55 years old male c/o pedal edema, burning micturition

55 years old male c/o pedal edema, burning micturition

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Chief Complaints:

C/o pedal edema since 5-6months

C/o burning micturition since 2days

History of Present Illness:

Patient is apparently asymptomatic 6 months ago then he developed CKD with pedal edema 3hemodialysis is done till now, burning micturition since 2days(after foleys insertion)

History of Past illness:

H/o Hypertension since 20yrs (on regular medication)

No h/o DM,asthma, epilepsy, TB, CAD, cervical lymphadenopathy

Personal History:

Married

Diet: mixed

Occupation: daily wage labour

Bowel movements: regular

No drug allergy

Addiction: no

Family History:

No h/o DM, asthma,TB, CAD, cervical lymphadenopathy in family members

General Examination:

Vitals:

Temp: Afebrile

Respiratory rate:23bpm

Pulse:86bpm

Blood pressure:130/80mmhg

Sp O2:96%

Systemic Examination:

-Cardiovascular Examination:

Thrills:no 

Cardiac sounds:S1,S2 sounds

Cardiac murmurs:no

-Respiratory system:

Position of trachea: central

Breath sounds: Vesicular

Adventitious sounds:no

Dysponea:no

Wheeze:no

-Abdomen:

Shape of abdomen: Scaphoid

Tenderness:no

Palpable mass:no

Henias orifices:normal

Free fluid:no

Bruits:no

 

-Liver:not palpable

-Spleen:not palpable

-Bowel sounds:yes

-Central Nervous system:

 Pt is conscious

Speech: normal

Signs of meningitis:no

Cranial nerves: normal

Motor and sensory system:normal

-Provisional Diagnosis:

    CKD ON MHD

-Investigation:

     Ultra sound:-

-Treatment:

Tab.NICARDIA 10mg PO BD

Tab.NODOSIS 500mg PO BD

Tab.LASIX 40mg PO BD

Tab.OROFEX PO OD

Tab.SHELCAL PO OD

 Inj.ERYTHROPOITEIN 4000 IV Weekly once