68 yr old female with uretric calculi
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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
