29 year old male with VISCERAL metabolic syndrome

 Rambai 

Roll no 89 

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

 This is a case 26 year old male, farmer by occupation resident of coochbihar came for regular follow up.

HOPI : 

Patient was apparently asymptomatic until 2 years ago then he had sudden onset of severe pain in  left loin  region, squeezing type of pain, non radiating , aggravated on lying down , decreased in intensity on activity ,pain was associated with burning micturition.

No h/o  decreased urine output, increased frequency, or painful urination.

No h/o nausea and vomiting.

Patient went to local hospital and got admitted, conservatively managed and discharged next day. Used medications (unknown) for three months and switched to homeopathy for three months.

USG in 2021 showed calculus at left vesicoureteric junction with mild hydronephrosis and hydroureter. Cystitis.

Past history : 

H/o calculus at left vesico ureteric junction .

Personal history: 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder - regular

Occasional alcoholic 180ml 3-4times/month since 2 years

Occasionally consumes chewing tobacco 

Family history: 

Elder brother who lives under same roof had history of calculi in 2022

On examination 

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing, cyanosis,lymphadenopathy ,edema 

Vitals : 

BP 140/90mmhg

PR 88bpm

Spo2 99% at room air 

GRBS - 92 mg/dl

Temperature 98.6F 

Systemic examination : 

Cvs: s1,s2 heard 

Rs: BAE present ,NVBS

P/A: soft, non tender 

CNS:

Pt is conscious, 

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

Gcs: E4,V5,M6

Reflexes:

       R       L

 B  ++      ++

 T  ++      ++

S  ++     ++

K  ++     ++

A  ++     ++

P Flexor  Flexor   

Urology referal was taken i/v/o past urolithiasis 

INVESTIGATIONS  

Previous investigations 

PROVISIONAL DIAGNOSIS:

VISCERAL OBESITY METABOLIC SYNDROME WITH FATTY LIVER AND PAST UROLITHIASIS  

TREATMENT: 

Life style modification to reduce visceral fat