70 Yr OLD MALE WITH RIGHT SIDED FLANK PAIN

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I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

70 year old male patient who is a resident of west bengal came to OPD with

Chief complaints  : 

  Pain in the Right Flank since 5months

HOPI :

Patient was apparently asymptomatic 5 years ago (2018) then he developed difficulty in urination since 5 months . Patient has a history of pain in the groin area while urination associated with increased frequency, blood in urine (Hematuria) ,increased urge for micturition with feeling of bladder not getting emptied completely. 

For the above complaints patient went to nearby private hospital where he was diagnosed with bladder calculi . 

He was given medication for it . 

—Later he came to this hospital and was diagnosed with Horseshoe Kidney with bladder calculi and renal calculi .

—Patient underwent surgery bladder calculi was removed 

Kidney stone was apparently small and was not surgically removed .  

Since 5 months patient has complains of pain in the right side flank region Which is gradually progressive pricking type , aggrevates on walking and relieves on taking rest .

 There’s no history of difficulty in urination, increased frequency, increased urge,blood in the urine.

PAST HISTORY:

-Patient was hypertensive and diagnosed with HTN when he came for renal surgery 

-No H/O Diabetes, Thyroid disorders ,Epilepsy and Asthma

-History of surgery for bladder calculi 5 years back ( in 2018 ) 

-History of Stroke -20Yrs ago .

PERSONAL HISTORY:

Diet :Mixed 

Appetite :Normal 

Bowel and Bladder -Regular 

Sleep : Adequate 

Addictions : History of Tobacco Chewing - 3 times per day 

History of alcohol consumption 10yrs ago 

History of Smoking 15Years ago 

FAMILY HISTORY: Not Relevant 

General examination : 

Pallor :Absent 

Icterus : Absent 

Clubbing : Clubbing of digits is seen 

Cyanosis : Absent 

Lymphadenopathy: Absent 

Oedema : Absent 

Vitals  : 

Temp : 98.5 F 

Pulse Rate : 88 bpm 

Respiratory Rate : 14 cycles /Min 

Blood pressure : 130/80 mmHg 

Systemic examination: 

CVS Examination : S1 AND S2 Heard 

Respiratory : Bilateral Vesicular Breath sounds Present

CNS : No Focal Nerological Deficits

Abdomen : Soft and Non Tender

Investigations:

On 30/11/22

On 3/12/22

Xray :

Usg abdomen : 

CT scan abdomen and pelvis :

PROVISIONAL DIAGNOSIS:

RENAL CALICULI IN RIGHT KIDNEY (20 mm size) ,horse shoe shaped kidney

Rx:

Tab Ultracet

Tab Amlong