1801006083-SHORT CASE

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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.

70 year old male patient  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 caluculi 

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 caluculi.

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 Aggrevates 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 : absent

Cyanosis : Absent 

Lymphadenopathy: Absent 

Oedema : Absent 

VITALS : 

Temp : 98.5 F 

Pulse Rate : 76bpm 

Respiratory Rate : 16 cycles /Min 

Blood pressure : 130/80 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

Investigations:

Fasting blood glucose-83mg/dl

Blood urea- 36 mg/dl

Serum creatinine -0.8mg/dl

Complete urine examination:

Color -pale yellow

Appearance - clear

Albumin- positive

Pus cells-3-4/hpf

Epithelial cells-2-3/hpf

Hemogram:

Hb-11.9gm/dl

Total count - 6100cells/mm3

Neutrophils-58%

Lymphocytes -31%

Pcv-36.6vol%

RBC count-3.89 millions/mm3

Total serum electrolytes:

Sodium-137 meq/lt

Potassium-4.4 meq/lt

Chloride-105meq/lt

Liver function tests:

Total biluribin-0.69 mg/dl

Direct bilirubin-0.17mg/dl

Sgot-20 IU/L

Sgpt-25 IU/L

Alkaline phosphate-250IU/L

X ray :

USG ABDOMEN:

Impression -Right horse shoe kidney 

Right renal pelvic calculus(20 mm)

CT SCAN - ABDOMEN AND PELVIS:

Impression -horse shoe morphology, right renal pelvic calculus

CECT-

PROVISIONAL DIAGNOSIS:

RENAL CALICULI IN RIGHT KIDNEY (20 mm size) ,horse shoe shaped kidney

Rx:

Tab Ultracet

Tab Amlong 5mg