Final pratical long case
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A 70 year old, labourer by occupation presented to OPD with chief complaints of
Decreased urinary output since 30 days
Burning micturition since 30 days
Urgency and hesitancy of micturition since 30 days
Mass per abdomen since 25days
History of 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.
History of past illness:-
She was hysterectomised 20 years back for fibroid uterus.
Not a know case of diabetis mellitus, hypertension, asthma, epilepsy, tuberculosis.
Personal history:-
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel movements- normal
Family history:-
No similar history in family members
General physical examination:-
Patient is conscious, coherent, cooperative
Pallor present
No icterus
No cyanosis
Clubbing present
No generalized lymphadenopathy
No pedal edema
Vitals:-
Temp- afebrile
BP- 90 /50 mm hg
PR - 86bpm
RR- 20 cpm
Spo2- 98%
Systemic examination:-
Respiratory system:- bae+
CVS :- S1, S2 +
P/A:- distended, tenderness+ a hard mass of size 12×8 cm palpable in the suprapubic region
CNS:- no abnormality detected
DIAGNOSIS:-
Urosepsis secondary to bilateral hydroureteronephrosis with bladder calculi with AKI with UTI.
Plan of 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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