Urosepsis ,post renal AKI with B/L Hydronephrosis secondary to bladder calculi

 Gen med case presentation;

Jan 22,2022

Name;Ramya reddy pebbeti.

 Roll no;105 .

This is 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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome. 

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

Following is the view of my case :

CASE PRESENTATION ;

DOA:20/01/22

chief compliants: A 66 yr old female , residence of mothkur came to the opd with C/O

*Burning micturition  since 10 days

*Decreased urine output since 10 days

*Fever on and off since 10 days

*Abdominal pain since 3 days 

ON 18/01/22 She went to private hospital near their house with the same complaints , where they did some investigations like shown below;

CUE;

CBP;

CT ABDOMEN;

CT ABDOMEN showed the large calculus in the bladder and also B/l Hydronephrosis .

She is referred to our hospital .

On 20/08/22 she came to our opd with the same complaints,

And there is no H/o loin pain,hematuria.

Past history; 

She was hysterectomised 18 years back for fibroid uterus.

Not a k/c/o DM,HTN,epilepsy,asthma,TB

Personal history;

Diet ;mixed

Appetite;normal

Bowel movements;normal

Sleep; adequate

General physical examination;

Pt is conscious, coherent, cooperative

Vitals; 

Temp;afebrile now

Bp;110/80mm of hg

PR;86bpm

RR;20cpm

SPO2; 98%on room air

Systemic examination;

RS; BAE+

CVS:S1,S2 HEARD

P/A;

Inspection;

Distended,no scars and sinuses

Position of umbilicus; central and inverted

Palpation;

 soft,tender, a hard mass of 12*8 cm size is palpable in suprapubic region.

Normal bowel sounds heard.

CNS:NAD

The investigations are;

Xray abdomen;

USG ABDOMEN;

Serum electrolytes;

HBsAg ;

BLOOD SUGAR;

BLOOD GROUP AND TYPING;

CUE;

ECG;

#Diagnosis:

Urosepsis ,post renal AKI with B/L Hydronephrosis secondary to  bladder calculi.

Treatment:

*Plan of treatment; 

Tab.Nitrofurantoin 100 mg oD

Tab.orofer xT Po OD

Tab nodosis  500 mg po oD

Tab.shelcal po OD

Tab .Lasix 20 mg PO BD

Tab .PCM 650 mg po OD

*Planned for OPEN CYSTOLITHOTOMY ON 4/5 Feb