right renal caliculi and left ectopic kidney

8/3/2022
Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

CHEIF COMPLAINT

32  yrs /F  daily worker (labour) by occupation came to OPD with c/o Pain in right loin  since 1 month with no history of past illness

HOPI(History of past illness):
Patient was apparently asymptomatic 1month back.
Then one day she developed non-radiating pain in right loin
And there is no history of Vomitings and nausea ,fever,
No history of burning micturation
No history of gravel urine

PAST HISTORY:
Not a K/c/o DM , HTN , BA , Thyroid disorder and Epilepsy.

PERSONAL HISTORY:
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
She have no habit of drinking alcohol 

FAMILY HISTORY:
No similar history in the family

GENERAL EXAMINATION:
-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

-No malnutrition

-No dehydration 

 ▪️VITALS:
Temperature - 98F
Pulse rate - 83 bpm
Respiration rate - 12cpm
BP - 110/70 mmhg
Spo - 99%

SYSTEMIC EXAMINATION:

▪️CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

▪️RESPIRATORY SYSTEM 
No Dysponea
No Wheeze 
Vesicular beath sounds


▪️CNS
 No nerological defect

Investigation
HIV1/2rapid test -ve


Diagnosis 

Right renal caliculi causing mild hydronephrosis
and left ectopic kidney


Treatment planning

T.DFCox  200mg PO/BD
T.PAN 40 mg PO/OD

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