70 year old male patient with right sided flank pain

 

70 year old male patient who is a resident of West Bengal came to OPD with

Chief Complaints : 
  Pain in the Right Flank since 5months

HOPI : 
Patient was apparently asymptomatic 5years back and Then he developed Pain during micturition 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 occasionally.

For this He went to hospital and later diagnosed with Bladder calculi 
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 calculi.
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 Aggravates 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

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 : Clubbing of digits is seen 
Cyanosis : Absent 
Lymphadenopathy: Absent 
Oedema : Absent 

VITALS : 
Temp : 98.5 F 
Pulse Rate : 76bpm 
Respiratory Rate : 16 cycles /Min 
Blood pressure : 130/80 mm of Hg 

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




Investigations:


X ray  :

USG ABDOMEN:


CT SCAN - ABDOMEN AND PELVIS:





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

Rx:
Tab Ultracet
Tab Amlong

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