GENERAL MEDICINE CASE

SHIVANI KOMMERA 


• A 70 year old labourer by occupation came with the 

CHIEF COMPLAINTS  - 
 
• Decreased urine output since 20 days 
• Burning micturation since 20 days 
• Urgency and hesitency of micturation since     20 days 
• Mass per abdomen since 15 days

HISTORY OF PRESENT ILLNESS 
 
• Patient was asymptomatic 3 Months back , then she developed slight  burning micturation for which she was not on any medication .

• 20 days back she suddenly noticed decreased urine output , with increased frequency and urgency assosiated with burning micturation for which she visited local hospital where investigations were done and Ultrasound shows Bladder calculi .

• She denies H/o Fever , Loin pain , Hematuria 

PAST HISTORY 

Not k/c/o HTN ,DM , Epilepsy , Bronchial asthma ,TB .

SURGICAL HISTORY - 

She underwent Hysterectomy 20 yrs ago

PERSONAL HISTORY 

• Diet - Mixed 
• Appetite - Decreased 
• Bladder movements - Oliguria 
• Bowel - Normal 
• Ocasional Alcoholic + 
• Tobacco chewer 

FAMILY HISTORY 

• No H/o DM , HTN , CVA , CAD , Bronchial asthma , Thyroid disorders , epilepsy in the family  


GENERAL EXAMINATION

• Patient is concious , coherent , co-operative 
• Moderately built and moderately nourished 

• Pallor + 
• Icterus - 
• Cyanosis - 
• Koilonychia -
• Clubbing - 
• Lymphadenopathy - 
• Oedema - 

XRAY ERECT ABDOMEN 
ECG
USG 
DOPPLER
INVESTIGATIONS
HEMOGRAM
CUE 


VITALS

• Temperature - afebrile 
• Bp-90/50 mm Hg
• Pr- 86 bpm
• Rr-20 cpm
• Spo2- 98% on RA



SYSTEMIC EXAMINATION 

Cardiovascular system 

INSPECTION

• Chest wall is bilaterally symmetrical .
• No precordial bulge .
• No visible pulsations, engorged veins, scars, sinuses .


PALPATION

• JVP - Normal 
• APEX BEAT - Felt in the left 5 th intercostal space in the midclavicular line .

AUSCULTATION
 
• S1 S2 heard .
• No murmurs 

Respiratory system 

• Position of the trachea  - Centre 
• Bilateral air entry +
• Normal vesicular breath sounds heard 
No added sounds .

Per abdomen 

• Distended,tenderness + a hard mass of size 12x8 cm palpable . 

Central nervous system 

• Patient is Conscious , drowsy .
• Speech: normal
• No signs of Meningeal irritation
• Motor & sensory system: normal
• Reflexes: normal
• Cranial nerves: intact 


Diagnosis 

• Urosepsis secondary to B/L Hydroureteronephrosis .
• Bladder calculi 
• Post renal AKI 

Treatment 

Day 1 

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

Day 2 

Inj . MEROPENEM 500mg / IV / TID
Inj . OPTINEURON 1 ampule in 100 ml NS / IV OD 
TAB . OROFER XT OD
TAB . NODOSIS 500 mg OD 
TAB . SHELCAL OD 








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