50 year old female suffering from left sided PUJ obstruction seeking health experts help

Albizia chinensis 

This is a de-identified open-online-patient-record with initial information from Doctors notes, diagnostic test results as well as patient's voice. Posted here after collecting informed "Patient Concent" (downloadable here) by Community Health Worker Debasish Acharjee from pin-code-area 736 for discussion.

Name of Patient: albizia736chinensis04

This is a case of 50years-old-lady who is suffering from abdominal pain, fever and vomiting since last  2 weeks. Treatment advice of local physician did not response, except recovery from fever. USG of whole abdomen detected “ Left sided mild hydronephrosis with pyelonephritis”. X-ray of KUB showing a radio opaque shadow on right side of pelvis.

1. Prescription of Physician
2. USG Whole Abdomen Image
3.  USG Whole Abdomen Report
4. X Ray KUB Image
5. X Ray KUB Report
6. Haematology
7. Clinical Pathology Urine
8. Biochemistry

Consultant Urologist  advised
Tab Nitrofurantoin 100mg 1 tab twice after meal x 5 days
Tab Tamsulosin 0.4 mg, 1 tab at bed time X 10 days
Tab Pantoprazole 40 mg + Domperidone 30 mg, 1 Cap daily before breakfast X 10 days
Suspension Aluminium hydroxide + Magnesium hydroxide + Oxethazaine, 3 tea spoon full three times before meal X 7 days
USG of Lower abdomen
Urine C/S test
Blood for Urine, Creatinine

1. Prescription of Urologist Page 1
2. Prescription of Urologist Page 2

 

USG lower abdomen detected “ Left sided PUJ obstruction and increased residual urine. 

1. USG Lower Abdomen Image
2. USG Lower Abdomen Report

With suggested medication, nothing improvement achieved.

Patient seeking health experts’ treatment advice.

Thank you
Debasish Acharjee
Community Health Worker

Update
May 15, 2016
Current Medications: 
1. Syrup Lysine + Vitamin B 1,2,3,6,12 (LysiconV), 2 teaspoon full twice before meal for 20 days
2. Cap Pantoprazole 40mg + Domperidone 30mg (Pantocid DSR), 1 cap once daily before breakfast for 30 days

Diagnostic or imaging tests:
Intravenous Urography X-Ray Report: Findings are suggestive of left sided pelviureteric junction obstruction and hydronephrosis.
Intravenous Urography X-Ray Image 1
Intravenous Urography X-Ray Image 2 
Prescription of Consultant Urosurgeon
Urine CS Test
Chemical Pathology

Thank you