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Trascrizione

Mr H.

DOB: 19/09/75 (40 years old)

Sex: Male

Ethnicity: Asian

Follow up appointment with the urologist

  • Persistent ache radiating from the lower back towards the groin
  • Severe pain ("7/10") leading to nausea
  • "Hurts to urinate"
  • Type II Diabetes Mellitus
  • Overweight
  • Hypertension
  • History of kidney stones
  • History of Type II Diabetes Mellitus
  • Simvastatin (40mg, once daily)
  • Aspirin (75mg, once daily)
  • [Anti-hypertensive]
  • Married with children
  • Does not drink or smoke
  • No usage of recreational drugs

Cardiovascular - risk of CVD

Respiratory - none

Gastrointestinal - none

Central Nervous System - none

Musculoskeletal - hip pain (past 2 weeks)

Genitourinary - none

Dermatology - none

  • Urinary tract infection
  • Kidney stone
  • Urine sample
  • CT scan (preferably ultrasound)
  • 2 kidney stones (calcium) were observed
  • Treatment options
  • Stone now passed, follow up in 3 months (CT scan)
  • Lifestyle changes advised

Any questions?

Patient History: Case Presentation

By Aly Khan Tejani, 2.2

Patient History

Diagnosis

The Patient

Systems Health Review

Initial Presenting Complaint

Medical History

Differential Diagnosis

Special Investigations

Family History

Definitive Diagnosis

Drug History

Social History

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