General medicine case history 10

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


A 70 year old female patient, resident of Chityal, Farmette by occupation, came to our hospital with chief complaint of lower back pain.

Date of Admission:-04/04/2022

History of present illness:-
Patient was apparently asymptomatic 15 days back and developed pain in the back which was sudden in onset and suffering from watery episodes of vomitings.

History of past illness:-
Known case of diabetes, hypertension.
Not a known case of tb, epilepsy.

Personal history:-
Patient has normal eating habit with mixed diet.

Daily routine:-
Patient used to wake up at 4.00AM , goes to farm at 7.00AM, takes breakfast in between 9.00AM-10.00AM. Then she continues her work, takes rice in between 2.00PM-3.00PM, dinner at 9.00PM and goes to bed by 10.00PM.

Family history:-
No significant family history.

General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
Pallor present
No icterus
No clubbing
No Lymphadenopathy

Vitals:-
Temperature-99 F
Pulse rate-70 bpm
RR-16 cpm
BP-110/70 mmhg
SPO2-96% at room temperature
RBS-70mg/dl
















Investigations:-
LFT
RFT
RBS
FASTING BLOOD SUGAR
POST LUNCH BLOOD SUGAR
CUE
CBP
BLEEDING TIME AND CLOTTING TIME
PROTHROMBIN TIME
NCCT-KUB(PLAIN)
ECG
APTT

Provisional Diagnosis:-
Left Renal Calculi(Proximal Ureteric Calculi)

Treatment:-
Inj. Magnex Forte × 1.5gm
Tab. Pan 40mg × OD
Tab. Dolo 650mg × TID
Syp. Alkastone × 10ml × BD
Surgery required

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