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


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

 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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


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

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