45 yr old female with B/L groin hydroureteronephrosis,B/L ureteric calculi ,Post right sided DJ stenting

45 year old female patient came to OPD with c/o reduced urine output since 1 week,easy fatigabiility from 1 week and sob since 3 days and facial puffiness since 1 week.

She is a daily wage labourer and she stopped working 3 years back because she would easily get tired. 
1 year back she experienced severe right loin pain along with reduced urine output and generalized anasarca. 
She underwent right DJ stenting and also 3 sessions of hemodialysis
She didn't undergo hemodialysis or wasn't on any treatment for 1 year due to the COVID pandemic. 
1 week back, patient started experiencing reduced urine output and would easily get tired. She also told us that she noticed facial puffiness 1 week back. She also started feeling dyspneic after walking a few steps since 5 days, though it wasn't associated with any orthopnea, PND, chest pain, palpitations. Also no complaints of cough, wheeze.
General Examination:

Patient was a moderately built individual, with pallor  and facial puffiness 
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy.

Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98% 
GRBS -116 mg/dl
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender 

Diagnosis:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 


Investigations:

BGT: B positive 
Serology: negative

  17/2/2022

Right kidney:

Left kidney:
Not visualised
19/2/2022:

22/2/2022

23/2/2022

Plan of treatment :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. Tab NODOSIS 500 mg PO BD
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. MONITOR VITALS



SOAP NOTES

ICU BED 4 18/2/22

S:
NIL URINE OUTPUT SINCE LAST HEMODIALYSIS

A:

Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:
PR- 80 bpm
BP- 130/70 mmHg
RR- 22 cpm
SpO2- 98% 
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
 

A:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

P :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD


SOAP NOTES

AMC BED 3

19/2/22

GENERALISED WEAKNESS
vomitings 6-8 episodes /day since after dialysis ,
Hypoglycemia post that, 
Decreased intake of food

S:
C/O generalised weakness

A:

Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:
PR- 87 bpm
BP- 150/90 mmHg
RR- 22 cpm
SpO2- 98% 
GRBS - 166
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
 

A:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

P :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO OD
7. Tab SHELCAL PO OD
8. INJ PIPTAZ 2.25 gm IV TID

http://vikyatsarvagna.blogspot.com/2022/02/45-yr-old-female-with.html

SOAP NOTES

AMC BED 3

20/2/22

S:
C/O generalised weakness

A:

Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:
PR- 82 bpm
BP- 140/80 mmHg
RR- 21 cpm
SpO2- 98% 
GRBS - 90mg/dl
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
 

A:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

P :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO
 OD
7. Tab SHELCAL PO OD
8 plan for DJ stent removal


SOAP NOTES

AMC BED 3

21/2/22

S:
 No further episodes of vomiting s

A:

Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:
PR- 104 bpm
BP- 120/80 mmHg
RR- 21 cpm
SpO2- 98% 
GRBS - 90mg/dl
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
 

A:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

P :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO
 OD
7. Tab SHELCAL PO OD
8 plan for  DJ stent removal


SOAP NOTES

 D WARD

23/2/22

S:
 Pain in the lower abdomen

A:

Patient was C/C/C
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema

Vitals at admission:
PR- 92 bpm
BP- 120/80 mmHg
RR- 21 cpm
SpO2- 98% 
GRBS - 90mg/dl
CVS: S1 S2 +,
RS: B/L AE +
P/A: soft nontender .
 

A:
 B/L groin hydroureteronephrosis 
B/L ureteric calculi 
Post right sided DJ stenting 

P :

1. INJ. LASIX 40 mg IV BD
2. INJ PAN 40 mg IV OD 
3. INJ ZOFER 4 mg IV OD
4. INJ erythropoietin 4000 IU SC once weekly
5. MONITOR VITALS
6. Tab OROFER XT PO
 OD
7. Tab SHELCAL PO OD
8 Urology plan : 
Is to remove the displaced DJ stent along the renal stones and place the other one on right side after decreasing the creatinine values
9. Tramadol 1 mL (50 mg) in 100 mL NS

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