70 year old male with right 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
70 year old male patient with right sided flank pain
This is an online e log book to discuss
our patient de-identified health data shared after taking his / her /
guardians signed informed consent. Here we discuss our individual
patients problems through series of inputs from available global online
community of experts with an aim to solve those patients clinical
problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
Cheif Complaints :
Pain in the Right Flank since 5months
HOPI :
Patient
was apparently asymptomatic 5years back and Then he developed Pain
during micturation and He has Urge to pass urine but he was unable to
empty the bladder , Patient had a history of pain in the groin area
while urinating ,which is associated with increased frequency and it is
associated with hematuria occassionally.
For this He went to hospital and later diagnosed with Bladder calculi
For which he was given medication.
Later he came to our hospital and diagnosed with Horseshoe kidney with Bladder Calculi and Renal Calculi .
For which he under went a Surgery To remove Bladder calculi.
Renal Stone was apparently small and not operated .
After
5 years patient came to this hospital with Complaints of Right Side
flank pain which is of pricking type since 5 months which is
progressive and Aggravates on Walking relieves on taking rest.
There no history of Difficulty in urination,increase frequency hematuria.
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 : 76bpm
Respiratory Rate : 16 cycles /Min
Blood pressure : 130/80 mm of Hg
Systemic Examination :
CVS Examination : S1 AND S2 Heard
Respiratory : Bilateral Vesicular Breath sounds Present
CNS : No Focal Neurological Deficits
Abdomen : Soft and Non Tender
Investigations:
X ray :
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
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