69 YEAR OLD MALE

69 year old male came to OPD with chief complaints of 

Bilateral pedal edema present since 15 days
Burning micturation since 15days
Increased frequency of micturition (10-15times per day ) and urgency 
Nocturia 5-6 times 
Itching all over the body since 7 days

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently asymptomatic 15 days back and later he developed bilateral pedal which is pitting type of edema since 15 days and burning micturition .
There is increased frequency of urination i.e; 10 to 15times per day and nocturia with 5 to 6 times at night.

PAST HISTORY:

Patient had chronic eczema over right lower limb with uremic pruritis and generalised xerosis for which he was using liquid parafin and diphenaramine hydrochloride tablets.
He was not a known case of DM,HTN and asthma

PERSONAL HISTORY:

Diet : Mixed diet
Sleep : disturbed because of nocturia with a frequency of 5 to 6 times
Bowel movements are regular
Bladder movements had increased frequency of micturition and urgency with 10 to 15times per day.
Addictions : occasional drinker

GENERAL EXAMINATION:

Patient was consious cooperative and well oriented to time place and person.
PALLOR : absent
Icterus : absent
Lymphadenopathy : Absent
Clubbing : Absent
Edema : Bilateral Pedal Edema present

VITALS:

Temp: 98F
Respiratory rate : 16 cpm
Pulse rate: 82bpm
Bp : 110 /80 mm of hg
Spo2 : 92 at room pressure.

SYSTEMIC EXAMINATION:

CVS : no murmurs heard, s1 and s2 heard
Respiration :no dyspnea and vesicular breath sounds are heard.
Abdomen : Normal 
But itching over the upper abdomen

CNS : normal reflxes and intact senses.
SKIN: chronic exzema with genralized xerosis on right lower limb

RENAL FUNCTION TESTS:
Hemogram:
Blood urea:
Liver function tests:
CT- KUB
PROVISIONAL DIAGNOSIS:
patient developed AKI on CKD with bilateral hydrouretero nephrosis.

TREATMENT:
Inj Lasix 40mg iv/bd
Inj Pan 40mg iv/bd
Inj Zofer 4mg iv/od
Tab shelcal po/od
Tab orofer po/od
Tab nodosis 550mg po/bd
Monitor vitals
Inj erythropoietin 4000iu weekly once sc


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