A 60 yr old Female case with anuria

LEARNER REPORT
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 March 8th 2022.

60Y/F FOLLOW UP CASE.
I HAVE 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 A DIAGNOSIS AND TREATMENT PLAN.

A 60yr old dailywage labourer came to casuality with complaints of rentention of urine since 4days

HISTORY OF PRESENTING ILLNESS

pt was apparently asymptomatic 15 days back.Then she developed fever 15 days back , low grade wih chill and rigor.
It is not associated with profuse sweating on and off increased during night.  She also complains of cold which is not associated with cough which lasted for 10 days and relieved on medication . She also complains of suprapubic tenderness and bulge is noted 3 days back 
She went to local hospital for examination , foley's was passed ( approx 1 lit of urine was passed ) 
No C/O  of chest pain , palpitations and syncopial attacks 

PAST HISTORY
N/k/c/o  HTN , DM , Thyroid , TB 

PERSONAL HISTORY:
She follows a mixed diet. 
Appetite -Normal,
Bladder movements- abnormal 
Bowel movements- Normal . 
Sleep- Adequate.

FAMILY HISTORY: No significant family history.
DRUG HISTORY: No known drug allegies

General examination : patient is conscious ,coherrent, co operative and well oriented to her surroundings.she is moderately built and nourished.no pallor ,no cyanosis, no icterus, no lymphadenopathy. 

Vitals:. Temperature: afebrile. 
Pulse rate: 98 beats / min.
 Respiratory rate: 19 cycles / min.
 Bp: 110/70 , 
Spo2: 99 
GRBS - 112 mg/dl


SYSTEMIC EXAMINATION:
CVS: S1S2 heard, no murmurs
RS: BAE+ NVBS+
P/A: Soft, Non-tender
CNS: NAD



Provisional Diagnosis 
Acute kidney injury secondary to sepsis 

Treatment 








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