A 38 year old male with fever and urine retention

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Chief complaints-

A 38 year old male patient, agricultural labourer by occupation came to general medicine OPD on 06-09-2022 with chief complaints of

 fever - since 3days

Urine retention since 2days

                        

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 

     not associated with cough, cold  and night sweats 

He devoloped urinary retention since  2  days.

Past history-

He is a known case of hypertension since   5 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

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. 

  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:-

Treatment:

1) Salt restriction <3.4gm/day

2)Fluid restriction <1 lit/day

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

4)Tab.noclosis 500mg/po/bd

5)Tab. Orofer xj /po/od

6)Tab.shelcal 500 mg/po/od

7)INJ.erythropoietin 4000 IU after each dialysis