70 year old male with right sided flank pain.

December 02, 2022

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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.

A 70 year old male patient came to medicine OPD with chief complaints of-

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

History of presenting illness:—

Patient was apparently asymptomatic 5 years ago (In 2018) then he developed difficulty in urination since 5 months . Patient has a history of pain in the groin area while urination associated with increased frequency, blood in urine (Hematuria) ,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.

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