A 65yr old male with urinary retention

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Chief complaints-

A 65 years old male patient, agricultural labourer by occupation came to general medicine OPD  with chief complaints of

 fever - since 3 days

Urine retention since 2 days

Abdominal distension since 2 days                          

History of presenting illness-

patient is apparently asymptomatic 3 days back. 

Then he developped fever which was

      insidious in onset 

      gradually progressive 

      No diurnal variations 

      Relieved on medication

      Associated with chills, rigors 

      Has generalised body pains

      not associated with cough, cold, shortness  of breath      and night sweats 

He devoloped urinary retention since 2 days &

He devoloped abdominal distension since 2 days.

Past history-

He is a known case of hypertension since 4 years.

Not a known case of diabetes mellitus, tuberculosis,asthma and epilepsy.

Surgical history-

No significant surgical history 

Personal history-

.Diet- mixed

.Appetite - normal

.Sleep - adequate

.Bowel - regular 

.Allergies- none

 Alcohol- regularly

Family history-

No similar complaints were present in the family members.

No H/O DM,HTN.

General examination-

Patient is conscious, coherent, co operative and well oriented to time, place, and person.

 moderately build and moderately nourished.

.Temperature-98.7°F

.Pulse rate-82 beats per minute

.Respiratory rate-22 cycles per mimute

.BP-140/70 mm of Hg

.GRBS-134 mg/dl

.SpO2-99% at room air

.Pallor- present

.Icterus-absent

.cyanosis- absent

.Clubbing- absent

.Lymphadenopathy- absent

.Edema- present( gradually progressive,pitting type,bilateral,grade-3 , below knee present upto ankle region from below)

Not relieved on rest

Systemic examination

CVS: 

No visible pulsations, scars, engorged veins. No rise in jvp

Apex beat is felt at left 5th intercostal space medial to mid clavicular line.

S1 S2 heard . No murmurs.

Respiratory system

Shape of chest is elliptical, biIlaterally symmetrical.

Trachea is central. Expansion of chest is symmetrical

 Bilateral Airway entry - positive

 Per abdomen examination:

 No visible pulsations and scars,sinuses and     swellings. 

 abdominal distension present

  Soft, non tender, no organomegaley.

  Umbilicus is everted

CNS EXAMINATION: 

.Conscious 

.Speech- normal

.Cranial nerves: normal

.Sensory system: normal

.Motor system: normal

.Reflexes- Right    Left

Biceps      ++          ++

Triceps    ++          ++

Supinator ++         ++

Knee        ++        ++

Ankle        ++         ++

Provisional Diagnosis:

Chronic kidney disease on maintainance hemodialysis.

Investigations:--

Hemogram-

RFT-

 

LFT:-

SAAG:- 

Random blood sugar-

USG report: 

1)Bilateral grade -3 Renal pelvis dilation  (RPD)

2) large multiple renal calculi in left kidney

3) moderate to gross ascites

Treatment:

1)Inj. Lasix 40 mg/i.v/stat

2)Tab.noclosis 500mg/po/bd

3)Tab. Orofer xj /po/od

4)Tab.shelcal 500 mg/po/od

5)Tab. Pan 40mg /po/ od

6)Tab. Nicardia 20 mg/po/bd

7)INJ. Iron sucrose 1 Amp /iv/od

8)INJ.erythropoietin 4000 U/S.C /weekly once.