KURSK STATE MEDICAL UNIVERSITY DEPARTMENT OF SURGERY

CASE HISTORY
Patient Age Sex Date of Admission : ANNA VLADHIMIRAVNA : 49 years old : Female : 09-10-2011

Primary Diagnosis : Nephrolithiasis, Stone in Left kidney Clinical Diagnosis : Stone in Left kidney Complication :

Name: Shobika Raviraj Group: 05 Course: 4th Year 1st Sem

KURSK-2011

Identification of Patient
Name Age Sex Nationality Occupation Address : Anna Vladhimiravna : 49 years old : Female :Russian :Cleaner :Kursk

Marital Status : Married Date of Admission Room No. : 09-10-2011 :04

Chief Complaints
The patient complains of pain. Localization of the pain was at the left inguinal region. Radiation of pain was towards the middle near the umbilicus. Pain is characterized as intensive. Pain lasted for few minutes, constant. Severity of pain decreased after urination. Pain also decreased after amplipulse therapy at the hospital.

Anamnesis Vitae
She has never had major illness. She has never been hospitalized. Her ovary had been removed. Patient never underwent any blood transfusion before this. She had no history of allergies. She does not smoke. She does not drink alcohol Patient has no history of veneral diseases, TB. Patients parents are not alive. Patients children are healthy.

Anamnesis Morbi
Patient started having pain on the 08-10-2011. Pain lasted for few minutes. Severity of pain was constant. Pain was at the left inguinal region and radiated towards the urinary bladder. She was admitted on 09-10-2011 with initial diagnosis of stone in left kidney.

Subjective Examination
Respiratory System: Breathing through nose easily. No rasping and dryness feeling in the throat. Absent of cough, sputum, and hemoptysis and dyspnoea. Cardiovascular System: Regular heart beat, no symptom of palpitation or pain in cardiac region. Absence of edema Digestive System: Appetite is normal. Distinguish tastes: normal No dryness in the mouth Chewing food: Normal Swallowing is normal Passage of food: normal No pain in the abdomen Flatulence is absent. No constipation, no bleeding, no pain, no anal itching No diarrhea. Feces: Fatty grey colored stool with no mucous, no blood, no undigested food. Urinary System: Pain in the left inguinal region radiating to lumbar region Skin: Not icteric, no itching .skin is normal. There are no ulcers. No bruises and no abnormal sweating. There are no rashes and normal pigmentation on both hands. Lymphatic System: No enlargement of any lymph nodes Osteomuscular System: Joints and bones are normal.. No muscles pain, no trembling, no convulsions. Nervous System: Normal and memory sleep. No paresthesia, no sensation of numbness, no fever, no prickling, no blurring of colors Organs of sense: Vision: Normal Audition: Normal Smell: Normal Taste: Normal Touch: Normal

OBJECTIVE EXAMINATION
GENERAL INSPECTION: General condition: Satisfactory Show: Confirms to age Consciousness and Alert stages: Posture: Normal Face: No specific face Nutritional state: Good Skin and mucous Normal color of the skin, not icteric, no rashes membranes: . PALPATION Skin: Normal turgor, mild dryness in the skin Nails: Normal Hair: Normal Subcutaneous Normal, no subcutaneous emphysema, symmetrical fat: distribution of fat Lymphatic No enlargement of lymph nodes system: Muscles: Symmetrical, no pain, no weakness, no convulsions, no tremor Bones: No deformities, no clubbing of fingers Joints: Normal size, skin is normal over the joints, normal temperature, no pain during palpation Movement: Active, no difficulty in movement. Head: Normal size and form of skull, no scars, no tremor Nose: Normal form. Septum is normal and there is no deviation. Participates in respiration Eyes: Normal, no enophthalmus or exophthalmus Lids: No edema, no ptosis. Sclera: white. Conjunctiva: normal. Cornea: no scars, no ulceration. Pupils: normal. Vision: Normal. Neck (thyroid No enlargement gland):

RESPIRATORY SYSTEM: General inspection: Type of respiration: Surface palpation: Normal form , symmetrical, no deformation Abdominal breathing Not painful, no fractures of ribs, sternum is normal, intercostals spaces are normal, vocal fremitus: normal Comparative percussion- resonance sound Topographic percussion Altitude of apex- 3.5 cm above from the upper border of clavicle. 4cm laterally from the 7th cervical vertibra-posteriorly. Kronigs isthmus- 4cm in right and 5cm in left. Lower border of lungsLine Parasternal Midclavicular Anterior axillary Mid axillary Posterior axillary Scapular Paravertibral Right lung 5th interspace 6th rib 7th rib 8th rib 9th rib 10th rib T 11- spinous process Left lung 7th rib 8th rib 9th rib 10th rib T 11- spinous process

Percussion:

Traubes space is not diminished Lung mobility- mid axillary 6cm mid clavicular 4cm scapular 4cm Auscultation: vesicular breathing Absent of rales or cripitation Absent of wheezes or rhonchi

CARDIOVASCULAR SYSTEM Inspection: No abnormality revealed in the region of the heart: no cardiac humpback, normal apex beat. Region of the neck: Normal Trachea: Position : In the midline, no lagging Peripheral artery Normal pulsation: Epigastric pulsation: Abdominal aorta pulsation absent Palpation: Apex beat palpated in the 5th ICS 1 cm laterally from the left margin of sternum. Aortal palpation and Normal pulmonary artery palpation: Configuration of the Normal configuration of heart heart: Relative Absolute dullness dullness Right 1cm right to the Left margin of border right margin of the sternum the sternum Apex 1.5cm medially 2cm medially from from midclavicular midclavicular line line rd Upper 3 rib 4th rib margin Vessel bundle:- 4cm; Transverse diameter of heart 13cm. Auscultation: Normal heart sounds without murmurs, gallop rhythm No Duroziers double murmur or Traubes double tone Hypertension(systolic pressure=160mm of Hg)

Arterial pressure:

GASTROINTESTINAL SYSTEM Inspection Oral cavity: Normal odour without acetone smell, fetor hepaticus, putrefactive or urine smell Gums: Normal pinkish color without pigmentation, ulceration and pyosis Mucous membranes: No ulcers, no pigmentation Tongue: Normal size, color, dryness clean without pathological features Tonsils: Normal size, color& texture Abdomen: Normal size, without retracted belly or frog belly. Its symmetry without diverticulus, there are no striae, pigmentation or scars. Umbilicus is normal, not intruded. Surface abdominal Not painful, no muscle tension over the region of palpation: projection of the gall bladder and no hernias Palpation of intestine: Sigmoid: Caecum: Ascending colon: Transverse colon: Descending colon: Stomach Liver: Spleen: Murphys sign Mussys sign Rebound sign Not palpable due to subcutaneous fat Palpable, painless, rumbling with passive mobility of caecum Not palpable Palpable, easily movable, painless and silent Not palpable Not palpable Not palpable Not palpable Negative Negative Negative

NERVOUS SYSTEM: Patients vision is satisfactory. No abnormalities in orbital movements. Both pupils are reactive to light at same degree. patients hearing is satisfactory. No abnormal twitching movements are observed. Knee reflex, triceps reflex, biceps reflex, ankle reflex and planter reflexes are positive. No areas of anaesthesia or paraesthesia in body. URINARY ORGANS: Inspection of lumber Normal, No edema, no redness region Percussion Paternatsky symptom. Positive Palpation Painful., No swellings or abnormal structures can be palpated Kidney displacement: No displacement of the kidney. Normal size and form of the kidneys Urinary bladder: Not palpable

Initial Diagnosis
Stone in left kidney

PLAN OF INVESTIGATIONS
1. 2. 3. 4. 5. Full blood test and urine analysis Biochemical analysis Ultrasound Urography ECG

LABORATORY Urine Analysis Urine colour Gravity Protein Leucocytes Erythrocytes Epithelial cells Total blood Test Hemoglobin Erythrocytes Color Index Leucocytes Lymphocytes Monocytes Segmented neutrophils Band Nuclei 126 4.1 x 1012 1.0 6 x 109 25% 3% 62 4 Cloudy 1.013 0.6g/l 1.2 6-8 9-10

Biochemical analysis Nitrogen Creatinine Common Protein Common Billirubin 7.7 (2.5-8.3) mmol/l 84 (44-100) mkmol/l 78 (65-85) g/l 10.8 (8.5-20.5) mKmol/l

INSTRUMENTAL Plain X-ray Abdominal X-ray shows oval shape suspicious shadow of stone in the left kidney. Urography Exretory urography. 1st degree hydronephrosis of left kidney. Contrast stop at shadow at left kidney. Ultrasound Parenchyme 1.8cm on both sides. Uretherohydronephrosis on 2nd degree on left side. Right no obstruction. ECG ECG shows normal.

Complete diagnosis
Stone in Left Kidney.

EPICRISIS
Patient was admitted to the hospital on 09-10-2011 with the symptoms of pain in the left inguinal region. General blood analysis, biochemical analysis and general analysis of urine were done on the same day. The disease was diagnosed as stone in left kidney.

Treatment
1) Antibiotic-Cephataxin (1g twice a day) 2) Infusion therapy 3) Analgesic(boralhin) 4) Heparin