general medicine blog 3

I am G sravanthi of 3rd semister
This is an E log book to discuss our patient health data
Cheif complaints : A 64 year old male came with a cheif complaints of pain in the right loin since 1 month and vomitings since 1 month .
HOPI : patient was apparently asymptomatic 10 years ago ,then he developed pain in the right loin for which he diagnosed to be having renal stones and got  operated for it . After 3 years he developed bilateral loin pain and diagnosed to be having bilateral renal stones and got operated for it. After 3 years he had a midline swelling and got operated for it. Then after a year he got diffused abdominal pain he went to hospital and endoscopy was done and diagnosed it as intestinal ulcer and managed conservatively . At that time he was also diagnosed with hypertension and diabetes mellitus.  and since 1 month abdominal pain in right loin and vomitings.
Personal history : 
Married 
Farmer 
Appetite : normal 
Nonveg 
Bowel : regular 
Micturation : normal
No known allergies.
Habits: occasional alcohol.
No other habits
No Family history.
Drug history: 
General examination:
Conscious and coherent
No pallor 
No icterus
No cyanosis
No clubbing of fingers
No edema
No malnutrition.
Systemic examination: 
Abdomen 

Shape of abdomen-scaphoid 

Tenderness-no

Palpable mass-no 

Hernial orifices-normal

Freefluid-no 

Liver-not Palpable 

Spleen-not Palpable 

Bowel sounds-no

Cns

Conscious 

Speech -normal 

Cranial nerves-normal 

Sensory system-normal 

Motor system-normal 

Reflexes-normal 

Cerebral signs-normal 

Finger nose in coordination-yes 

Knee heel in coordination-yes

Investigation : 

diagnosis: obstructive uropathy and acute kidney infection

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