65 yr old with cystitis with AKI

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CBBLE UDHC Similar case



This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."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 a diagnosis and treatment plan

65 yr old female came with C/o burning micturition since 4-5 days
Decreased urine output since today morning 
Pedal edema since 5-6 hrs 

HOPI : 
Patient was apparently asymptomatic 4 to 5 days ago then she developed
BURNING MICTURITION 
No h/o    loin pain , pain abdomen, fever & chills , vomitings, diarrhoea, itching in genital region, white discharge . 

 Complaints of DECREASED URINE OUTPUT  since one day only few drops of urine passed since morning &  went to the outside Hospital and the treatment of INJ. LASIX 40 mg was given after which she passed urine 
No h/o fever, vomitings,diarrhoea 
No h/o hematuria , loin pain 

 Complaints of  bilateral PEDAL EDEMA , insidious in onset, gradually progressive, pitting type , grade 2 ( upto knees). 
No h/o of exertional dysnea, orthopnea , PND, 
NO h/o of jaundice , pruritus , facial puffiness 

HISTORY OF PAST ILLNESS: 

k/c/o HTN since 6yrs & using T.TELMA mg OD 
N/k/c/o of Dm, BA, TB, EPILEPSY, CVA , THYROID DISORDERS . 

PAST SURGICAL  HISTORY : Hysterectomy 4yrs ago. 

 PERSONAL HISTORY : 
Diet : mixed
Appetite : normal
Sleep : adequate 
Bowel & bladder habits : regular
                                    Burning micturition + 
No known addictions 

EXAMINATION : Pt is c/c/c
VITALS : 
TEMP : 98.6 f
HR : 75bpm
BP : 140/80 mm hg
RR : 18cpm
SPO2 : 98 % @RA
GRBS: 111mg/dl 

P/A : soft, obese ,suprapubic tenderness+ 
CVS : s1, s2 + . No murmurs 
RS : bae + NVBS + 
CNS  : NAD 

INVESTIGATIONS : 
Usg abdomen on 3/3/22 : NO sonological abnormality detected. 
 
 
DIAGNOSIS : Cystitis with AKI 

TREATMENT : 
1) IVF NS & RL @urine output + 30ml / hr
2) INJ. PANTOP 40mg i.v BD 
3) Inj. LASIX 20mg i.v BD 







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