LONG CASE
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A 70 year old female patient,labourer by occupation came with chief complaints of
Diagnosis:
1)decreased urine output since 30days
2)burning micturition since 30 days
3)urgency and hesitency of micturition since 30 days
4)mass per abdomen since 25 days⁷
PRESENT ILLNESS:
Patient was apparently asymptomatic 30days back, then she noticed a decrease in urine output, burning micturition, urgency and hesitancy of micturition, so she visited to local hospital and investigations were done.
She denies h/o fever, loin pain, hematuria.
PAST HISTORY
She was hysterectomised 18 years back for fibroid uterus.
Not a k/c/o DM,Hypertension,asthma , epilepsy,TB
PERSONAL HISTORY
Diet - mixed
Appetite - normal
Sleep- adequate
Bowel movements- normal
Addictions : no addictions
General physical examination:
Patient is conscious, coherent, cooperative, moderately built and nourished well oriented to time and place
Pallor is present
No cynosis
No icterus
Clubbing is present
No bilateral pedal edema
Vitals-
Temp- afebrile
Bp-90/50 mm hg
Pr- 86 bpm
Respiratory rate:20 cpm
SYSTEMIC EXAMINATION:
respiratory : bilateral air entry is normal
CVS : s1 and s2 are heard
Per abdomen : distended and hard mass approximately 10×8cm present in supra public region
CNS : no abnormalities detected
Diagnosis:
Urosepsis secondary to bilateral hydroureteronephrosis with bladder calculi with AKI with UTI.
Treatment:
Tab.NITROFURANTOIN 100MG OD
Tab.OROFER PO OD.
Tab.NODOSIS 500MG PO BD
Tab.SHELCAL PO OD
Tab.LASIX 20MG PO BD
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