70 year old male with right sided flank pain

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 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.



History of Presenting Illness:

Patient was apparently asymptomatic 5 Years ago and then he complained of difficulty in micturition and pain during micturition.

There is pain in groin area, and there was blood in urine occasionally.

He went to a private hospital where he was diagnosed with bladder calculi and took medication.


After an Year, He came to this Hospital where he was diagnosed with Horse Shoe Kidney along with Renal Calculi and Bladder Calculi for which he underwent surgery for removal of bladder calculi and

 renal calculi removal was not done as it is  too small to operate.


Presently, 3yrs later he has come to the hospital with complaints of pain in the flank and asks for removal of his renal stone surgically. 

He has Complaints of Bloating as well for which he takes PanD as Medication.




Past History: 

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

History of surgery for bladder calculi 4 years back 

History of Stroke -20Yrs ago .

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



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 : No Relevant family history 


General Examination : Pt is conscious, coherent & cooperative well oriented with time, place& person

No Signs of Pallor, Ictreus, Clubbing, Cyanosis, Lymphadenopathy, Edema












VITALS : 

Temp : 97.9 F

Pulse Rate : 86bpm 

Respiratory Rate : 14cycles /Min 

Blood pressure : 135/76 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



Provisional Diagnosis:

Renal Caliculi In Right Kidney which is 20mm in size


Investigations:








03/12/22






Radioimaging: 

USG report: 


Doppler: 









Diagnosis:

Right side Renal Calculi with Horse-shoe Kidney.


Treatment:

Tab Ultracet (Tramadol + Pcm)

Tab Amlong (Amlodipine)

Monitor vitals 6hrly



















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