A 45 year old female patient with pain abdomen, vomtings and lower back pain .

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Here is a case i have seen:

A 45 year old woman , working as a farmer presented with complaints of         

pain abdomen 2 days back vomiting since 2 days
Lower back pain since 1 day

She attained menarche at 15years of age and  got married to a farmer when she was 17 years old.  Her husband had to go to jail after he got into a fight with his neighbours. She has no children. 
She was apparantely alright  until 10 years  back after which she started having recurrent  pain abdomen associated with recurrent episodes of vomitings whenever she would get tired after work. She ignored her symptoms and continued to work.  5 years later, she one day had severe pain in her right lower back after which she visited a local hospital where in she was told that she had to get operated as the stone in her kidney was huge. She didn’t opt for surgery and she used certain medications prescribed by her doctor. 3 years later, she noticed a small, mobile, non painful lump in her right breast which alarmed her and she visited a local doctor who advised her to go to Hyderabad for further evaluation. She visited MNJ hospital, where in an FNAC of her right breast lump was performed and she was diagnosed with Right Ca Breast. She underwent mastectomy for her right CA breast along with right axillary lymph nodes removal. She was asked to receive 7 cycles of chemotherapy. After receiving 2 cycles, she noticed that after each cycle she had frequent episodes of vomitings and lot a lot of hair. She decided to discontinue her chemotherapy and she was apparently alright until 2 days back  while she was getting ready to go to shopping she suddenly developed diffuse abdominal pain following which she had 7-8 episodes of vomitings which were yellow in colour , non projectile  , non bilous , non blood tinged.
She subsequently developed right lower back pain the next day.
She has no complains of burning micturation, fever, loose stools, cough. 


Family history - her mother has history of breast CA 

LMP-  10-11-20 

She appeared overweight and her tongue was dry

General Examination:
PR- 62 BPM
BP - 140/90 mmHg
Temperature - 98.6

Systemic Examination:
CVS - S1S2 heard
RS - BAE +, NVBS
Per Abdomen:
soft,non tender, tenderness present on deep palpation in right lumbar region, no organomegaly, bowel sounds positive.
CNS - no FND

Investigation:

CBP: Hb- 11.4gm/dl
TLC-
10,900cells/mm3
PCV-32.2
MCH-29.7
MCHC-25.4
PLATELET COUNT: 1.96lakhs/mm3

CUE:
Albumin-1+
Sugar-nil
Pus cells- 3-4 
RBC-nil

LFT:

ChestX ray:
CECT:
Impression: 
A K/C/O CA Breast
No evidence of liver or nodal metastasis
Right mid ureteric caliculus causing right hydroureteronephrosis.
Cervical uterine fibroid. K/C/O right carcinoma breast, post mastectomy with incomplete chemotherapy.

Diagnosis:
1.Right mid ureteric calculus with right mild hydroureteronephrosis 
2.History of Right CA breast - complete mastectomy 2 years back, received incomplete chemotherapy

Treatment:

Day 1
INJ. PAN 40 mg IV OD
INJ.ZOFER 4mg IV TID
IVF RL @ 75ML/HR
      DNS 75ML/HR
INJ CEFTRIAXONE 1GM/IV/BD
INJ BUSCOPAN 1AMP IM STAT
MONITER VITALS BP, PR, TEMP, 2 HRLY
PLENTY OF ORAL FLUIDS
ORS SACHET IN 1 LITRE WATER SMALL SIPS AFTER EACH EPISODE

DAY 2
NBM SINCE 12 AM TILL FURTHER ORDERS
PLENTY OF ORAL FLUIDS
ORS SACHET IN 1 LITRE WATER 200ML AFTER EACH EPISODE
INJ. PAN 40 mg IV OD
INJ.ZOFER 4mg IV TID
IVF RL @ 75ML/HR
      DNS 75ML/HR
INJ CEFTRIAXONE 1GM/IV/BD
INJ BUSCOPAN 1AMP IM STAT
SRICT I/O CHARTING
INFORM SOS

DAY 3:
PLENTY OF ORAL FLUIDS
ORS SACHET IN 1 LITRE WATER SMALL SIPS AFTER EACH EPISODE
IVF RL @ 75ML/HR
      DNS 75ML/HR
INJ CEFTRIAXONE 1GM/IV/BD
INJ. PAN 40 mg IV OD
INJ.ZOFER 4mg IV TID
IVF RL @ 75ML/HR
      DNS 75ML/HR
INJ BUSCOPAN 1AMP IM STAT
INFORM SOS

On Day 4 
She was advised to visit a urologist for her right mid ureteric calculus

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