68 yr old female with uretric calculi

​This is an online e log book to discuss our patient’s deidentified health data shared after taking his/her/ guardians signed informed consent . Here we discuss our patients 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 . This e log book also reflect my patient centered online portfolio and your valuable inputs and comments.

A 68 year old female came with the chief  complaint of left loin pain since one week and also with the history of nausea and vomitings 

HISTORY OF PRESENT ILLNESS 

Patient was apparently normal one week back and then later she developed pain in left loin which was insidious onset and progressive in nature has an history of nausea and vomitings and also dysuria 

HISTORY OF PAST ILLNESS 

Has diabetes and hypertension since one year 

No tb,asthma and epilepsy 

No past surgery 

Hypertension: tab.amiloride 5mg , olmesartan 40mg 

Diabetes mellitus : gemer-1(metformin 500mg ,glimpride1mg)

PHYSICAL EXAMINATION 

TREATMENT HISTORY         

History of diabetes and hypertension 

No known history of asthma,tb, cad,antibiotics hormones,chemo and radiation and surgeries 

PERSONAL HISTORY 

Married 

Apetite :normal 

Diet:mixed diet 

Bowels:regular 

Micturition:normal 

No known allergies 

No known family history 

VITALS 

Bp:130/70mmhg 

Pulse rate:88bpm

CVS:S1S2

Temperature:98.6F

SYSTEMIC EXAMINATION 

CVS

No thrills , Cardiac murmurs 

Cardiac sounds :S1S2

RESPIRATORY SYSTEM 

No dyspnoea ,wheeze 

Position of trachea: central 

Breathe sounds: vesicular 

ABDOMEN 

Shape of abdomen :scaphoid 

No tenderness, palpable mass, free fluid , bruits 

Hernial orifice : normal 

Liver,spleen not palpable 

CNS

Conscious,normal,no neck stiffness ,no kernings sign 

PROVISIONAL DIAGNOSIS 

Left proximal upper uretric calculi 

MEDICATION:

Inj.mjnex forte 1.5gm IV bd

T pan 40mg od 

T dolo 650mg tid

Right kidney stones measures about 8.5 cm and left kidney stones measures about 17mm 



 4th April 



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