60 year old female
60 year old female came to OPD with chief complaints of
TREATMENT:
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:
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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