Case 40 76 Male with fever,abdominal pain and burning micturition

Doa 9/1/24

Dod 17/1/24

Diagnosis

UROSEPSIS

AKI-PRERENAL(RESOLVED)

DENOVO T2DM

B/L RENAL CALCULUS

BPH

Case History and Clinical Findings

PT CAME WITH C/O FEVER SINCE 5 DAYS

PAIN ABDOMEN SINCE 3DAYS

BURNING MICTURITION SINCE 10DAYS

PT WAS APPARANTLY ASYMPTOMATIC 10DAYS BACK THEN HE DEVOLEPED BURNING

MICTURITION INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE WITH INCREASED

FREQUENCY

PAIN ABDOMEN SINCE 3 DAYS, BURNING TYPE INSIDIOUS NOT RADIATING, NO

AGRRAVATING AND RELIEVING FACTORS.

FEVER SINCE 5 DAYS LOW GRADE A/W CHILLS GRADUALLY PROGRESSIVE NO

AGRRAVATING AND RELIEVING FACTORS.

NOT A K/C/O HTN, DM, CAD, THYROID DISORDERS, SEIZURES, ASTHMA, TB.

GENERAL EXAMINATION :

PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .

NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMP - AFEBRILE

PR- 76 BPM

RR-18CPM

BP- 120/80MMHG

SYSTEMIC EXAMINATION :

CVS - S1,S2 HEARD , NO MURMURS

RS - VESICULAR BREATH SOUNDS HEARD , NO WHEEZE AND DYSPNEA, CREPTS IN RAA,

ISA

P/A- SOFT , NON-TENDER , NO ORGANOMEGALY

CNS - NFND

UROLOGY REFFERAL WAS DONE 11/1/24

ADV: CONTINUE PIPTAZ

LIMIT WATER INTAKE 2-3L/DAY

SYP ALKASTONE B6 15ML IN 1 GLASS OF WATER PO/BD

TAB TAMSULOSIN 0.4MG PO/HS

SYP CREMAFFIN 15ML PO/HS

USG DONE ON 9/1/24

B/LRENAL CALCULI WITH B/L GRADE 1 RPD CHANGES

REVIEW USG ON 16/1/24

B/LRENAL CALCULI WITH B/L GRADE 1 RPD CHANGES

\RIGHT SIMPLE RENAL CORTICAL CYST

PROSTATIC CALCIFICATION

SIGNIFICANT PVR.

2D ECHO WAS DONE ON 10/1/24

EF 56%

NO AR/MR/TR

NO RWMA NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTUION, NO PAH/PE

REVIEW 2D ECHO WAS DONE 16/1/24

EF 65%

NO RWMA

TRIVIAL AR:NO MR/TR

GOOD LV SYSTOLIC FUNCTION

IVC SIZE 1.11 CM COLLAPSED.

Investigation

COMPLETE URINE EXAMINATION (CUE) 09-01-2024 10:02:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGAR+++BILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilBLOOD UREA09-

01-2024 10:02:PM6 88 mg/dl50-17 mg/dlSERUM CREATININE09-01-2024 10:02:PM 5.5 mg/dl1.3-0.8

mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 09-01-2024 10:02:PM

SODIUM138 mEq/L145-136 mEq/LPOTASSIUM4.4 mEq/L5.1-3.5 mEq/LCHLORIDE105 mEq/L98-

107 mEq/LCALCIUM IONIZED1.14 mmol/Lmmol/LABG 09-01-2024 10:02:PM

FBS 124 mg/dl

Plbs 180 mg/dl

Hba1c 6.6 %

PH7.35PCO227.7PO279.1HCO315.3St.HCO317.7BEB-8.4BEecf-9.1TCO230.6O2 Sat94.5O2

Count17.8LIVER FUNCTION TEST (LFT) 09-01-2024 10:02:PM Total Bilurubin1.26 mg/dl1-0

mg/dlDirect Bilurubin0.58 mg/dl0.2-0.0 mg/dlSGOT(AST)52 IU/L35-0 IU/LSGPT(ALT)59 IU/L45-0

IU/LALKALINE PHOSPHATE270 IU/L119-56 IU/LTOTAL PROTEINS5.0 gm/dl8.3-6.4

gm/dlALBUMIN2.66 gm/dl4.6-3.2 gm/dlA/G RATIO1.14HBsAg-RAPID09-01-2024 10:02:PMNegative

Anti HCV Antibodies - RAPID09-01-2024 10:02:PMNon Reactive RFT 11-01-2024 12:04:AM

UREA39 mg/dl50-17 mg/dlCREATININE1.6 mg/dl1.3-0.8 mg/dlURIC ACID3.8 mg/dl7.2-3.5

mg/dlCALCIUM10.1 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.9 mg/dl4.5-2.5 mg/dlSODIUM141

mEq/L145-136 mEq/LPOTASSIUM3.5 mEq/L5.1-3.5 mEq/LCHLORIDE100 mEq/L98-107

mEq/LBLOOD UREA12-01-2024 12:18:AM21 mg/dl50-17 mg/dlSERUM CREATININE12-01-2024

12:18:AM0.9 mg/dl1.3-0.8 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED

CALCIUM 12-01-2024 12:18:AM SODIUM133 mEq/L145-136 mEq/LPOTASSIUM3.4 mEq/L5.1-3.5

mEq/LCHLORIDE100 mEq/L98-107 mEq/LCALCIUM IONIZED1.09 mmol/Lmmol/L

Treatment Given(Enter only Generic Name)

FLUID RESTRICTION 2-3L/DAY

INJ MEROPENAM 1GM/IV/BD

INJ PAN 40MG IV/BD

INJ HAI SC/TIC

INJ OPTINEURON 1AMP IN 100ML NS IV/OD

INJ NEOMOL 1GM IV/SOS

INJ LASIX 40MG IV/STAT

TAB TAMSULOSIN 0.4MG PO/HS

SYP ALKASTONE B6 15ML IN 1 GLASS OF WATER PO/BD

SYP CREMAFFIN 15ML PO/HS

NEB WITH IPRAVENT AND BUDECORT 6TH HRLY

SYP SUCRALFATE 10ML PO/TID

Advice at Discharge

FLUID RESTRICTION 2-3L/DAY

TAB TAXIM 200MG PO/TWICE DAILY X 5DAYS

TAB PAN 40MG PO/ ONCE DAILY X5DAYS

TAB NEUROBION FORTE PO/TWICE DAILY X10 DAYS

TAB DOLO 650 MG PO/SOS

TAB TAMSULOSIN 0.4MG PO/HS CONTINUE

SYP ALKASTONE B6 15ML IN 1 GLASS OF WATER PO/TWICE DAILY X5DAYS

SYP CREMAFFIN 15ML PO/HS X5DAYS

SYP SUCRALFATE 10ML PO/THRICE DAILY X5DAYS

TAB DYTOR 10MG PO/ONCE DAILY X3DAYS

/ONCE DAILY

Follow up in april 2024

Fbs 128 mg/dl

Plbs 178 mg/dl

Hba1c - 6.6 %

Follow up in march 2025

Fbs 120 mg/dl

Plbs 156 mg/dl

Hba1c 6.4-%

Patient is adherent to diabetic diet