60 year old female

60 year old female came to OPD with chief complaints of 

Acute retention of urine since 5 days

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 20 days back .she visited her younger sister house for attending some function there she had a fever which was low grade associated with chills and rigor.which was on and off.increased during night time. Associated with cold she visited local rmp fever was relieved on medication .after 10 days she had decreased urine out put and not passed stools for 2 days and had 1 syncope attack. She felt on the ground which was observed by her relatives

* Suprapubic bulge was noted and she had pain over suprapubic region. her son taken her to local hospital for examination and Foley's catheter was kept and she passed approximately about 1 litre of urine .

* Their they told that infection is there and referred to our hospital.

No c/o chest pain, sob, palpitations

PAST HISTORY:

She is not a k/c/o diabetes, hypertension,asthma,tb, epilepsy cva,cad

FAMILY HISTORY  - insignificant

PERSONAL HISTORY:

Appetite : decreased
Diet ; mixed
Bowel : regular
Bladder : decreased urine output
Sleep : adequate
Addictions : occasional toddy drinker

GENERAL EXAMINATION:

The patient is conscious, coherent, cooperative and moderately built and moderately nourished.
Pallor - present
Icterus : absent
Cyanosis,; absent
Clubbing: absent
Edema : absent 
No generalized lymphadenopathy

VITALS:

Temperature; 98.3° f
Pulse rate: 90bpm
Blood pressure; 100/70 mmHg
Respiratory rate : 22cpm
Spo2 : 98%@room air
GRBS: 112mg/dl

SYSTEMIC EXAMINATION:

Per abdomen examination;
Inspection:

Shape of abdomen : scaphoid, suprapubic bulge was noted

Umbilicus ; central

No visible pulsations,engorged viene,no visible peristalsis 

Movements equal on respiration

Skin over abdomen normal

Palpation:

Tenderness in suprapubic region ,

No loacl rise of temperature

No organomegaly 

Percussion:

Resonant note heared

Auscultation; bowel sounds were heared

Respiratory system;

Bilateral air entry present,trachea is in central position.

Normal vesicular breath sounds were heared

Cardiovascular system;

S1,S2 heart sounds heared.

Central nervous system;

Higher mental functions;

Leave of consciousness ; normal

Speech: normal

No meningeal signs

Cranial nerve s : intact

Provisional diagnosis;

Acute kidney injury secondary to urosepsis


INVESTIGATIONS:

Serum electrolytes; 

Sodium- 139

Potassium- 5.2

Chloride- 99

Serum creatinine - 8.0- 6.1

Serum urea- 333- 260

TOTAL bilirubin: 1.8

Direct bilirubin: 0.83

AST : 26

ALT : 28

ALP ; 902

Total protein: 4.9

Albumin,; 2.2
ECG:
Chest X-ray:
TREATMENT:

On 4/3/22

1) inj.piptaz 4.5gm iv start 

2)Inj piptaz 2.25gm/iv/qid

3) Inj pan 40mg iv od

4)iv fluids NS/RL @100ml/,hour

5) Inj zofer 4mg iv od

6) Inj optineuron 1amp iv 500ml NS od

7) tab Nodosis500mg po od

8) Inj lasix40 mg iv tid
On7/3/22 ; on examination 

On7/3/22 ; on examination :

Pt is conscious coherent, cooperative

PR: 80bpm

BP: 130/90mmhg

1) inj.piptaz 4.5gm iv start 

2)Inj piptaz 2.25gm/iv/qid

3) Inj pan 40mg iv od

4)iv fluids NS/RL @100ml/,hour

5) Inj zofer 4mg iv od

6) Inj optineuron 1amp iv 500ml NS od

7) tab Nodosis500mg po od

8) Inj lasix40 mg iv tid

9)tab Tamsulosin0.4mg Hs

     *-*-1

On8/3/22;

Pt is conscious coherent, cooperative

PR: 80bpm

BP: 130/90mmhg

1)Inj piptaz 2.25gm/iv/qid

2) Inj pan 40mg iv od

5)iv fluids NS/RL @100ml/,hour

6) Inj zofer 4mg iv od

7) Inj optineuron 1amp iv 500ml NS od

8) tab Nodosis500mg po od

9) Inj lasix40 mg iv tid

10)syp cypon 10ml TID



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