Polycystic Kindey Disease

							     Weekly Case Presentation



Presents by : Dr. Md.Mustafizur Rahma MBBS
                    Intern Doctor
                  Medicine Unit-III
                      CoMCH.
Particulars of the Patient :
Name           : Rokeya Begum
Age            : 50 years
Sex            : Female
Religion       : Islam
Occupation : Housewife
Marital Status : Seperated

Address :
  Present Address    : Kuchaitoli, Comilla.
  Permanent Address : Dhonaghanda, Matlob,
                       Chandpur
Date of Admission    : 04.04.2011
Date of Examination : 04.04.2011 at
Date of presentation : 18.05
Chief Complaints :

1.   Occational Loin pain for --------- 3 years
2.   Headache for --------- 2 days
3.   Vomiting for --------- 2 days
History of Present Illness :
  According to the patient’s statement she was reasonably well 3 years back.
  Then she developed occational loin pain for 3 years which was mild, dull
  aching, localized, no aggravating or relieving factor noted, not associated
  with fever but was associated with increased frequency of micturation for
  initial 2 years for which she was admitted into CoMCH & treated
  accordingly. For last one year she has lumpy feelings in both side of the
  abdomen which is progressing in size. For last 2 days she developed
  sudden mild aching pain in frontal region which was worsening throughout
  the day, but relieved by sleep. It was not aggravated by coughing, straining,
  sneezing forward bending. It was associated with photophobia & vomiting.
  Vomiting occurred 10 to 15 times per day which was projectile, not related
  to food intake, moderate in amount, no foul smell and not blood & bile
  stain. Vomiting & headache was not associated with convulsion,
  unconsciousness, weakness of any part of the body. She is a known case of
Continued :
 hypertension for last 18 years for which she took various antihypertensive
 drug irregularly from local doctors.She gave no history of scanty
 micturatin, generalized swelling, weakness, lathergy, polyuria, polydipsia,
 breathlessness, blurring of vision, joint pain, weight loss or weight gain,
 palpitation, chest pain, bodyache, hair loss, increase sweating, enlargement
 of hands & feet, heat or cold intolerance.Her bowel & bladder are normal.
History of Past Illness :
  She gave history of still birth of her first pregnancy due to
  Gestetional Hypertension 18 years back.
  She is a known case of hypertension for last 18 years.
  She has no history of DM, Valvular heart disease,
  Subarachnoid haemorrhage, Renal failure, Abdominal or
  inguinal hernia, Peptic ulcer disease, GERD, Bronchial
  asthma, TB, Jaundice.
Menstrual History :

 Menarche : 13 year
 Menopouse : Two years back

Drug History :
 Tab. Losarton potassium 100mg
 Tab. Amlodipine       20 mg
 Tab. Indepamide       1.5 mg
 Tab. Enalapril        10 mg
 Tab. Labetelol        200mg
Personal History :
 She is a house wife.
 She has no history of alcohol intake, Smoking & Betal nut chewing.


Family History :
Father : Alive
Mother : Expired due to end stage Renal Disease (ESRD).
Brother : She has four brothers, two brothers was expired. One was for CVD
          & ESRD & another she did not mention.
Sister : She has 3 sister, one sister expired due to CVD & ESRD
Daughter : She has one daughter. She is in good health.
Socio-economic History :

 She belongs to lower middle class family
Physical Examination :
 General Examination :
Appearance : Ill-looking
Body Build : Average
BMI          : 23.33kg/sq. meter
waist circumference:
waist to hip ratio:
Nutrition    : Well nourished
Co-operation : Co-operative
Decubitus : On choice
Intelligence : Intelligent
Anaemia      : Absent
Jaundice      : Absent
Cyanosis     : Absent
Oedema         : Absent
Dehydration : Absent
Continued :
Clubbing           : Absent
Koilonychia       : Absent
Leuconychia       : Absent
Pigmentation : Absent
Hair distribution : Normal
Xanthelasma,tendon xanthomas: Absent
Lymph node        : Not palpable
Neck vein         : Not engorged
Thyroid gland : Not enlarged
Pulse             : 60 b/min
Blood pressure : Systolic- 210 mm of Hg
                    Diastolic- 110 mm of Hg
Temperature      : 98°F
Respiratory rate : 20/min
Systemic Examination :
 Cardiovascular System :
 Arterial Pulses : 60 b/min regular, normal in volume, no radio-radial or
                    radio-femoral delay & all peripheral pulses are palpable.
                    Carotid, abdominal, and femoral bruits- Absent
 Blood Pressure : Systolic - 210 mm of Hg
                     Diastolic - 110 mm of Hg without drugs.

 Jugular Venous Pressure : Not raised.

 Precordium :
    Inspection: No visible pulsation, venous engorgement, sweilling,
                defomity, scar marks.
Continued :

  Palpation :
    Apex beat : Left 5th intercostal space, just medial to the mid clavicular
                line, heaving in nature.
    Left parasternal heave : Absent.
    Thrill : Absent.
    P2 not palpable.

  Percussion : Area of cardiac dullness normal

  Auscaltation : 1st & 2nd heart sound are audible & normal in intensity in
                all areas & no added sound audible.
Genitourinary System :
  Inspection : Abdomen is distended, no scar marks.

  Palpation : Tenderness at the renal angle.
   Kidney : Both right & left kidneys are enlarged, extend downwards,
              rounded border, bimanually palpable & ballotable, nodular
              suface, cystic in consistency, non tender, not moves with
              respiration.
   Urinary bladder : Not palpable.

  Percussion : Resonance all over the abdomen & over the mass.

  Auscultation : No renal bruits.
Alimentary System :
Oral cavity : Normal.
Abdomen :
  Inspection : Abdomen is distended, umbilicus is central in position &
               inverted, no visible peristalsis & visible pulsation, moves
               with respiration, no pigmentation & scar mark, hernial orifice
               is intact & external genitalia is not inspected.

  Palpation :
     Superficial Palpation : Temperature is normal, non tender, no muscle
              guard, no localized swelling & no hyperaesthesia.
     Deep Palpation :
              Liver : Not palpable.
              Right Kidney : Right kidney is enlarged, extend downwards,
Continued :

         rounded border, bimanually palpable & ballotable, nodular
          surface, cystic in consistency, non tender, not moves with
          respiration.
    Spleen : Not Palpable.
    Left kidney : Left kidney are enlarged, extend downwards,
          rounded border, bimanually palpable & ballotable, nodular
          surface, cystic in consistency, non tender, not moves with
          respiration.
    Urinary Bladder : Not Palpable.
    Hernial orifice : Intact.
Continued :
Percussion : Resonance, no shifting dullness, upper border of liver dullness is
   in right 6th intercostal space.

Auscultation :
   Bowel sound : Present
   Bruit : No renal bruit.
   No venous hum & succussion splash.
Respiratory System :
Inspection : Elliptical in shape, movement of chest is regular, no itercostal
   recession, no scar mark, no visible impulse & visible engorged vein in
   chest.

Palpation :
   Trachea is central in position.
   Apex beat is in left 5th intercostal space just medial to the mid clavicular
   line.
   Vocal fremitus is normal
    Expansibility of chest is 4 cm.
    Symetrical movement on both side of the chest.
    Transverse & anterior-posterior diameter is 7:5.
    No rib tenderness.
Continued :
Percussion : Resonance.
             Upper upper border of liver dullness is in right 6th intercostal
             space.

Auscultation : Vesicular Breath sound.
               Normal vocal resonance.
               No added sound.
Nervous System :
GCS : 15
Higher Psychic Function : Intact
Cranial Nerve : intact
Motor Function :
    i) Bulk of the Muscle : Normal
    ii) Tone of the Muscle : Normal
    iii) Strength of the Muscle : Normal
    iv) Reflexes : All are normal.
    v) Co-ordination of movement : Normal
    vi) No involuntary movement.
    vii) Gait
Sensory Function : Normal.
No signs of Meningeal irritation.
Cerebellar Function : Normal
Fundoscopic Finding : Grade I hypertensive change.
Musculoskeletal System :
Gait : Normal
Arms : No joint tenderness or swelling, range of motion of all joint are normal.
Legs : No joint tenderness or swelling, range of motion of all joint are normal.
Spine : No deformity, no tenderness & movement of all direction are nomal.
Salient Features :
   Mrs. Rokeya Begum 50 years old housewife hypertensive non diabetic non
  smoker non alcoholic hailing from Kuchaitoli, Comilla was admitted into
  Comilla Medical College & Hospital on 04.04.2011 at 12:30 pm with
  complains of occasional loin pain for 3 years which was mild, dull aching,
  localized, not associated with fever but associated with increased frequency
  of micturation for initial 2 years.For last 2 days she developed sudden mild
  aching pain in frontal region which was worsening throughout the day
  without any aggravating factor, but relieved by sleep. It was associated
  with photophobia & vomiting. Vomiting occurred 10 to 15 times per day
  which was projectile, not related to food intake, moderate in amount, no
  foul smell and not blood & bile stain. Vomiting & headache was not
  associated with convulsion, unconsciousness, weakness of any part of the
  body. She has no history of scanty micturation, haematuria, breathlessness,
  heat or cold intolerance, lathergy, joint pain, blurring of vision, any change
  in weight. Her bowel habit is normal. On general examination I found BMI
  is ------ pulse 60 b/min, BP 210/110 mm of Hg, Temperature 98.2º F,
  Respiratory rate 20/min.Other general examination findings are normal.
Continued :
 On genitourinary system examination I found both right & left kidneys are
 enlarged, extend downwards, rounded border, bimanually palpable &
 ballotable, nodular suface, cystic in consistency, non tender, not moves
 with respiration, no renal bruit. On CVS examination I found apex beat is
 shifted to 6th intercostal space which is heaving in nature. On fundoscopic
 examination I found Grade I hypertensive change. Other systemic
 examination reveales no abnormality.
Provisional Diagnosis :




                  ?
Polycystic Kidney Disease.

Differential Diagnosis :
Investigations :
1.   Complete Blood count : W.B.C – 9200/cu mm of blood
                            E.S.R – 35 mm/1st hour
                            Hb% – 67%
                            polymorph – 68%
                            Lymphocytes – 27%
                            Monocytes – 02%
                            Eosinophils – 03%