Pt came with complaints of
1 burning micturition :: 15 days
2 fever :: 15 days
3 urge incotinence :-5days
Pt complaints of burning micturation after urination not associated with loin pain.
Fever high grade intermittent relieved with medication , :: 15 days associated with chills and rigors .
Urinary urgency :: 15 days :: not able to hold urine & wetting of clothes ,foleys catherization was done
H OPI
pt was apparently alright 8 year back had h/o poor stream of urine burning micturation ,fever,
underwent TURP (6 years in nims back )
Was symptom free for 2 yrs , again he developed similar complaints ,underwent TURP 4 yr back in kims Nkp.
Was symptom free for 2 yrs , again he developed similar complaints ,underwent TURP 4 yr back in kims Nkp.
Past illness:
Kco ,HTN ::10 yrs.
On Medications AMLODIPINE 5 mg , ATENOLOL 50mg .
DM2 10 yrs inj . HM 15 IU -x-x -8am.
H/O TURP. 4 YRS BACK -NIMS,symptom free upto 1 yr ,TURP -2 yr back.
PERSONAL H/O
Appetite normal ,
Mixed diet,
Bowel and bladder movements are regular
Micturation : Urinary urgency c:: 15 fays :: not able to hold urine & wetting of clothes ,foleys catherization was done for it.
No known allergies
No Addictions.
Family History
No kco dm, htn, cvd ,tb.
On Physical examination :
Pt was concious, coherent, cooperative
Moderately built,moderately nourished
No signs of pallor ,icterus ,cyanosis, lymphadenopathy, clubbing of fingers/toes.
Temp 98.6F
Pr 62 bp.
RR 22CPM
BP 120/50mm hg
sPO2 96%on RA
GRBS 197 mg%
Provisional Diagnosis:
Post renal Acute kidney injury on chronic kidney disease
Secondary to benign prostate hyperplasia with bilateral Moderate hydronephrosis
TRANS URETHERAL PROSTATE RESECTION 4 years----nims
2yrs back ---kims.
With urosepsis 4 yrs back DM2 & HTN.(10yrs)
PROSTATE ADENOCARCINOMA,
B/L ORCHIDECTOMY
CLD
TREATMENT:
1)FOLEYS catheterization
2) IUF 0.9 %Nacl ( 0.0+30ml/hr)
3)inj. LASIX 40 mg /wBd
4) inj . PIPTAZ 4.5 gm/IU /Stat.
5) inj. PANTOP 40 mg /PO/OD .
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
8) hold OHA and Anti hypertensiveS
9) AMLONG 5 mg PO/ OD.
CXray
Reports dated 4-7-21
culture report from day 1 sample.
TREATMENT:
1)FOLEYS catheterization
2) IUF 0.9 %Nacl ( 0.0+30ml/hr)
3)inj. LASIX 40 mg /wBd
4) inj . PIPTAZ 4.5 gm/IU /Stat.
5) inj. PANTOP 40 mg /PO/OD .
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
8) hold OHA and Anti hypertensiveS
9) AMLONG 5 mg PO/ OD.
I n v e s t i g a t i o n s :
Previous Reports :
Investigations done after hospitalization
Uribe bag after catherization on 2/7/21.
DAY - 3
DISCHARGE SUMMARY
Treating doctors
Dr.Rakesh biswas HOD
Dr. Arjun asst.prof
Dr. Nikitha PGY2
Dr. Pradeep PGY1
Dr. Ranjith Intern
Dr. Tejaswini Intern
Dr.Shravani Intern
Dr. Krupa Intern
Dr. Nikitha Intern
DIAGNOSIS:
Post renal Acute kidney injury on chronic kidney disease
Secondary to benign prostate hyperplasia with bilateral Moderate hydronephrosis
TRANS URETHERAL PROSTATE RESECTION 4 yrs ago nims AND 2 YRS ago kims
Case history
73 yr male
Pt came with complaints of
1 burning micturition :: 15 days
2 fever :: 15 days
3 urge incontinence ::5 days.
Pt complaints of burning micturation after urination not associated with loin pain.
Fever high grade intermittent relieved with medication , :: 15 days associated with chills and rigors .
Urinary urgency :: 15 days :: not able to hold urine & wetting of clothes ,foleys catherization was done .
H OPI
pt was apparently alright 8 year back had h/o poor stream of urine burning micturation ,fever,
Pt came with complaints of
1 burning micturition :: 15 days
2 fever :: 15 days
3 urge incontinence ::5 days.
Pt complaints of burning micturation after urination not associated with loin pain.
Fever high grade intermittent relieved with medication , :: 15 days associated with chills and rigors .
Urinary urgency :: 15 days :: not able to hold urine & wetting of clothes ,foleys catherization was done .
H OPI
pt was apparently alright 8 year back had h/o poor stream of urine burning micturation ,fever,
underwent TURP (6 years in nims back )
Was symptom free for 2 yrs , again he developed similar complaints ,underwent TURP 4 yr back in kims Nkp.
Was symptom free for 2 yrs , again he developed similar complaints ,underwent TURP 4 yr back in kims Nkp.
Pt c/o abdominal distension & pain,stools not passed on day1.
--Pt abdominal distension & pain decreased,stools passed,Pt attendant complaining of irritable behaviour & Sleeplessness at night on day 2.
--stools passed twice .abdomen distension and pain abdomen relieved on day 3.
---burning sensation in the mouth since 5 days.
Past illness:
Kco ,HTN ::10 yrs.
On Medications AMLODIPINE 5 mg , ATENOLOL 50mg .
DM2 inj . HM 15 IU 00-8am.
H/O TURP. 4 YRS BACK -NIMS,symptom free upto 1 yr ,TURP -2 yr back.
PERSONAL H/O
Appetite normal ,
Mixed diet,
Bowel and bladder movements are regular
Micturation : Urinary urgency c:: 15 fays :: not able to hold urine & wetting of clothes ,foleys catherization was done for it.
No known allergies
No Addictions.
Family History
No kco dm, htn, cvd ,tb.
On Physical examination :
Pt was concious, coherent, cooperative
Moderately built,moderately nourished
No signs of pallor ,icterus ,cyanosis, lymphadenopathy, clubbing of fingers/toes.
Temp 98.6F
Pr 62 bp.
RR 22CPM
BP 120/50mm hg
sPO2 96%on RA
GRBS 197 mg%
On Medications AMLODIPINE 5 mg , ATENOLOL 50mg .
DM2 inj . HM 15 IU 00-8am.
H/O TURP. 4 YRS BACK -NIMS,symptom free upto 1 yr ,TURP -2 yr back.
PERSONAL H/O
Appetite normal ,
Mixed diet,
Bowel and bladder movements are regular
Micturation : Urinary urgency c:: 15 fays :: not able to hold urine & wetting of clothes ,foleys catherization was done for it.
No known allergies
No Addictions.
Family History
No kco dm, htn, cvd ,tb.
On Physical examination :
Pt was concious, coherent, cooperative
Moderately built,moderately nourished
No signs of pallor ,icterus ,cyanosis, lymphadenopathy, clubbing of fingers/toes.
Temp 98.6F
Pr 62 bp.
RR 22CPM
BP 120/50mm hg
sPO2 96%on RA
GRBS 197 mg%
Course in the hospital
Day 0(2/7/2021)
Rx
1)Change FOLEYS catheterization
2) IVF 0.9 %Nacl ( U.0+30ml/hr)
3)inj. LASIX IV 40 mg /Bd
4) inj . PIPTAZ 4.5 gm/IV /Stat.
5) inj. PANTOP 40 mg /IV/OD .
6)GRBS 6th hrly .
7) INJ. HAI S/C TID after informing PG .
8) with hold OHA and Anti hypertensive
S:-Pt c/o abdominal distension & pain,stools not passed
O:-Abdominal Distension Present
Pt is c/c/c
Bp:-120/80mmhg
Pr:-84/min
Cvs:-S1S2 +
Rs:-B/LAE+
CNS:-NFD
P/A:-Soft,Tenderness all over the abdomen,Bowel sounds +
A:-
Post renal AkI on CKD.
Secondary to BPH With B/L Moderate hydronephrosis,
s/p TURP 2yrs back ---kims.
4 yrs back Kims
K/c/o DM2 & HTN.(10years)
P:-
Inv
USG abdomen
X-ray erect abdomen
Urology referal i/v/o urinary incontinence
Rx
1)IVF 0.9 %Nacl ( U.0+30ml/hr)
2)inj. LASIX IV 40 mg /Bd
3)inj . PIPTAZ 2.25 gm/IV /TID
4)inj. PANTOP 40 mg /IV/OD .
5)GRBS 6th hrly .
6)INJ. HAI S/C TID after informing PG .
7)Tab Amlodipine 5mg/po/OD
8)Abdominal girth measurement 2nd hrly
9)Proctolysis enema
10)Syp Lactulose 20ml /PO/HS
Day 2(4/7/2021)
S:-Pt abdominal distension & pain decreased,stools passed,Pt attendant complaining of irritable behaviour & Sleeplessness at night
O:-
Pt is c/c/c
Bp:-110/70mmhg
Pr:-92/min
Cvs:-S1S2 +
Rs:-B/LAE+
CNS:-NFD
P/A:-Soft,Bowel sounds +
Serum Na :-130—->125——>123
A:-
Post renal AkI on CKD.
Secondary to BPH With B/L Moderate hydronephrosis,
s/p TURP 2yrs back ---kims.
4 yrs back Kims
K/c/o DM2 & HTN.(10years)
K/c/o Prostate Adeno CA with B/L Orchidectomy,Hyponatremia
P:-
Inv
Sr sodium at 6:00pm
Rx
1)IVF 3%NACL infusion @10ml/hr Till 6:00pm
2)inj. LASIX IV 20 mg/IV /Bd
3)inj . PIPTAZ 2.25 gm/IV /TID
4)inj. PANTOP 40 mg /IV/OD .
5)GRBS 6th hrly .
6)INJ. HAI S/C TID after informing PG .
7)Tab Amlodipine 5mg/po/OD
8)Syp Lactulose 20ml /PO/HS
D A Y 3 (5/7/21)
S-stools passed twice .abdomen distension and pain abdomen relieved.
O - BP : 110/70
PR : 78
TEMP : 97.6 F
Abd girth 91---57 cms.
Hb 6.9-- 7.1---7.3----7.3
TLC 30,000,26,700--19000---21400 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109
Creat 3.1 -3.1--3.3--3.3
Electrolytes
Na 130 --- 125--124--124
K 3.6--3.7---3.8---3.7
Cl 99--90---91--90
A-
Post renal AkI on CKD.
Secondary to BPH With B/L Moderate hydronephrosis,
s/p TURP 2yrs back ---kims.
4 yrs back Kims
K/c/o DM2 & HTN.(10years)
K/c/o Prostate Adeno CA with B/L Orchidectomy,Hyponatremia
P
TREATMENT:
1) inj 3% Nacl 100ml@10ml/hr iv infusion
2) syp LACTULOSE PO 20ML/HR
3)inj. LASIX 40 mg /wBd
4) inj . PIPTAZ 2.25 gm/IU /Stat.
5) inj. PANTOP 40 mg /PO/OD .
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) AMLONG 5 mg PO/ OD.
Treatment
Day 0(2/7/2021)
Rx
1)Change FOLEYS catheterization
2) IVF 0.9 %Nacl ( U.0+30ml/hr)
3)inj. LASIX IV 40 mg /Bd
4) inj . PIPTAZ 4.5 gm/IV /Stat.
5) inj. PANTOP 40 mg /IV/OD .
6)GRBS 6th hrly .
7) INJ. HAI S/C TID after informing PG .
8) with hold OHA and Anti hypertensive
Day1
Rx
1)IVF 0.9 %Nacl ( U.0+30ml/hr)
2)inj. LASIX IV 40 mg /Bd
3)inj . PIPTAZ 2.25 gm/IV /TID
4)inj. PANTOP 40 mg /IV/OD .
5)GRBS 6th hrly .
6)INJ. HAI S/C TID after informing PG .
7)Tab Amlodipine 5mg/po/OD
8)Abdominal girth measurement 2nd hrly
9)Proctolysis enema
10)Syp Lactulose 20ml /PO/HS
Day2
Rx
1)IVF 3%NACL infusion @10ml/hr Till 6:00pm
2)inj. LASIX IV 20 mg/IV /Bd
3)inj . PIPTAZ 2.25 gm/IV /TID
4)inj. PANTOP 40 mg /IV/OD .
5)GRBS 6th hrly .
6)INJ. HAI S/C TID after informing PG .
7)Tab Amlodipine 5mg/po/OD
8)Syp Lactulose 20ml /PO/HS
Day3
TREATMENT:
1) inj 3% Nacl 100ml@10ml/hr iv infusion
2) syp LACTULOSE PO 20ML/HR
3)inj. LASIX 40 mg /wBd
4) inj . PIPTAZ 2.25 gm/IU /Stat.
5) inj. PANTOP 40 mg /PO/OD .
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) AMLONG 5 mg PO/ OD.7
10) 10) inj. OPTIEURON 1AMP IN 100 MLNS IV/OD.
11) CANDIN mouth paint. BD
Day4
S- pt complaints of burning sensation in mouth.
O - BP : 100/60
PR : 84
TEMP : 98. F
Abd girth 91---87--86cms.
Hb 6.9-- 7.1---7.3----7.3--6.8
TLC 30,000,26,700--19000---21400 --'
22,000 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108
Creat 3.1 -3.1--3.3--3.3---2.5
Electrolytes
Na 130 --- 125--124--124---126
K 3.6--3.7---3.8---3.7-3.2
Cl 99--90---91--90---94
A-
Post renal AkI on CKD.
Secondary to BPH C BL Moderate hydronephrosis,
s/p TIRP 2yrs back ---kims.
C urosepsis 4 yrs back Kims
Kco DM2 & HTN.
O - BP : 100/60
PR : 84
TEMP : 98. F
Abd girth 91---87--86cms.
Hb 6.9-- 7.1---7.3----7.3--6.8
TLC 30,000,26,700--19000---21400 --'
22,000 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108
Creat 3.1 -3.1--3.3--3.3---2.5
Electrolytes
Na 130 --- 125--124--124---126
K 3.6--3.7---3.8---3.7-3.2
Cl 99--90---91--90---94
A-
Post renal AkI on CKD.
Secondary to BPH C BL Moderate hydronephrosis,
s/p TIRP 2yrs back ---kims.
C urosepsis 4 yrs back Kims
Kco DM2 & HTN.
Bladder wash with 100 ml NS is done
1) inj 3% Nacl 100ml@10ml/hr iv infusion
2) syp LACTULOSE PO 20ML/HR
3)inj. LASIX 40 mg /wBd
4) inj . PIPTAZ 2.25 gm/IU /Stat.
5) inj. PANTOP 40 mg /PO/OD .
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) AMLONG 5 mg PO/ OD.7
10) 10) inj. OPTIEURON 1AMP IN 100 MLNS IV/OD.
11) CANDIN mouth paint. BD.
Day 5
S- pt C/O loose stools 10-15 times ,small quantity,non blood stained ,non foul smelling since last night,
Decreased urine output since yesterday.
Decreased urine output since yesterday.
Dehydration is present.
Abd distention decreased.
O - BP : 110/50
PR : 72
TEMP : 98. F
Abd girth 91---87--86--cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7
TLC 30,000,26,700--19000---21400 ---
22,000 ----- 26,400 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Electrolytes
Na 130 --- 125--124--124---126--125
K 3.6--3.7---3.8---3.7-3.2--3.4
Cl 99--90---91--90---94--94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
Abd distention decreased.
O - BP : 110/50
PR : 72
TEMP : 98. F
Abd girth 91---87--86--cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7
TLC 30,000,26,700--19000---21400 ---
22,000 ----- 26,400 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Electrolytes
Na 130 --- 125--124--124---126--125
K 3.6--3.7---3.8---3.7-3.2--3.4
Cl 99--90---91--90---94--94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
Hyponatremia.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4URS BACK NIMS.
KCO DM 2 ,HTN.
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3)T. SPORLAC DS PO TID
4) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each ep.
14) CANDIN mouth paint
15)saline gargle BD.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4URS BACK NIMS.
KCO DM 2 ,HTN.
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3)T. SPORLAC DS PO TID
4) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each ep.
14) CANDIN mouth paint
15)saline gargle BD.
Day 6
S- pt C/O loose stools subsided,
Decreased urine output since yesterday.
Abd distention present. Moderat eascites
O - BP : 110/50
PR : 62
TEMP : 98. F
Abd girth 91---87--86--99cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7--6.7
TLC 30,000,26,700--19000---21400 --
22,000 ----- 26,400 ----22800 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114--118
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Sr. Electrolytes
Na 130 --- 125--124--124---126--125--122
K 3.6--3.7---3.8---3.7-3.2--3.4--3.5
Cl 99--90---91--90---94--94---94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4URS BACK NIMS.
KCO DM 2 ,HTN.
With dilution Hyponatremia (hypovolemia)
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each
14)ascitic tap ,for culture,LDH, cytology
15)Lft, sr.ldh
Decreased urine output since yesterday.
Abd distention present. Moderat eascites
O - BP : 110/50
PR : 62
TEMP : 98. F
Abd girth 91---87--86--99cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7--6.7
TLC 30,000,26,700--19000---21400 --
22,000 ----- 26,400 ----22800 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114--118
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Sr. Electrolytes
Na 130 --- 125--124--124---126--125--122
K 3.6--3.7---3.8---3.7-3.2--3.4--3.5
Cl 99--90---91--90---94--94---94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4URS BACK NIMS.
KCO DM 2 ,HTN.
With dilution Hyponatremia (hypovolemia)
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each
14)ascitic tap ,for culture,LDH, cytology
15)Lft, sr.ldh
Day 7
S- pt C/O pain abdomen.
0utput : 1000ml
O - BP : 120/60 mmhg
PR : 70 bpm
TEMP : 98. F
Grbs 239 mg dl
Abd girth 91---87--86--99----92cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7--6.7
TLC 30,000,26,700--19000---21400 --
22,000 ----- 26,400 ----22800 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114--118
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Sr. Electrolytes
Na 130 --- 125--124--124---126--125--122
K 3.6--3.7---3.8---3.7-3.2--3.4--3.5
Cl 99--90---91--90---94--94---94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4yRS BACK NIMS.
KCO DM 2 ,HTN.
With dilution Hyponatremia (hypervolemia)
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each
0utput : 1000ml
O - BP : 120/60 mmhg
PR : 70 bpm
TEMP : 98. F
Grbs 239 mg dl
Abd girth 91---87--86--99----92cms.
Hb 6.9-- 7.1---7.3----7.3--6.8---7--6.7
TLC 30,000,26,700--19000---21400 --
22,000 ----- 26,400 ----22800 cells/cumm
Sr:
Serum
Urea: 121---111 --108---109--108--114--118
Creat 3.1 -3.1--3.3--3.3---2.5---3.2
Sr. Electrolytes
Na 130 --- 125--124--124---126--125--122
K 3.6--3.7---3.8---3.7-3.2--3.4--3.5
Cl 99--90---91--90---94--94---94
A-
Post renal AKI resolving, with UTI on CKD ,secondary to Diabetic Nephropathy 2o to BPH WITH BL MODERATE HYDRONEPHROSIS.
WITH BL ORCHIDECTOMY, S/P TURP 2YRS BACK KIMS, 4yRS BACK NIMS.
KCO DM 2 ,HTN.
With dilution Hyponatremia (hypervolemia)
.
TREATMENT:
1) IVF 0.9% Nacl 0.0 + 30 ML /HR
2) inj. PANTOP 40 mg /PO/OD
3) inj . PIPTAZ 2.25 gm/IU / TID
5) T. AMLONG 5 MG PO OD 8AM
6)GRBS 6th hrly pre meal.
7) INJ. HAI S/C TID agter informing PG .
9) INJ HUMAN MIXTARD S/C
8am( 15IU ) -----x-----8pm ( 12 IU )
Grbs 103 8 AM
10) BLADDER WASH DAILY ONCE
11) Strict I/O charting
12) Bp /PR/ T daily charting
13) ORS Sachets 2 in 1 water ,200 ml after each
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