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 signed 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.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box

BLADDER CALCULI


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

1)decreased urine output since 20days
2)burning micturition since 20 days
3)urgency and hesitency of micturition since 20 days
4)mass per abdomen since 15 days

The patient was apparently asymptomatic 20 days back ,then she noticed a decrease in her urine output , burning micturition,urgency and hesitency of micturition ,so she visited 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 T2DM,HTN,asthma , epilepsy,TB 

PERSONAL HISTORY
Diet - mixed
Appetite - normal
Sleep- adequate
Bowel movements- normal

General physical examination
Pt is conscious, coherent, cooperative, 
 Vitals-
Temp- afebrile 
Bp-90/50 mm hg
Pr- 86 bpm
Rr-20 cpm
Spo2- 98% on RA

Systemic examination
RS- bae+, nvbs
Cvs-S1 S2 +
P/A - distended,tenderness + a hard mass of size 12x8 cm palpable in the suprapubic region.
Cns- nad






X RAY ERECT ABDOMEN

ECG

ULTRASOUND ABDOMEN



INVESTIGATIONS









DIAGNOSIS
UROSEPSIS secondary to b/l hydro ureteronephrosis with Bladder calculi with AKI  with UTI.

PLAN OF TREATMENT
Tab.NITROFURANTOIN 100 MG OD
Tab.OROFER XT  PO OD
Tab. NODOSIS 500 MG PO BD
Tab.SHELCAL PO OD
Tab. LASIX  20 MG PO BD



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