalgonda came to the causality with complaints of back pain radiating towards the abdomen region. On 12th June 2022


HISTORY OF PRESENT ILLNESSES:


Patient was apparently asymptomatic 3 days ago, the patient developed c/o pain at the abdominal region (left side) with many episodes of vomitings and loose motions , patient also presented with burning micurition and low urine output on 12th June 2022.

Patient visited a local physician on 12th June '22 and the physician prescribed him with around 6 antibiotics and suggested a scan at a hospital in Nalgonda.

The patient visited the hospital for a scan and reports showed a stone in the left kidney.

 No c/o fever cold or cough  


PAST HISTORY:


 Patient suffered with similar conditions in 2018 (4 years ago)

Tests reports showed increased creatinine values which was treated conservatively but there was a variation in the creatinine values regularly

11/5/2018 - 3.3 mg/d

12/5/2018- 4.4 mg/d

13/5/2018- 3.2 mg/d

14/5/2018- 2.5 mg/d

15/5/2018- 1.9 mg/d

15/6/2018- 1.4 mg/d

25/7/2018- 1.2 mg/d

An ultrasound scan of abdomen was taken on 12/5/18 .

Impressions-

Hepatomegaly

Right renal cortical cyst (BOSNIAK TYPE 1)

 No past h/o diabetes , HTN, tuberculosis, asthma.


 FAMILY HISTORY:


Patient reported there may be a similar condition in his grandfather


PERSONAL HISTORY:

 

Appetite decreased since the past 2 days

Diet - mixed

Bowel and bladder movements irregular since the past 2 days 

Micurition - burning micurition present


GENERAL EXAMINATION:


No Pallor/ icterus/ cyanosis/clubbing/lymphadenopathy/edema

 Abdomen distended.



CLINICAL IMAGES:










LAB FINDINGS:







PROVISIONAL DIAGNOSIS:

Large bowel diarrhoea??



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