Case of 40- year old male , with history of renal calculi

September 15, 2022

Case of 40- year old male , with history of renal calculi

CHIEF COMPLAINT

This is a case of a 42-year-old male, a shopkeeper by occupation, with a history of renal calculi, who underwent surgery for renal calculi.

The patient presented to the hospital with chief complaints of

Severe pain in the left lumbar region for 15 days.
Burning micturition for the past 15 days

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 10 years ago.

10 years ago, the patient experienced excruciating pain in the left loin. The patient was taken to the casualty in another hospital . It was found that he had renal calculi and he underwent surgery. The pain subsided after the surgery.

5 years ago the patient complained of pain in the left lumbar region, over the scar of the surgery. The pain was dragging in character, experienced on and off. The patient also had burning micturition and visited our hospital and Underwent USG abdomen, where it was found that there were left renal calculi. On urine culture, Escherichia Coli was isolated. The patient was started on

Tablet Nitrofurantoin
Syrup Ascoril
Syrup Citralke 10 ml in 40 ml of water

The patient felt relief in symptoms for 1 year after the treatment.

4 years ago, the patient had a reappearance of symptoms. The pain is of dragging type, present on the left lumbar region, specifically over the scar of the surgery, radiating to the entire abdomen. The pain is insidious in onset and gradually increases in severity over 1-2 hours. The patient continued to take the same medication prescribed to him 5 years ago every time he experienced an episode, and the pain used to subside. The pain is associated with vomiting. There is presence of burning micturition with every episode.

The frequency and severity of this pain have increased in the last 4 years

4 years ago, the patient experienced 2 such episodes.
3 years ago the patient experienced 3 such episodes.
2 years ago, the patient experienced 4 such episodes

4 Months ago, the patient presented to a hospital with similar complaints, this time the pain was continuous and present the entire day, with burning micturition and vomiting. A diagnosis of Left Renal Calculi / Staghorn calculus with mild hydroureteronephrosis was made. The patient was given the following treatment

Tab Nitrofurantoin 100 mg for 5 days, BD
Tab Pantop 40 mg
Tab Drontin 1 SOS
Syrup Alkasol 15 ml for 7 days, with water.

Since then, whenever the patient experiences pain, he takes Tab Drontin and sleeps for a few hours. The pain subsides.

For the past 15 days, the patient is having excruciating pain, and burning micturition as described above. The severity of pain has increased and it is not subsiding on taking tablet Drontin.

The appetite of the patient is reduced for 2-3 days with every episode and the patient is unable to go to work due to the pain.

Past History

The patient underwent surgery for renal calculi 10 years ago.
The patient is not a known case of DM, HTN, TB, Epilepsy

Drug History

Prescribed 5 years ago

Tablet Nitrofurantoin

Syrup Ascoril

Syrup Citralke 10 ml in 40 ml of water

The patient continued taking this medication for 4 years every time he experienced an episode.

Prescribed 4 months ago

Tab Nitrofurantoin 100 mg for 5 days, BD
Tab Pantop 40 mg
Tab Drontin 1 SOS
Syrup Alkasol 15 ml for 7 days, with water.
The patient took Tablet Drontin, every time he experienced pain since. For the past 15 days, the tablet is providing relief.

Family History

No family history of renal calculi.
No other relevant family history.

Occupational History

The patient is unable to present at work on the days he is experiencing pain.

Personal History

Appetite - Decreased for the past 15 days, Decreased for 2-3 days with every episode.
Burning Micturation is present for the past 15 days
Bowel movements normal
Sleep - disturbed
Diet - Mixed
No addictions
No allergies

Previous investigations and reports

5 years ago