64 year old male with vomiting and burning micturition since 1 month

Date of Admission:22/07/2022


A 64 yr old male resident of Jaikaisaram choutuppal farmer by occupation came to OPD with chief complaints of pain in right loin, vomiting and burning micturition since 1 month.

History of present illness:

Patient was apparently asymptomatic 10yrs back then developed pain in the right loin for which he was diagnosed to having renal stone and was operated for it later after 3 yrs he developed bilateral loin pain and was diagnosed having bilateral renal stones and at was operated after a gap of 1 month.and later after 3 yrs and 4yrs back He developed midline swelling later which is diagnosed as hernia and mesh was placed later after 1 yr developed diffuse abdominal pain which he went to an Hospital,endoscopy was Done and diagnosed as intestinal ulcers and managed it conservatively this time he was diagnosed with Diabetes and hypertension.And 1 yr back he had Generalised weakness and Sob on exertion for which he went Hospital and diagnosed with having low Hb and using Iron Injections and 1 month back he developed burning micturition, pain in right loin and vomiting.
Pain is dragging type with no aggravating factors and relieved on medication. He had vomiting 2 to 3 times in a week from past 1 month.



History of past illness:

History of DM and Hypertension from 1 year
For diabetes he is using metformin
for Hypertension he was not using any medication
Not a K/c/o TB, asthma,epilepsy

Treatment history:

He was on Diabetic Medication
NO history of use of any other medication

Family history:

There is no significant family historys

Personal history:

Mixed diet
Normal Appetite
Decreased Bladder movements and Bowel movements are normal
No known allergies
Adequate sleep

Habits:
Occasionally consumes alcohol
Cigarette smoking 20 years back 1 pack per day for 2 yrs 

Daily Routine:

He generally wakes up at 5 o clock in the morning and does daily work of home.At 7 o clock he has his Breakfast and after some time he goes into the village and Chit chat with neighbours .At 1 o clock he take his lunch and take nap for atleast 2-3 hours.He do not have any habit of drinking tea in the evening.At last he will take his dinner at 8 o clock and then goes to bed. 

General Examination:

On Examination patient is conscious,coherent,co - operative and well Oriented to time,place and person.

There are no signs of
Icterus,cyanosis,clubbing,Lymphadenopathy, oedema and pallor.

Vitals: 

Temp:99:6 F
Pulse rate:88 bpm
Bp:160/70 mm Hg
Resp rate:16 / min

Systemic examination:

CVS: No thrills
S1 and S2 +
No murmurs

Respiratory system
No Dyspnoea
No Wheeze
Trachea is centrally located

Abdomen
soft and non tender
No palpable Mass
Liver and Spleen are not palpable

CNS
No abnormality detected


Provisional diagnosis:
Renal stones

Investigations:



USG
Right moderate hydrouretero nephrosis

NCCT
Right kidney is enlarged,there is dilatation of pelvicalceal System
Left kidney normal.
Right mid ureteric calaulus causing proximal hydroureteroneprosis.

Provisional Diagnosis:
Renal calculi

Treatment

T. Lasix
T Nodosis
T shelcal 
T. orofer 
T Nicardia


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