70 Year Old Male Came To OPD With Complaint of Flank Pain on Right Side

 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.

Ankur Kumar
Roll no 14

Chief Complaints:

A 70 Year Old Male with Chief complaints of pain in the right flank.

HOPI : 
Patient was apparently asymptomatic 5 Years ago and then he complained of difficulty in micturition. There was pain during micturition.
Pain in groin area, and there was blood in urine occasionally.
He went to a private hospital where he was diagnosed with bladder calculi. 
He was given medication.
After an Year, He came to this Hospital where he was diagnosed with Horse Shoe Kidney along with Renal Calculi and Bladder Calculi.
Bladder Calculi was Surgically Removed.
Renal Stone was apparently small and not operated.
Now Four years Later he has come to the hospital with complaints of pain in the flank.
He also wants his renal Stone Removed Surgically.
He has Complaints of Bloating as well for which he takes PanD as Medication.

Daily Routine
He wakes up at 6 am, He has Tea at 7am
Breakfast by 10am where he has Rice and Dal.
He is a farmer by occupation and has own land.
He has Lunch at 2pm for which he has Rice,Fish,Dal, Vegetable,and meat. After which he sleeps for 2hours.
He wakes up and watches TV and has Tea.
Dinner at 10pm for which he has Rice, Dal and vegetables
He goes to bed by 11:00pm

Past History

Patient was diagnosed with Hypertension after he came here for renal Stone Surgery 
Not a known case of Diabetis Mellitus, Epilepsy, Asthma, Thyroid abnormalities.

History of Stroke 25 years ago - Twice

Personal history

Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bowel and Bladder - Regular
Addictions - H/o Tobacco Chewing until 5 years ago and H/o of alcoholism which he quit 10 years ago.

Family History : Not Relevant 

General Examination

Pallor - Absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Clubbing of Digits 
Lymphadenopathy - Absent
Pedal Edema - Absent

Vitals
Temperature - 98.5° F
Pulse  - 82 BPM
Respiratory Rate - 20 Cycles/min
Blood Pressure - 140/80 mmHg

Systemic Examination
CVS : S1 and S2 Sounds Heard
Respiratory: Bilateral Vesicular Breath Sounds Present
CNS : No Focal Nerological Deficits
Abdomen : Soft and Non Tender

















Investigations























Provisional Diagnosis

Right side Renal Calculus With
Horse Shoe Kidney

Treatment:
Tab Ultracet 
Tab Amlong

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