40 yr old man c/o left loin pain with history of renal stone and hydronephrosis

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: The patient is a 40 yr old male, by profession Grocery shop owner.

Till 2011, he claimed to be feeling alright.

In 2012, he started c/o slight pain in the left loin region (continuous) with gradual swelling of the left side of the abdomen which was more prominent when he lay down. His urine output was low. After staying like that for 1.5 months he visited a Dr. Test confirmed hydronephrosis due to left renal calculi. Sx was done after 7 days.

His symptoms resolved after Sx. For 5 yrs he claimed to be feeling alright.

In 2017, one day he noticed pain in the left loin region (first 1 hr slight pain, then it would intensify and last for 4-5 hrs, sometimes more). He went to a pharmacy and took tablets which reduced the pain within an hr. Lying down at a stretch for long hr caused slight lower back pain, which would go away on getting up. He also c/o burning micturition once a month. For further consultation went to Hyderabad. Medicine was prescribed.

In 2018, again one day he c/o pain which went away within hrs of taking prescribed medications.

In 2019, again this incident of pain happened 2 times, which went away with tablets.

In 2020, happened 3 times

In 2021, 4 times

In 2021 September, he reported 2 incidents of burning micturition each lasting for 2-3 days, then again after 4 months lasting for 2-3 days.

In 2022 Feb, one day he started c/o intense pain in the left side of his abdomen which would not go away even on taking medicine. Each episode of pain lasted for 12-14 hrs and would happen every day, because of which could not sleep. Pain used to increase on doing the movement. And if he ate something during the painful episode he would instantly vomit. Sometimes, because of pain he even had fever.

5 months ago, went to Bhopal, where Dr. informed him of renal stones, and medicine was given. Pain reduced slightly with medication and episodes of pain also reduced after medication). Afterward, he would take medicine only during episodes of pain. 

Decreased urine output in past 2 months.

He had not vomited for the past 16 days. 

16 days ago, he again c/o intense pain in the left side of his abd, sometimes fever during intense pain. The pain is continuous for the past 16 days but its intensity has reduced. On walking or movement pain will increase. 

Pt has no history of HTN or Dm

He is non-alcoholic and started smoking bidis (2/day) and cigarettes (2/day), a total of 4/day since 30 (peer pressure). Stopped for the past 6 months. 

CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: c/o continuous pain in the left side of abd for the past 16 days, with decreased urine output for the past 2 months and rarely burning micturition (once a month).

FAMILY HISTORY: 

Father - HTN

Mother and siblings with no c/o health issues

REPORTS: 

2017 







         16.4.22                                        





9.15.22




























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