Case 39 65 Male with increased urinary frequency since 3 months

Doa 31/5/24

Dod 3/6/24

Diagnosis

DIABETES INDUCED CHRONIC PYELONEPHRITIS

DIABETIC NEPHROPATHY WITH RIGHT HYDROURETERONEPHROSIS , WITH LOWER

URINARY TRACT SYMPTOMS

K/C/O HTN AND DM SINCE 15YRS

K/C/O BRONCHIAL ASTHMA SINCE 6YRS

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O INCREASED URINARY FREQUENCY SINCE 3MONTHS.

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3MONTHS AGO THEN DEVELOPED

INCREASED URINARY FREQUENCY AND URINARY URGENCY, INCREASE URINE FLOW. NO

DRIBBLING OF URINE.

C/O BURNING MICTURITION SINCE 2DAYS AND WAS NOT ASSOCIATED WITH CHILLS AND

RIGORS. AND PAIN ABDOMEN

NO C/O HEADACHE, GIDDINESS ,BLURRING OF VISION

C/O POLYURIA,POLYDYPSIA, POLYPHAGIA

NO C/O CHEST PAIN, PALPITATIONS.ORTHOPNEA AND PND

NO C/O PAIN ABDOMEN, NAUSEA, VOMITING,LOOSE STOOLS.

PAT HISTORY:

K/C/O T2DM SINCE 15YRS &ON MEDICATION

K/C/O HTN SINCE 15YRS &ON MEDICATION

BRONCHIAL ASTHMA SINCE 6YRS &ON MEDICATION

FAMILY HISTORY :

NOT SIGNIFICANT.

PERSONAL HISTORY:DIET- MIXED ,NORMAL APETITE , BOWEL HABITS REGULAR

,INCREASED URINARY FREQUENCY PRESENT.NO KNOWN ALLERGIES , ALCOHOL -

TEETOTALER

GENERAL EXAMINATION:PALLOR PRESENTNO ICTERUS, CYANOSIS, CLUBBING

,LYMPHADENOPATHY,EDEMA

VITALS:TEMP: 98.4F

PR: 92BPM

RR: 16CPMBP: 150/70MMHG

CVS: S1S2 HEARD , NO THRILLS, NO MURMURSRESP: BAE+ , NO WHEEZE , NVBS:

HEARDPER ABDOMEN: SOFT ,NON TENDERCNS: CONSCIOUS,NORMAL SPEECHCRANIAL

NERVES NORMALMOTOR AND SENSORY SYSTEM NORMALREFLEXES: RT LTBICEPS : 2+

2+TRICEPS : 1+. 1+SUPINATOR : 1+ 1+KNEE: 2+. 2+ANKLE: 1+ 1+

SURGERY REFERRAL WAS DONE ON 1/6/24 I/V/O SWELLING OF BOTH HEMISCROTUM

SINCE 15 YRS

ADVICE: CONSERVATIVE TREATMENT FOR BPH.AFTER RESOLUTION OF SYMPTOMS CAN

BE POSTED FOR B/L JABOULAYS PROCEDURE

NEPHROLOGY REFERRAL WAS DONE ON 3/6/24 I/V/O NCCT-KUB CHANGES

ADVICE : TAB.NODOSIS 1-1-1

CAP.BIO D3 PO/OD

T.TELMA 40 0-1-0

ON ANTI-DIABETIC TREATMENT

REVIEW SOS

UROLOGY REFERRAL WAS DONE ON 3/6/24 I/V/O INCREASED FREQUENCY OF MICTURITION

ADVICE : T.TAMSULOSIN 0.4MG PO/OD 8AM X 3 MONTHS

T.SOLITEN 5MG PO/HS 9PM X 2 MONTHS

REST RX AS PER NEPHROLOGIST AND PHYSICIAN

R/A 1 MONTH TO UROLOGY OPD

Investigation

BLOOD UREA 31-05-2024 03:08:PM 35 mg/dl 50-17 mg/dl SERUM CREATININE 31-05-2024

03:08:PM 2.1 mg/dl 1.3-0.8 mg/dlLIVER FUNCTION TEST (LFT) 31-05-2024 03:08:PMTotal

Bilurubin 0.63 mg/dl 1-0 mg/dlDirect Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 21 IU/L 35-0

IU/LSGPT(ALT) 11 IU/L 45-0 IU/LALKALINE PHOSPHATASE 167 IU/L 119-56 IU/LTOTAL

PROTEINS 6.7 gm/dl 8.3-6.4 gm/dlALBUMIN 4.5 gm/dl 4.6-3.2 gm/dlA/G RATIO 2.0 COMPLETE

URINE EXAMINATION (CUE) 31-05-2024 03:08:PMCOLOUR Pale yellow APPEARANCE Clear

REACTION Acidic SP.GRAVITY 1.010 ALBUMIN Nil SUGAR + BILE SALTS Nil BILE PIGMENTS Nil

PUS CELLS 2-4 EPITHELIAL CELLS 2-3 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil

AMORPHOUS DEPOSITS Absent OTHERS Nil SERUM ELECTROLYTES (Na, K, C l) 31-05-2024

03:08:PMSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 4.9 mmol/L 5.1-3.5 mmol/LCHLORIDE

104 mmol/L 98-107 mmol/L HBsAg-RAPID 31-05-2024 03:08:PM Negative Anti HCV Antibodies -

RAPID 31-05-2024 03:08:PM Non Reactive POST LUNCH BLOOD SUGAR 01-06-2024 07:14:AM

292 mg/dl 140-0 mg/dlHAEMOGLOBIN 9.7gm/dlTOTAL COUNT 7,300cells/cummNEUTROPHILS

74%LYMPHOCYTES 17%EOSINOPHILS 01%MONOCYTES 08%BASOPHILS 00%PCV 28.3vol

%M C V 87.6flM C H 30.0pgM C H C 34.3%RDW-CV 13.1%RDW-SD 42.5flRBC COUNT

3.23millions/cummPLATELET COUNT1.70lakhs/cu.mmRBC Normocytic normochromicWBC With in

normal limitsPLATELETS Adeqaute

2D ECHODONE ON 31/5/24:

MILD AR+/TR+ WITH PAH

NO MR NO RWMA

SCLEROTIC AV,GOOD LV SYSTOLIC FUNCTION,GRADE II DIASTOLIC DYSFUNCTION

IVC-0.8 CM COLLAPSING

EF-65%

RFT 2/6/24UREA - 42

CREATININE - 2.2

URIC ACID - 4.4

CALCIUM - 9.6

PHOSPHOROUS 3.2

SODIUM - 141

POTASSIUM - 4.8

CHLORIDE - 106

FBS 101 mg/dl

PLBS 140 mg/dl

Hba1c 6.6%

SPOT URINE PROTEIN - 6

SPOT URINE CREATININE - 53

Ratio-0.11

COURSE IN THE HOSPITAL : PATIETN WAS ADMITTED I/V/O ABOVE MENTIONED

COMPLAINTS AND WAS INVESTIGATED FURTHERAND ON FURTHER EVALUATION WAS

DIAGNOSED AS DIABETES INDUCED CHRONIC PYELONEPHRITIS, DIABETIC NEPHROPATHY

WITH RIGHT HYDROURETERONEPHROSIS AND WITH LOWER URINARY TRACT SYMPTOMS.

GENERAL SURGERY REFERRAL WAS DONE ON 1/6/24 I/V/O SWELLING IN THE SCROTUM ,

UROLOGY REFERRAL WAS DONE ON 3/6/24 AND WAS ADVISED T.TAMSULOSIN 0.4MG

PO/OD 8AM X 3 MONTHS , T.SOLITEN 5MG PO/HS 9PM X 2 MONTHS AND NEPHROLOGY

REFERRAL WAS DONE AND WAS ADVISED TAB.NODOSIS 1-1-1 , CAP.BIO D3 PO/OD T.TELMA

40 0-1-0 ,ON ANTI-DIABETIC TREATMENT. PATIENT WAS MANAGED CONSERVATIVELY WITH

ORAL HYPOGLYCEMICS,ANTI BIOTICS , ANTI HYPERTENSIVES.PATIENT IS

HEMODYNAMICALLY STABLE AT THE TIME OF DISCHARGE

Treatment Given(Enter only Generic Name)

T.DOXY 100MG PO/OD

T.GLIMI M1 PO/BD

T.TENEGLIPTIN M PO/OD

T.OROFER XT PO/OD

T.PAN 40MG PO/OD

T.TECZINE 5MG PO/HS 0-0-1

CAP.BIO D3 PO/OD(WEEKLY TWICE)

MOMATE F CREAM L/A

VENUSIA MAX CREAM L/A

NEB WITH BUDECORT 12TH HOURLY

T.MUCINAC 600MG PO/BD

T.TAMSULOSIN 0.4MG PO/OD

T.SHELCAL 500MG PO/OD 0-1-0

Advice at Discharge

T.DOXY 100MG PO/ODX 1 DAY

T.GLIMI M1 PO/BD 1-0-1

T.TENEGLIPTIN M PO/OD 0-1-0

T.OROFER XT PO/ODX 2MONTHS

T.PAN 40MG PO/ODX 7 DAYS

T.TECZINE 5MG PO/HS 0-0-1X 1 WEEK

T.NODOSIS PO/TID 1-1-1

CAP.BIO D3 PO/OD 1-0-0 (WEEKLY TWICE) X 2 WEEKS

MOMATE F CREAM L/A

VENUSIA MAX CREAM L/A

FOROCORT 200 MG ROTAHALER/2 PUUFS BD FOLLOWED BY SOS

T.MUCINAC 600MG PO/BDX 3 DAYS

T.TAMSULOSIN 0.4MG PO/OD

T.TELMA 40 PO/OD 1-0-0

T.CINOD PO/OD 0-0-1

T.SHELCAL 500MG PO/OD 0-1-0

Follow up in january 2025

Patient id doing well and adherent to diabetic diet

FBS 100 mg/dl

Plbs 120 mg/dl

Hba1c 6.4%