A 54 years old male with renal calculi in right kidney

March 11, 2022

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A 54 years old male came with a chief complaint of renal calculi in right kidney. 

HISTORY OF PRESENT ILLNESS :-

Patient was apparently asymptomatic 1 year back. Then patient developed pain in right loin. The he went to the hospital. He was on ayurvedic medicine for few days. And then he developed pain 1 month back and was admitted in the hospital. 

He has no history of pyrexia, graveluria, hematuria. 

HISTORY OF PAST ILLNESS :-

Patient has a history of hypertension since 5 years and is in treatment since 4 years. 

Patient has a history of hemorrhoidectomy 4 years back. 

No history of Dm/Tb/epilepsy/asthma.

Patient has a history of right dj stenting under LA 1 month back. 

PERSONAL HISTORY :-

Diet - mixed

Sleep - normal

Appetite - normal

Addictions - alcohol intake since 10 years

Allergies - no allergies

FAMILY HISTORY :-

No relevant family history. 

GENERAL EXAMINATION :-

Patient is examined under well lit room amd adequate ventilation with his consent taken. 

Patient is conscious, coherent and cooperative, well oriented to time space. He is moderately built and well nourished. 

No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals :-

Temperature - afebrile

Blood pressure - 130/80 mm Hg

Pulse rate - 83 bpm

Respiration rate - 12 cycles/min

SYSTEMIC EXAMINATION :-

Cardiovascular system -

S1 and S2 sounds are heard. 

Respiratory system -

Central position of trachea. 

No wheeze, no dyspnoea. 

Central nervous system -

No neurological defects. 

INVESTIGATIONS :-

    Ultrasound report :-

   Colour doppler :-

   Ecg report :-

    Bleeding and clotting time :-

    CBP :-

    Complete urine examination :-

    RFT :- 

    Liver function test :-

    Blood sugar levels :-

TREATMENT :-

Tab Pantop 40mg

Tab Oflox 200 mg

Tab Dolo 650 mg

Syp Citraika 10 ml