2. Particulars of the patient:
Name : Rahim
Age : 3years
Sex : Male
Religion : Islam
Address : Muktagachha
Date of admission : 5/11/22
Date of examination : 5/11/22
3. Chief complaints :
1)Abdominal mass for 2 months.
2)Abdominal pain for 1 month.
3)Passage of blood in urine for 3 times within last 7
days.
4. History of present illness :
According to the statement of the patient’s mother he
was reasonably well about 2 months back. Then he
developed abdominal mass in the left sided lumber
region which is gradually increasing in size. He also
developed abdominal pain for 1 month. The pain is
mild in severity, situated in the left sided lumber region,
non radiating, aggravated by playing and relieved by
taking analgesics.
5. She further added that he had passed blood mixed
urine for 3 times within last 7 days which was painless,
total, episodic and resolved spontaneously. There is
no history of fever,night
sweat,jaundice,cough,haemoptysis,bone pain and
significant weight loss. His bowel habit is normal.
6. History of past illness :
There is no significant past history.
7. Birth history :
Rahim was born by normal vaginal delivery at term at
home with an average weight.
8. Feeding history :
Exclusive breast feeding upto 6 months of age then
complementary feeding continued with appropriate
weaning food. Now he is on family diet.
11. Family history :
2nd issue of non consanguineous parents. There is no
positive family history of such kinds of health problem
among the family members.
13. General examination :
Appearance : ill looking, conscious.
Body built : average
Co operation : co operative
Decubitus : on choice
Edema : absent
Jaundice : absent
Anaemia : mild
14. Dehydration : absent
Pulse rate : 70 beats/min
Blood pressure : 90/60 mm of hg
Respiratory rate : 20 breath/min
Temperature : 98°F
Lymph nodes – not palpable
Hernial orifice – intact
15. Systemic examination :
Gastro intestinal system :
Inspection:
Mouth and oral cavity : No bleeding manifestation,
gum and oral mucosa was healthy.
Abdomen : Abdomen was distended in the left sided
lower abdomen. Umbilicus was centrally placed and
Inverted. There was no visible peristalsis and engorged
vein.
16. Palpation : There is a mass in the left sided lumber
region measuring approximately 10×8 cm in diameter,
non tender, firm in consistency, smooth surface, ill
define margin, free from overlying skin and fixed with
underlying structure and doesn’t cross the midline.
17. Right sided kidney was not ballotable. Liver and spleen
was not enlarged. There was no ascites and external
genitelia appears normal.
Percussion note was tympanic.
Auscultation : Bowel sound was present.
19. Respiratory system :
Breath sound was vesicular and there was no added
sound.
Examination of other system reveals no abnormality.
20. Salient features :
Master Rahim 3 years old, male,2nd issue of non
consanguineous parents, hailing from Muktagachha,
presented to me with the complaints of abdominal
mass in the left lumber region which is gradually
increasing in size for last 2 months. He also developed
abdominal pain for last 1 month. The pain is situated in
the left sided lumber region which is mild in severity,
aggravated by playing and relieved by taking analgesic.
21. She further added that he had passed blood mixed
urine for 3 times within last 7 days which was painless,
total, episodic and resolved spontaneously. There is no
history of fever, night sweat, jaundice,
cough,haemoptysis,bone pain or significant weight
loss. His bowel habit is normal.
22. He is ill looking, co operative, conscious, mild
anaemic,non icteric,non edematous, non dehydrated,
pulse rate – 70 breath /min ,blood pressure -90/60 mm
of hg,respiratory rate is 20 breath / min,temperature is
98°F.
Abdomen was distended in the left sided lumber
region, umbilicus was centrally placed and inverted.
There was no visible peristalsis and engorged vein.
23. There is a mass in the left sided lumber region
measuring approximately 10×8 cm in diameter, non
tender, firm in consistency, smooth surface, ill define
margin, free from overlying skin but fixed with
underlying structure and doesn’t cross the midline.
Right kidney is not ballotable, liver and spleen is not
enlarged. There is no ascites and external genitelia
appears normal. Examination of others system reveals
no abnormality.
26. Investigation :
USG of whole abdomen
CT scan
MRI
IVU
To see metastasis : CxR,LFT
General: CBC, S.Creatinine, RBS, Urine for R/E, 24h
urinary VMA.
27. Treatment :
1)Resectable tumor:
Radical nephrectomy followed by chemotherapy.
2)Inoperable tumor:
Chemotherapy then radical nephrectomy
3)Metastasis :
Chemotherapy in favourable tumor.
Radiotherapy in unfavourable tumor.
Then palliative care.
28. 4)Bilateral tumor:
Favourable tumor: Chemotherapy if good response
then bilateral partial nephrectomy.
Unfavourable tumor : Radiotherapy > Bilateral
nephrectomy > Renal haemodyalysis > Renal
transplantation.
