52yr old female with loin pain

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 
History:
A 52 yr old  female with loin pain came to opd on 13/07/2022.

Before that she felt that pain for three days and went to local hsptl and in the scanning she came to know that she has kidney problem.

18yrs back she is diagnosed with diabetes mellitus type 2 ( on oral medications for 12 yrs and after shifted to  insulin injection)
10yrs back diagnosed with HTN ( occasional consumption of medications).
3months back she went to general checkup and diagnosed with UTI .
9days back she felt loin pain bilaterally and went to local hsptl there she diagnosed with some kidney prblm.
6dys back (on 13/09/2022) admitted in our hsptl..and on observation for five days.
4dys back _ decreased urine output 
3dys back _ anuria for one day and SOB (grade 3)
PERSONAL HISTORY:
Diet:mixed with occasional consumption of meat 
Appetite: normal before ( can't eat much now)
Sleep: adequate 
Bowel and bladder: normal before (but 4days back decreased urine output and anuria for one day )
Habits: none
FAMILY HISTORY:
Patient's mother and father are with Diabetes mellitus and HTN.
GENERAL EXAMINATION:
General weakness
Pallor: present
Icterus: absent 
Cyanosis: absent 
Clubbing: absent 
Lymphadenopthy: absent 
Edema :mild pitting edema b/l
VITALS:
Temp:98.4F
BP  : 180/80mmHg
PR: 78/ min
CVS: S1 S2 Heard
RS: BAE+
I/O: 1800/1000 ml
SYSTEMIC EXAMINATION:
Patient is conscious, oriented to time and place.
Reflexes:
             Biceps  Triceps  supinator  knee  ankle
Right        ++        ++      ++       ++      ++ 
Left         ++        ++      ++       ++      ++ 
 PROVISIONAL DIAGNOSIS:
      AKI
INVESTIGATIONS:

14/07/2022
BP : 140/80mmhg
P/A : soft and non tender
15/07/2022
Creatinine: 4.1
Na+: 131
K+ :4.5
16/07/2022
P/A:soft tenderness in epigastrium in right lumbar region.
17/07/2022
Hb-8.5
Na +: 127
K+: 5.3
18/07/2022
Na+:128
K+: 4.8
Colour Doppler 2D:
Ultrasound :
This edema during hsptl stay only.
TREATMENT :
1)  Inj HAI (10 U morning and  10 U night) s/c TID According to GRBS
2) T.TELMA 40mg
3) T.LASIX 20mg
4) T.SHELCAL 500mg
5) T.ULTRACET ( 1/2)
6) T.NODOSIS 500mg
7) T.OROFER
8) T.NITROFURANTOIN
9) T.PCM 500mg
10) ciprofloxacin 

24/07/2022:
Dialysis done in the morning.
After intake of food she  had an episode of vomiting and has weakness 
25/07/2022
Generalised weakness and bodypains 
Another dialysis was done in the Evening.













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