60 years old female patient with history of burning micturation

 Case history

Date of admission : 2/08/2021

60 year old female resident of Hyderabad presented to the opd with chief complaint of burning micturation since 2 weeks

History of present illness:

Patient was apparently asymptomatic or normal

-14 days back then she developed lower backpain

-followed by fever, shievering

-Slowly raised sugar levels and blood pressure

-followed by weakness and burning micturation

past history :

- From 6 years buring micturation is recurrent for every 6 months

-She undergone histerectomy before 20 years

-No history of trauma

-No history of epilepsy

-She has diabetes from 25 years

Personal history :

- Appetite : less

- diet: mixed

-addictions: No

- bowel and bladder movements : Normal

Family history:

-No history of similar complaints in family members

Treatment history:

-No history of drug allergy

General examination:

- Patient is coherent,  conscious,  well oriented, cooperative, normal built and nourishment 

- Pallor: present

-No icterus

-No cyanosis

-No clubbing

-No lympahadenopathy

-Pedal Edema: present

Vitals:

-Temperature : 96 degree Fahrenheit 

-Blood pressure: 110/80 mm of Hg

-Pulse rate: 95bpm

- respiratory rate: 23cpm

- GRBS: 135 mg/dl

Systemic examination :

-CVS: S1 and S2 are heard

- Resp. System: inspiratory crets noted

-No alterations in CNS

-No abnormality in muscle

-Abdomen: soft and no tender

Provisional diagnosis:

This is a case of urinary tract infection with sepsis

Investigations:

Vitals and temperature :


ECG:


Haemogram:



Serum urea,  creatinine

4//8/2021:

Serum creatinine:4.18

5/8/2021:

Urea:121

Serum creatinine:4.2

6/8/2021:

Urea:132

Serum creatinine:4.1


Treatment:

TAB PAN 40mg po/Of

Inj.levofloxacin 500mglv/od

Tab.tamsulosin 0.4mg po/hr

Tab.thyronom 50 microgram/po/of

Tab.ultracet1/2tab/po/of

Inj.piptaz 2.2g/iv/tid















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