36 M PTB BILATERAL RENAL CALCULI

CHIEF COMPLAINTS 

36 YEAR OLD MECHANIC BY OCCUPATION FROM PASHAMAGODAVARI CAME TO UROLOGY OPD WITH COMPLAINTS OF SCANTY URINATION SINCE 2 WEEKS

HISTORY OF PRESENT ILLNESS

C/O LOSS OF APETITE, SCANTY URINATION, LOWER ABDOMINAL PAIN, GENERALISED WEAKNESS

NO H/O HEAMTURIA, GRAVELURIA K/C/O URINARY STONE

K/C/O HTN SINCE 2 MONTHS AND ON T. MET-XL 50 MG PO/OD AND T.TELMA 40MG PO/OD

K/C/O PULMONARY TUBERCULOSIS ON ATT SINCE 1 MONTH

CT-KUB (PLAIN) :

1. RIGHT KIDNEY - 8.4 X 3.9 - MULTIPLE CALCULUS LARGEST 8MM (900-1000 HU)

7MM MID (400-500HU)

7 MM LOWER POLE (450-500 HU)

2. LEFT KIDNEY 7.9 X 3.7 - 5MM UPPER POLE (650-700 HU)

5MM MID POLE (400-500 HU)

7MM LOWER POLE (700-800 HU)

URETER - SUBTLE SOFT TISSUE STANDINGS ANTERIOR TO AORTA AND IVC WITH MEDIA DEVIATION OF MID PORTION OF BOTH URETERS

PANCREAS SHOWS ATROPIC PARENCHYMA AND NOMPD DILATION AND NO URETERS

USG DONE ON 18-03-2024

RIGHT KIDNEY-8.2 X 3.3 CM E/O FEW CALCULI, LARGEST 4-5 MM IN MID POLE LEFT KIDNEY - 8.2 X 3.2 CM CMD PARTIALLY LOST E/O FEW CALCULI LARGEST 3-4 MM IMPRESSION-

LEFT GRADE 1 RPD CHANGES

LEFT RENAL CYST

BILATERAL RENAL CALCULI

DIAGNOSIS 

BILATERAL RENAL CALCULI WITH ?RETROPERITONEAL FIBROSIS WITH? CKD WITH PTB ON ATT EITH ?CHF

NEPHROLOGY REFERRAL WAS DONE ON 18/3/24 I/V/O HIGH CREATININE LEVELS AND WAS ADVISED 2 SESSIONS OF HEMODIALYSIS WITH UF-500ML FOR 2 HOURS GENERAL MEDICINE REFERRAL WAS DONE ON 20/3/24 I/V/O BP 180/70MMHG.

ADVISE: LASIX 40MG IV/STAT

CONTINUE SAME ANTI HYPERTENSIVE TREATMENT

PULMONOLOGY REFERRAL WAS DONE ON 20/3/24 IN/O CHEST X RAY CHANGES

ADVISE: CONTINUE ATT

ISONIAZID 5MG/KG OD

RIFAMPICIN 10MG/KG OD

PYRIZINAMIDE 25MG/KGTHIRCE WEEKLY

ETHAMBUTOL 15MG/KGTHIRCE WEEKLY

TAB. BENADON 40MG PO/OD

Investigation

COMPLETE BLOOD PICTURE (CBP) 18-03-2024

HAEMOGLOBIN 11.3 gm/di

TOTAL COUNT 9300 cells/cumm

NEUTROPHILS 72 %

LYMPHOCYTES 19 %

EOSINOPHILS 03 %

MONOCYTES 06 %

BASOPHILS 00 %

PLATELET COUNT 3.24

SMEAR MICROCYTIC HYPOCHROMIC

BT 2 MIN 00 SEC

CT 4 MIN 30 SEC

COMPLETE URINE EXAMINATION (CUE) 18-03-2024

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN +

SUGAR NII

BILE SALTS NiI

BILE PIGMENTS NiI

PUS CELLS 2-4

EPITHELIAL CELLS 3-4

RED BLOOD CELLS NiI

CRYSTALS NiI

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS NiI

HBsAg-RAPID Negative

Anti HCV Antibodies - RAPID Non Reactive

HIV 1/2 RAPID TEST NON REACTIVE

RFT 18/3/24

SODIUM 141 mmol/L

POTASSIUM 5.6 mmol/L

CHLORIDE 104 mmol/L

PHOSPHOROUS 8.5 MG/DL

UREA 284 MG/DL

CREATININE 9.2 MG/DL URIC ACID 8.6MMOL/L

FBS 101MG/DL

LIVER FUNCTION TEST (LFT) 18-03-2024

Total Bilurubin 0.86 mg/di

Direct Bilurubin 0.18 mg/di

SGOT(AST) 17 IU/L

SGPT(ALT) 13 IU/L

ALKALINE PHOSPHATASE 181 IU/L

TOTAL PROTEINS 6.7 gm/di

ALBUMIN 3.97 gm/di

A/G RATIO 1.45

TREATMENT DURING HOSPITAL STAY

OPERATIVE PROCEDURE:

UNDER SAP UNDER LA, PARTS CLEANED AND DRAPED IN LITHOTOMY POSITION, WITH 19FR CYSTOSCOPY AND B/L RGP DONE.

NO NARROWING OF COLLECTING SYSTEM NOTED;NO FILLING DEFECTS NOTED BELOW PCS;PROMPT CLEARANCE OF CONTRAST NOTED AFTER 5 MINS FOLLOW UP FLOROSCOPY.

B/L 5F/26 DJ STENT PLACED

16FR FOLEYS PLACED

INJ MAGNEX FORTE 1.5G IV/BD

TAB.PCM 650 PO/TID

TAB PAN 40 MG PO/OD BBF

TAB.LIMCEE PO/OD

TAB.NODOSIS 500 PO BD

CAP. BIO D3 PO OD INJ.PCM 1G IV/SOS

CONTINUE HTN MEDICATION

INJ TRAMADOL 1 AMPULE SLOW

ADVICE AT DISCHARGE

TAB.TAXIM 200 PO/BD X 1 WEEK

TAB.PAN 40MG PO/OD BBF X 1 WEEK TAB.PCM 650 PO/BD X 5 DAYS TAB.LIMCEE PO/OD X 10 DAYS

TAB.NODOSIS 500 PO BD X 1 MONTH CAP. BIO D3 PO OD X 1 MONTH TAB.MET XL 50MG PO OD TAB.TELMA 40MG PO/OD CONTINUE ATT

SYP.ALKASTONE B6 15ML IN 1/2 GLASS OF WATER PO/BD

Follow Up

R/A 1 WEEK TO UROLOGY OPD`