Final practical short case

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.  

      A 70 year old female patient labourer by occupation came with chief complaints of 

Decreased urine output since 1 month  , 

burning micturition since 1 month,

 urgency of micturition since 1 month , 

mass per abdomen since 20 days 

History of Present Illness :

Patient was apparently asymptomatic 1 month back then she noticed decreased urine output , burning micturition , urgency and hesitency of micturition for which she visited local hospital where investigations are done . She denies history of fever , loin pain and hematuria .

Past History:

No history of diabetes mellitus, hypertension, asthma , tuberculosis , epilepsy . 

Personal History: 

Diet : mixed 

Apetite: Normal 

Bowel movements: Regular 

Micturition : burning sensation , decreased urine output 

Sleep : adequate 

Family history: 

 No similar history in the family 

General examination: 

 Patient is conscious , coherent and cooperative 

No pallor , cyanosis , icterus, lymphadenopathy, edema

VITALS : 

Temp- afebrile 

Bp-90/50 mm hg

Pr- 86 bpm

Rr-20 cpm

Spo2- 98% on RA

INVESTIGATION: 

X ray of erect  abdomen 

ULTRASOUND OF ABDOMEN : 

Blood urea:- 25mg/dl

Serum creatinine:- 0.9mg/dl

Diagnosis : 

 

Urosepsis secondary to bilateral hydroureteronephrosis with bladder calculi with AKI with UTI.

Treatment : 

Plan of treatment 

Tab.NITROFURANTOIN 100MG OD 

Tab.OROFER PO OD.

Tab.NODOSIS 500MG PO BD 

Tab.SHELCAL PO OD 

Tab.LASIX 20MG PO B