60yr old male with Cholelithiasis with AKI on CKD with k/c/o type 2 Diabetes mellitus with hypertensive urgency..

This is an online E log book to discuss our patients deidentified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients 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 box is welcome.

Here is a case I have seen
60 yr old male presented on 5/3/21 to casualty with 
C/o pain in the right hypochondrium from 3 days
C/o decreased urine output from 1 day
C/o vomitings from today morning

Patient was apparently asymptomatic 3 days ago then he developed pain in the right hypochondrium which was colicky type, continuous, with no aggravating and relieving factors.
Patient had 2 episodes of vomitings, non bilious, non projectile. 
Patient has c/o urinary retention from 1 day for which foleys catheterisation was done in a private hospital. 
No h/o fever, loose stools, burning micturition.
No h/o blurring of vision, headache.
No h/o chest pain, palpitations, shortness of breath.
K/c/o DM from 6 yrs and on Inj. INSULIN MIXTARD.
Not a k/c/o HTN, Asthma, thyroid disorders, TB, CVA, CAD. 

O/E
Patient c/c/c
BP- 230/110 mmhg
PR- 106 bpm
SpO2- 99% @ RA
CVS- S1S2 +
RS- BAE +,  no crepts
PA- 
Inspection- 
Abdomen shape- scaphoid
Umbilicus- central, inverted. 
No visible scars or sinuses.
No visible peristalsis.
All quadrants moving equally with respiration.
Palpation- 
Soft
Tenderness present in the right hypochondrium 
Murphy’s sign +
No organomegaly 
No guarding 
No rigidity
CNS- NAD.

Investigations:
Urea- 107 mg/dl
Creatinine-5.8 mg/dl

USG-
1. B/L kidneys grade 2-3 RPD changes.
2. B/L renal cysts.
3. Cholelithiasis with gall bladder sludge.

Provisional diagnosis
Cholelithiasis with AKI on CKD with k/c/o type 2 diabetes mellitus with hypertensive urgency

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