General medicine Case-4

  This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based input.

Case:

An 50 year old male patient , granite cutter  by  occupation came to the casualty with the Chief complaint:  shortness of breath, generalized body swelling, chest pain, body pain, cough since one week.
History of present illness:
Patient was apparently asymptomatic 3 months  back then he developed shortness of breath, swelling, chest pain, body pain and burning micturation.
He was admitted in a nearby hospital and was diagnosed with polycystic kidney disease and was under medication.
Since 1 week he again developed all the symptoms and was admitted here.
Personal history:
Diet: mixed
Appetite: Inadequate
Sleep: adequate
Bowel bladder movement : regular
Pernicious habits: alcohol since 10yrs
                                    smoking bidi since 25 yrs ( 4-5 per day)
Past history: no relevant past history
He is a known case of hypertension and is under medication.
History of traumatic injury to right eye.
Family history: no relevant family history

General examination:
Patient is conscious , coherent and cooperative moderately built.
pallor present
No cyanosis, clubbing, edema.
Vitals:
Temp: a - febrile

Spo2 : 97%

PR : 71 Bpm

RR : 20cpm

Bp: 140/90mmhg

Systemic examination:

CVS : S1 S2 heard, no murmurs, no added sounds.
Respiratory system: trachea is in central position
Abdomen:
P/A : soft , non - tender.

Investigation:
Ultrasound scan report shows multiple cyst in both right and left kidney .
















Provisional diagnosis : polycystic kidney disease.

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