A 45 year Old Man Came To Casualty with Complaints of Bilateral loin area pain and Fever with Chills and Shortness of Breath

This is an online e log 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 problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

Ankur Kumar
Roll no 14

A 45 Year male patient Plumber by Occupation Presented to Casualty with Chief Complaints of pain in the Loin Area on both Sides and Fever with Chills and Shortness of Breath.

HOPI 

Patient was apparently asymptomatic 2 Years ago. Then he started developing Mild pain in the Loin area which he ignored then. 2 months ago He suffered from Fever with Chills and had visited a hospital in nalgonda where he found that he had reduced Hb% in Blood.
The Doctor advised for a USG abdomen for his Complaints of Loin pain.
He was Diagnosed for Polycystic Kidney Disease 
With multiple Cysts of Varying Sizes in both the Kidneys.
One week ago he Came to KIMS for treatment.
He has undergone Dialysis twice since he was admitted a week ago.


PAST HISTORY 

Known Case of Diabetes mellitus since 10 years
Not a known case of Hypertension, Asthma, Thyroid abnormalities, Epilepsy.

PERSONAL HISTORY

Diet - Mixed
Appetite - Reduced
Sleep - Adequate
Regular Bladder and Bowel movements

Addiction - Drinks Alcohol once a week.

Treatment History

On Oral Hypoglycemic Drugs for DM Type 2.

GENERAL EXAMINATION

Pallor - Present

Icterus - Absent

Cyanosis - Absent 
Clubbing - Absent
Lymphadenopathy - absent
Pedal Edema - absent


Vitals

Temperature - 98.4
Pulse Rate - 84 bpm
Respiratory rate - 14 cpm
B.P - 130/80 mm Hg
SpO2 - 

SYSTEMIC EXAMINATION
Patient was conscious coherent and cooperative.

Cardiovascular System - S1 and S2 Heard, No murmurs

Respiratory system - 
BAE +

CNS - NAD

INVESTIGATIONS

USG

Serum Creatinine
13/07/22 - 7.8
14/07/22 - 7.4
16/07/22 - 6.3
18/07/22 - 4.7

Blood Urea 
13/07/22 - 179mg/dl
14/07/22 - 219
16/07/22 - 219
18/07/22 - 134


Hb% 
13/07/22 - 10.4
14/07/22 - 9.7
16/07/22 - 8.9
18/07/22 - 9.3

HbA1c - 6.9%



LFT

12/07/22
RFT
16/07/22


18/07/22


Hemogram 
13/07/22
14/07/22


16/07/22
18/07/22

CBP

Serum Electrolytes

Diagnosis

AKI on CKD 
Polycystic Kidney Disease 

Treatment

Dialysis Done Twice.

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