70M WITH SEPTIC SHOCK 2 TO UROSEPSIS WITH B/L RENAL CALCULUS WITH B/L HYDOROURETERONEPHROSIS

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I've 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 diagnosis and treatment plan

CHEIF COMPLAINTS:

Patient came with cheif complaints of abdominal pain in Right lower quadrant of abdomen since 1week 

HISTORY OF PRESENT ILLNESS: 

Patient was apparently asymptomatic 1week back then he developed pain in the Right lower quadrant abdomen which is

spasmodic type , intermittent, non radiating

H/o fever present which is intermittant, relieved on medication

H/o vomittings present(immediately after intake of food) which is non bilious non-projectile With food as content

PAST HISTORY:

Daily routine:

 he used to Woke up at 5am, had breakfast around 7am he used to roam in street He packed his lunch which he ate at his workplace around 1pm, and came home by 4pm

He ate at 8pm and slept at 10pm.

50 years back he had a pelvic surgery (transurethral cystolitholapaxy) for removal of bladder stone

* There is no history of similar complaints in the past.

* he is not a known case of Diabetes, Hypertension, Asthama, Epilepsy, Tuberculosis.

Personal history:-

Diet - mixed

Appetite- normal

Sleep - adequate

Bowel and bladder movements - regular.

Alcohol consumption since 20 yrs and currently consumes 45 ml of alcohol daily.

GENERAL EXAMINATION 

On examination, patient is conscious, coherent and cooperative and he is well oriented to time place and person

He is moderately built and well nourished

*Pallor - absent

*Icterus- present

*Clubbing-absent

*Cyanosis-absent

*Lymphadenopathy-absent

* Edema- absent

Vitals:-

BP- 120/70 mmHg

RR- 20cpm

PR-111bPm

Spo2- 99%at RA.

GRBS- 126mg/dl

 

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard. No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  

Normal vesicular breath sounds heard. 

ABDOMEN:

*non tender

*soft

CNS:

Conscious and coherent.

Normal sensory and motor responses

INVESTIGATIONS

PROVISIONAL DIAGNOSIS:

 SEPTIC SHOCK 2 TO UROSEPSIS WITH B/L RENAL CALCULUS WITH B/L HYDOROURETERONEPHROSIS

TREATMENT:

1) Iv Fluias 20ns @75ml/hr 

2) inj norad 46ml Ns +4ml 

3) inj buscopan im/OD

4) inj pipal 2.25 iv/tid 

5) inj metronidazole 500mg iv tid 

6) inj vasopressin 2ml +38ml ns @ 0.6ml /hr 

8)inj NAHCO3 50 meq iv/ stat

9)temp monitoring 4th hourly 

10) hourly abdomen girth monitoring 

11) monitor vital (bp pr rr sp02 

12) inj kcl 20meq iv/Stat