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
Patient History: Case Presentation
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