A 32yrs old patient came to hospital with pains in the groin region

 Hi, I am anirudh manne (roll no :11)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

A 35yr old patient cement worker by occupation came to hospital with complaints of pain in the abdomen 

Chief complaints 

The patient has complained of severe pain in his abdomen which is right loin region radiating to groin from 5days and also loss of urine.

History of present illness

The patient was asymptomatic 1yr ago then he developed abdominal pain and went to hospital where he got diagnosed with renal calculi and took treatment and got relieved.

Then 5 days back he developed abdominal pain and went to a local hospital where he was given medication but the pain is not releived.

He came to the hospital with abdominal distention and loss of urine output.

He is passing loose stools

History of past illness

The patient did not complain of any fever and is not a known case of hypertension,diabetes,asthma.

Family history 

No significant family history.

General examination 

Conscious and coherent 

No pallor 

Icterus present

No clubbing of fingers 

No cyanosis 

No lymphadenopathy 

No poedal oedema 

Vital signs

Temp:99f

Pulse rate :76/min

Respiratory count:28 cycles per minute 

Bp:120/90

Spo2:98%

Systemic examination 

Cardiovascular system :

S1 and s2 sounds heard 

No murmurs 

 No thrills

Respiratory system :

Trachea central in position 

Breath sounds vesicular 

No wheezing sounds heard

Central nervous sysytem :

The patient is conscious 

Speech: normal

Reflexes :present

Investigations ordered

Haemogram 

RFT

LFT

ABG

Complete urine examination (CUE)

E.C.G

Blood urea 

Serum creatinine 

Usg

Results:












Provisional diagnosis 

post renal AKI secondary to ureteric caliculi

Medication





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