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

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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.

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