UNCONTROLLED SUGARS(RESOLVING) ACUTE PAINLESS RETENTION O FURINE (RESOLVING) SECONDARY TO TIGHT PHIMOSIS WITH BPH WITH STRICTURE URETHRA WITH B/L EMPHYMETOUS PYLONEPHRITIS

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52YR OLD MALE WITH C/O UNABLE TO PASS URINE SINCE TODAY 1 PM

HOPI:

PT WAS APPARENTLY ASYMPTOMATIC TILL TODAY MORNING 11 AM,THEN WAS UNABLE TO PASS URINE SINCE THEN

BLADDER FULLNESS SENSATION PRESENT

NO PREVIOUS H/O SUCH COMPLAINTS

H/O FEVER YESTERDAY NIGHT LOW GRADE NOT ASSOCIATED WITH CHILLS RIGORS

NO H/O VOMITINGS AND LOOSE STOOLS

H/O DECRESED URINE SINCE 2 MONTHS

NO OTHER COMPLAINTS OF SOB/CHEST PAIN/PALPITATION

PAST HISTORY:

K/C/O DM2 SINCE 2 YEARS IS ON MEDICATION NOT KNOWN

SKIPPAGE OF OHA LIGHT DOSE

N/K/C/O HTN/EPILEPSY/THYROID DISORDERS/CVA

GENERAL EXAMINATION:

PT IS CCC

NO SIGNS PALLOR,ICTERUS,CYANOSIS,CLUBBING

TEMP AFEB

PR 118 BPM

BP 190/100

RR 18 CPM

GRBS 535 MG/DL

CVS S1S2 HEARD

RS BAE+

GIT SOFT NT

CNS NFND

UROLOGY REFERRAL

ACUTE RETENTION OF URINE SECONDARY TO PHIMOSIS +BPH

ADVISE:

DAILY APPLICATION OF TBAC OINTMENT

AUGUMENTIN 625 MG PO/BD X 1 WEEK

TAB CHYMEROL FORTE PO/TID X  1 WEEK

INVESTIGATIONS:

ABG   16-12-2023 12:16:AM   PH 7.38  PCO2 26.5  PO2 78.6  HCO3 15.7  St.HCO3 18.5  BEB -7.4  BEecf -8.4  TCO2 30.7  O2 Sat 95.6  O2 Count 19.6	COMPLETE URINE EXAMINATION (CUE)   16-12-2023 01:41:AM   COLOUR Pale yellow  APPEARANCE Clear  REACTION Acidic  SP.GRAVITY 1.010  ALBUMIN +  SUGAR ++++  BILE SALTS Nil  BILE PIGMENTS Nil  PUS CELLS 4-6  EPITHELIAL CELLS 2-3  RED BLOOD CELLS Nil  CRYSTALS Nil  CASTS Nil  AMORPHOUS DEPOSITS Absent  OTHERS Nil
HBsAg-RAPID   16-12-2023 01:41:AM Negative	Anti HCV Antibodies - RAPID   16-12-2023 01:41:AM Non Reactive
RFT   16-12-2023 01:44:AM   UREA 51 mg/dl  CREATININE 2.3 mg/dl  URIC ACID 5.9 mg/dl  CALCIUM 10.1 mg/dl  PHOSPHOROUS 1.6 mg/dl  SODIUM 135 mEq/L  POTASSIUM 4.1 mEq/L  CHLORIDE 99 mEq/L	LIVER FUNCTION TEST (LFT)   16-12-2023 01:44:AM   Total Bilurubin 1.16 mg/dl  Direct Bilurubin 0.43 mg/dl  SGOT(AST) 9 IU/L  SGPT(ALT) 7 IU/L  ALKALINE PHOSPHATE 143 IU/L  TOTAL PROTEINS 7.8 gm/dl  ALBUMIN 4.0 gm/dl  A/G RATIO 1.05
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   16-12-2023 11:55:PM   SODIUM 136 mEq/L  POTASSIUM 4.2 mEq/L  CHLORIDE 98 mEq/L  CALCIUM IONIZED 1.11 mmol/L	SERUM CREATININE   16-12-2023 11:55:PM 1.7 mg/dl
BLOOD UREA   16-12-2023 11:55:PM 42 mg/dl	BLOOD UREA   18-12-2023 08:56:AM 34 mg/dl
SERUM CREATININE   18-12-2023 08:56:AM 1.4 mg/dl	SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   18-12-2023 08:56:AM   SODIUM 138 mEq/L  POTASSIUM 4.5 mEq/L  CHLORIDE 99 mEq/L  CALCIUM IONIZED 1.23 mmol/L
BLOOD UREA   18-12-2023 05:49:PM 26 mg/dl	SERUM CREATININE   18-12-2023 05:49:PM 1.2 mg/dl
SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM   18-12-2023 05:49:PM   SODIUM 138 mEq/L  POTASSIUM 4.4 mEq/L  CHLORIDE 99 mEq/L  CALCIUM IONIZED 1.10 mmol/L	PHOSPHOROUS   18-12-2023 05:49:PM 3.3 mg/dl

USG

MULTIPLE HYPERECHOIC FOCI NOTED IN BILATERAL KIDNEYS

RIGHT SIMPLE CORTICAL CYST

MILD HEPATOPMEAGLY AND GRADE 1 FATTY LIVER

REVIEW USG ON 18/12/23

B/L GRADE 1 RPD CHANGES

RIGHT RENAL CORTICAL CYST

2D ECHO :

NO RWMA

MODERATE TR MILD AR TRIVIAL MR

SCLEROTIC AV NO AS/MS

EF 65%
GOOD LV SYSTOLIC FUNCTION

MINIMAL PF

IVC SIZE 1.22 CM COLLAPSING

DIAGNOSIS:

 UNCONTROLLED SUGARS(RESOLVING)

ACUTE PAINLESS RETENTION O FURINE (RESOLVING) SECONDARY TO TIGHT PHIMOSIS WITH BPH WITH STRICTURE URETHRA WITH B/L EMPHYMETOUS PYLONEPHRITIS

TREATMENT GIVEN :

IV FLUIDS NS @ 75ML/HR

INJ MAGNEX FORTE 1.5GM IV/BD

INJ HAI SC/TID

INJ PAN 40 MG IV OD

TAB DOLO 650 MG PO/SOS

TAB GLIMI M1 PO/BD

TAB TENIGLIPTIN 20 MG PO/OD

SYP ALKASTONE 15ML IN 1/2 GLASS OF WATER PO/BD

TAB CHYMEROL FORTE PO/TOD

TBAC OINTMENT LA /BD

ADVICE AT DISCHARGE:

TAB AUGMENTIN 625 MG/BD

TAB GLIMI M1 PO/BD 8 AM

TAB TENIGLIPTIN 20 MG PO/OD 8AM

SYP ALKASTONE 15ML IN 1/2 GLASS OF WATER PO/BD 8AM-8PM

TAB CHYMEROL FORTE PO/TID 8AM-2PM-8PM

TBAC OINTMENT LA /BD X 1 WEEK 8AM-8PM

TAB AUGMENTIN 625 MG/BD X 1 WEEK 8AM-8PM

TAB DOLO 650 MG PO/SOS

HYPOGLYCEMIC SYMPTOMS HAS BEEN EXPLAINED TO PATIENT.