Download presentation
Presentation is loading. Please wait.
1
CASE PRESENTATION By: Rubina Perween
2
Ward-C-4 Bed no.- 37 Cr. No. – Date of Admission: Personal Details: Name: Archana Age: yrs Sex-: Female Occupation: House Wife Religion: Hindu Marital Status: Married Anthropometric Measurements: Height: cm Weight: Kg .
3
. PAST MEDICAL HISTORY
4
Tuberculosis-8 years back
. T₂DM -15 years: Patient was a k/c/o T₂Dm intially on OAD now on insulin for 1½ yr. Patient . Tuberculosis-8 years back
5
. Patient was admitted in Sri GangaRam Hospital in December 2011 with the complain of shortness of breath. Patient was detected to have Emphysematous pyelonephritis and Right Nephrectomy was done on patient was discharged on 8th January and continued medicine-‘colistm’ for 1 week. Recurrent UTI
6
Maintained in following medicines: Tab. Martifur Inj. Glargine
She has been receiving check up in Renal OPD, AIIMS since feb Diagnosis:T₂DM, Recent Emphymateous Pyelonephritis, R Nephrectomy (? TB) Maintained in following medicines: Tab. Martifur Inj. Glargine Neurokind plus 10 Cap. Becosule Pantop 40mg R
7
. PRESENT COMPLAINT
8
PRESENT COMPLAINT Date: 6/3/12
Fever for 2 days which was High grade and associated with chills but no dengue. No complain of rashes over the body. No case of Seizures. Patient was febrile for last 1 day. No burning, cough/ expectoration.
9
. Left flank pain for 2 days which increase on inspiration. No complain of Haematuria. No loose stool and no bleed from any sides.
10
No complains of: Vomiting Nausea Dysuria Cough/Expectoration
. No complains of: Vomiting Nausea Dysuria Cough/Expectoration Loose Motions Bleed from any sides
11
. BP- 170/100 Pulse-140/min TLC Hb-9.7 S.Creatinine -1.3 Sodium-134 meq. Potassium- 4 meq. Input/output- 1350/900
12
. Adv: BS charting- BBF, BL, BD. Levoflox 250 mg.
Inj Glargine 12 units. Inj. H. Insulin 20,16 units. Inj. PentoProzole 40 mg. Emset.
13
. Date: 7-3-12 No fresh complain No fever Deceased abdominal pain
S.Creatinine increased to 3.3 TLC still high BP-127/83 Input/output-850/1200 blood sugar: BBF BL BD-184
14
. Adv: Add Inj Tazact 2.25gm Urgent USG Abdomen DMSA Scan
15
. Date: 8-3-12 No Fever No abdominal pain Good urine output
Input/ouput-750/1250 BBF BL BD- 235 Adv: USG abdomen DMSA Scan 24 hr Urin Protein Result: RBCs=Trace Protein= +
16
. Date: 9-3-12 Patient was stable No fever No pain Good urine output
BP-167/96 Chest-clear I/O 1400/2250 BBF BL BD- 190 Adv . Tab. Amlong 5mg USG + DMSA
17
. Date: 10-3-12 Stable Creatinine Good urine output No fever BP-155/87
Chest clear Input/output- 1400/1600 BBF- 58 BL BD-193 Adv. Continue IV antibiotic USG Report, DTPA
18
. Date: 11-3-12 No complains Stable febrile I/O-1150/1200
BBF BL BD- 270 Adv: IV Tazact Levoflox
19
. Date-12-3-12 Condition stable No complain Chest-clear 1350/1400
BBF BL- 180 BD-170 Remark: USG and DTPA reports awaited.
20
6/3/12 7/3/12 9/3/12 12/3/12 Hb 9.8 10.5 9.9 10.0 TLC 18900 8000 8500 Urea 58 27 32 34 Creatinine 3.3 1.5 1.4 Sodium 134 135 131 136 Potassium 3.5 4.4 5.0 4.5 Calcium 9.4 9.0 7.9 Phosphorus 5.5 3.9 4.0 Alk. Pho. 213 174 142 Uric Acid 5.6 5.3 Cholesterol 170 175 Triglyceride 104 Total Protein 8.4 7.6 7.8 Albumin 4.1 4.2 Globulin 3.6 Bilirubin 0.4 0.6 SGOT/SGPT 26/25 10/17 20/14 .
21
. Patient discharged on 12/3/12 Evening. With no complain
Good urine output Problem of UTI has been resolved. No abdominal pain No fever S. Creatinine is normal (1.4 mg%)
22
Nutritional Treatment:
. Nutritional Treatment: Age: 41 yrs Anthropometric assessment: Weight: 62 Kg Height: 165 cm Average Intake: 1400 Kcal, 50 gm protein.
23
Biochemical assessment
12/3/12 Hb 10.0 TLC Urea 34 Creatinine 1.4 Sodium 136 Potassium 4.5 Calcium 7.9 Phosphorus 4.0 Alk. Pho. 142 Uric Acid 3.5 Cholesterol Triglyceride Total Protein 7.8 Albumin 4.2 Globulin 3.6 Bilirubin 0.6 SGOT/SGPT 20/14
24
Diet Prescription: Diebetic diet chart 1600 Kcal, 62 gm Protein.
Food Stuffs Amount Milk & milk products 500ml Curd 100grms Palses 50grms Cerals 175grms Vegetables 500grms Fruit oil 15ml Egg(Egg-white) 2
25
Thank You .
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.