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    Case Discussion

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    Case Discussion

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    Case Discussion

    Uploaded by

    pedipccm

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    Case discussion

    Moderator :- Dr. Turegn (ID Fellow )


    Prepared by ; Dr.Mitiku (R2)

    1 07/02/2024
    Out line
    History
    Physical examination
    Investigation
    Hospital course
    Diagnosis

    2 07/02/2024
    Hx
    This is a 1 yr and 3 yr old male infant who was last relatively healthy
    since at the age of 7 month Presented with decrease urine out put and
    difficult to urinate since birth but not got medical attention until the age of
    7 month then went to LHC and took unspecified PO medication but not
    got improvement and went to Alert hospital and admitted for 3 weeks for
    complicated UTI with unspecified IV medication and catheterized then
    referred to our hospital then admitted and vesicotomy was done and
    treated complicated UTI and HAI then discharge with symptom free

    3 07/02/2024
    Hx
     Currently presented with HGIF , 2-3 episode of non projectile ,non bloody, non
    bilous vomiting of ingested matter , watery diarrhea and loss of appetite of 1
    week. In addition to this ,has hx of wound site pain and itching sensation
     20 days prior to this admission ,he had hx of admission for surgical intervention
    which is vesicostomy for BOO 2nd to PUV
     Other wise no hx Cough ,SOB ,
    No hx of ABM,LOC
     Born to a Para 2 mother after 9 month of amennorhea via SVD with unknown
    APGAR score but cried immediately after birth
     She is fully vaccinated according to EPI
     He is adequately sun light exposure

    4 07/02/2024
    PE
     GA- ASL
     VS –PR- 140 RR- 32 T- 37.8 SpO2- 96%
     Wt- 6kg Lt- 70cm MUAC- 11cm WFL- <-3SD
     HEENT- PC,NIS, sunken eye ball and dry buccal mucosal
     LG- NO LAP
     CHEST- clear chest with good air entry
     CVS – s1 an s2 well heard ,no M and G
     Abd- no organomegaly
     GUS- NEMG
     Ig- no rash /lesion
     Mss- no deformity
     CNS- alert

    5 07/02/2024
    Hospital course
    Admitted for complicated UTI and started on ceftraxone ,then developed
    hyponatremia and hyperkalemia and was started salbutamol puff and salt
    Subsquently ,develop fast breathing and LGIF and irritability for this
    consider metabolic Acidosis and initiated NaHCo3

    6 07/02/2024
    Con…
    Ecoli was growth from urine culture and antibiotics changed to
    meropenum for 10 days
    For otitis external started cefepime and vancomycin and subsequently
    changed to piperacillin tazobactam

    7 07/02/2024
    Ix
    11/06/24 17/6/24
    WBC 20.13 19.3
    Neu 61.3% 48.2%
    Lym 25.4% 40.4%
    Hgb/HCT 8.2/25.4 9.8/28.9
    MCV 89.1 88.1
    RDW 20.7 20.3
    PLT 406k 375k
    UAA Sg- 1.025 WBC- 6-10 RBC-
    10-15
    Lec- +2 BLD- +3 pro- +1
    RFT Cr- 1.2 0.8
    Urea- 56
    CRP -ve
    8 BLD 3x NG 07/02/2024
    Con….
    16/5/24 27/5/24 04/6/24
    Urine cul ECOLI Ng Yeast cell
    PUS GS- G+VE
    CUL- MIXED FLORA
    Na 140 135 142
    K 6.32 4.19 5.99
    Cl 110.7 103.5 116.1

    9 07/02/2024
    Ix
    Rt kidney measure 8*16 and Lt kidney 8.1*4.9cm and has bilateral
    moderate pelvicalceal dilation with evacuation ,less cortisone summary
    differentiation with cortical thickness and dilated renal pelvic measure
    2.6rt and 2.7lt from intemal echodebris in the dilated uretro and pelvic
    calciua on both side
    Con – bilateral moderate hydronephrosis + pyonephrosis

    10 07/02/2024
    Imaging
    Head CT scan
    Rt middle Ear and mastoid air cells as well external auditory canal
    effusion and likely Rt side otomastoditis and left mastod air cells partial
    opacification

    11 07/02/2024
    Dx
    P1; SAM(NE)
    P2; 3rd procedure month after vesicostomy was done for indication of BOO
    2nd to PUV
    P3; AKI on CKD
    P4; Complicated UTI
    P5;Metabolic Acidosis
    P6;Facial nerve palsy
    P7; malignant otitis Externa

    12 07/02/2024

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