70yr Old Male Came To OPD With C/0 of Flank Pain On the 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.

D.Naga Sai Rohith 
Roll no :38 

Cheif Complaints : 
 Plain in the Right Flank since 5months

HOPI : 
Patient was apparently asymptomatic 5years back and Then he developed Pain during micturation and Irregular frequency in micturation. He has Urge to pass urine but inable to empty bladder .  Pain in the groin area while urinating  .Blood in urine is seen 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 Horshoe kidney with Bladder Caluculi and Renal Caluculi .
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 .
There no history of Difficulty in urination ,haematuria and increased Urge . 

Daily Routine : 
Wake up 6:30 AM 
Break fast  is done between 10-10:30 AM
Chewing tobacco 
He is a farmer by occupation and has a cow he used to take of that daily  
Lunch at 2-2:30 and sleeps for 2hrs .
Chewing tobacco 
Dinner at 9:00PM
Goes to bed by 10:00PM 

PAST HISTORY: 
Patient was hypertensive and diagnosed with HTN when he came for renal surgery 
No H/O Diabetes, Thyroid disorders ,Epilepsy and Asthama 
History of Stroke -20Yrs ago .

PERSONAL HISTORY : 
Diet :Mixed 
Appetite :Normal 
Bowel and Bladder -Reggular 
Sleep : Adequate 
Addictions : History of Tobbaco Chewing - 3Times per day 
History of  alcohol consumption 10yrs ago 
History of Smoking  15Years ago 


Family History : Not Relevant 

GENERAL EXAMINATION : 
Pallor :Absent 
Icterus : Absent 
Clubbing : Clubbing oof digits is seen 
Cyanosis : Absent 
Lymphadenopathy: Absent 
Oedema : Absent 

VITALS : 
Temp : 98.5 F 
Pulse Rate : 78bpm 
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 : 
PROVISIONAL DIAGNOSIS: 
Renal Caluculi (20mm )in right kidney 
Horseshoe shaped kidney 

Rx: 
Tab Ultracet
Tab Amlong 














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