RIGHT PROXIMAL URETERIC CALCULI WITH RECCURENT HYPOGLYCEMIA 2° TO (?) OHA RIGHT LOWER LOBE PNEUMONIA RESOLVED

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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment

CHIEF COMPLAINTS:

A 47yr old male patient came to OPD with 
C/o colicky type of pain @ Right loin relays to back region 

HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10-15years back then he developed pain abdomen for which he was told some swelling in the abdomen. He underwent surgery for the swelling and it was excised. 3 years back he developed pain abdomen and vomitings and was diagnosed with cholelithiasis. Cholecystectomy was done at a local hospital. Now since 8 days patient had right loin pain, sudden, colicky type associated with intermittent  fever, burning micturition, decreased urine output for which he went to a local hospital he was told he has right ureteric stones. 4 days back patient visited another hospital with old reports for second opinion, then incidentally had FBS -89, PLBS - 240 then he was started on OHA's for 3 days following which he stopped OHA's as he developed  Hypoglycemia. 

PAST HISTORY:
Not a K/C/O DM, HTN, TB, Asthma, COPD

PERSONAL HISTORY:
Diet - Mixed 
Appetite- Normal
Bowel and Bladder - Regular
Addictions - Alcohol twice a month 90ml (whiskey)

FAMILY HISTORY:
Not Significant

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative 
Vitals:
BP - 110/70mmHg
PR - 82bpm
SpO2 - 98% on RA
RR - 18cpm

 No Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema

SYSTEMIC EXAMINATION:
CVS - S1, S2 +, No murmurs
RS - BAE + , NVBS heard
P/A - Soft, Non-tender
CNS - NAD

PROVISIONAL DIAGNOSIS:
RIGHT PROXIMAL URETERIC CALCULI WITH MILD RIGHT HYDRONEPHROSIS WITH RECCURENT HYPOGLYCEMIA 2° TO ?OHA

FEVER CHART:
INVESTIGATIONS:
HEMOGRAM:
HB - 11.3gm/dl
TLC - 35000/cumm
PLT - 1.62lakh

CUE:
SERUM CREATININE













TREATMENT GIVEN UNTIL NOW:
1) IVF 25% DEXTROSE  100ml/hr slow IV over 1 hour
2) IV FLUIDS NS, RL & DNS  @75ml/hr
3) INJ. OPTINEURON 1amp in 100ml  NS/IV/OD
4) INJ. PAN 40mg IV/OD
5)INJ. ZOFER 4mg IV/OD
6) INJ. PIPTAZ 2.25gm IV/TID
7) FOSFOMYCIN SACHET 3gm in 100ml water OD once in 2 days for 3 doses
8) TAB. AZEE 500mg PO/OD
9) TAB. SPOROLAC 2 tabs/TID




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