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 .