A 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.


A 70 year old male patient resident of West Bengal came to OPD with 

CHIEF COMPLAINTS :-  Pain in the right flank since 5 months . 


HOPI :-
            Patient was apparently asymptomatic 5 years back then he developed difficulty in urination since 5 months . Patient history of pain in the groin area while urination associated with increased frequency, Hematutia ,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 . 
After 5 years he came back to this hospital. 
Since 5 months patient has complains of pain in the right side flank region Which is gradually progressive pricking type , aggrevates on walking and cycling and relieves on taking rest . There’s no history of difficulty in urination, increased frequency, increased urge , blood in the urine . 


DAILY ROUTINE:- patient gets up in the morning at 6:30 am has a cup of tea and does rearing of cow ( he was a farmer stopped working 15 years back ) . Has one meal ( rice and dal ) at 10:00 am then he has his lunch at 2-2:30 pm and sleeps for 2 hours . After he gets up he has a cup of tea again at 6:00 pm , he watches TV and later has dinners at 10:00pm and sleeps after some time around 11 : 00 pm . 


PAST HISTORY:- 
Patient was diagnosed with hypertension after coming here . 
No history of Diabetes Mellitus , Epilepsy, Coronary Artery Disease , Asthma or Thyroid abnormality.
History of surgery for bladder calculi 5 years back ( in 2018 ) 


FAMILY HISTORY:- 
No significant family history 

PERSONAL HISTORY:- 
Diet - mixed 
Appetite- normal 
Bowel and bladder- regular 
Sleep- adequate 
Addictions- history of alcohol intake 15 years back 
                   History of smoking occasionally 15 years back 
                   History of tobacco intake - 3 times per day 
  

GENERAL EXAMINATION:- 
Patient is conscious, coherent and well oriented to time place and person . 
Moderately built and nourished. 
Pallor - absent 
Icterus- absent 
Clubbing- present 
Cyanosis- absent 
Lymphadenopathy- absent 
Edema - absent 


VITALS:- 
Temperature- afebrile 
RR - 14 cpm
PR - 71 bpm
BP - 130/70 mm of hg 


SYSTEMIC EXAMINATION:- 

Respiratory system:- bilateral air entry is present , normal vesicular breath sound heard

CVS :- s1 , s2 heard 
            No abnormal murmurs 

CNS :- no focal neurological deficits
ABDOMEN:- soft non tender













PROVISIONAL DIAGNOSIS:- 

Renal calculi ( 20 mm ) in right kidney 
HORSESHOE SHAPED KIDNEY 




INVESTIGATIONS :- 













TREATMENT:- 
Tab Ultracet 
Tab Amlong 






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