This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs
A 50 yr old male patient presented to opd with the chief complaint of generalized swelling, sob , chest pain, cough, and body pains since one week.
History of present illnes: patient was apparently normal 3 months back then he developed generalized swelling of the body , shortness of breath, chest pain, and body pains. then he visited to the nearby hospital there he was diagnosed with poly kidney cystic disease. He used medication for that and it subcided. One week back he again developed the symptoms along with cough and burning micturition.
Past history: he is a known case of hypertension since 3 months. He had a traumatic eye injury due to rocks at his work place . He lost his right eye in that incident.
Personal history: patient follows a mixed diet. There is loss of appatite.normal bowel movements.burning micturition. He is having adequate sleep . He has a habit of smoking beedi since 20 yrs And smokes 3-4 beedis per day.he also has a habit of alcohol consumption since 10 yrs .
Daily routine before the illness: used to wake up 5 in the morning has breakfast goes the the work .he has lunch around 1:30 then again does work.then in the evening returns home has dinner by7 and goes to bed by 8.
Daily routine after the illness: wakes up late in the morning has food only one in a day and complaints of fullness of stomach.
Drug history: no allergy to any of the known drugs
Nicardia 20 mg BD, nodosis 500 mg BD,
General examination : patient is conscious ,coherrent, co operative and well oriented to his surroundings.he is well built and nourished. pallor ,no cyanosis, no icterus, no lymphadenopathy. Pedal edema .
Vitals: temperature: afebrile. BP : 140/70mmhg pulse rate: 72 BPM. Respiratory rate: 20cpm spo2: 99, random blood sugar: 154.
Systemic examination:
Cvs: bilaterally symmetric chest wall .no precordial bulge .no thrills and no murmurs. s1 and s2 heard
Respiratory system: shortness of breath, no wheeze
Position of trachea- central, no adventious sounds heard
CNS: patient is normal and concious .reflexs are normal.
Investigation:
USG: shows multiple cysts filling the entire renal parenchyama of size 16.6×7.75 cm on right kidney and15.6× 7.2 cm on left kidney
Provisional diagnosis: polycystic kidney disease.
Comments
Post a Comment