General medicine Case-4

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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.