Post TURP with non oliguric ATN

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A 52 yr old male patient who is a farmer by occupation


Presented to hospital on 14 June 2021 with  Chief Complaints of  

Fever since 4 days

 Pus in the Urine



 


History of presenting illness

Patient was apparently asymptomatic 5years back, On routine investigations diagnosed with type 2 diabetes and on treatment Tab GLIMI M1 and goes for regular check up.

 1 year back, he gradually developed drippling of urine, Hesitation, reduced flow of urine, Difficulty in void initially not associated with suprapubic pain or burning micturition

But,since 3 months patient had burning micturition not associated with fever or suprapubic pain then he consulted a urologist, where he was told , He had Prostomegaly (60gm) and advised TURP

preoperative patient sugars were high and serum creatinine 2.2mg/dl and serum bilirubin 2.8mg/dl Before preoperative patient had fever associated with chills and rigor and yellowish discolouration of eyes, treated accordingly ( given iv antibiotics)

underwent TURP on 24th March 2021


patient had 1 episode of fever after 2 days of surgery .  On 27 th March 2021, his serum creatinine was 7.2mg/dl  and on 

29th March 2021  it was 6.2 mg/dl and on 6thApril it was 4mg/dl and serum bilirubin was 1.7mg/dl

Few days after his surgery, He presented to the hospital on 14th April 2021 with decreased Appetite and Generalised weakness  and he was treated and discharged (1st admission in hospital)


Again he  presented to the hospital with drowsiness on  27 April 2021  and excessive sleep that attenders felt difficult to wake him up from sleep and attenders were regularly monitoring his BP , which was found to be fluctuating and patient was brought to the hospital and was found with Hyponatremia, After correction patient improved symptomatically within 2 days 

 and also his creatinine levels were elevated upto 5.2mg/dl , was  given treatment and it was decreased to 3mg/dl when he got discharged (2nd admission )


 He presented to the hospital on 17May 2021 with SOB since 4 days which is on exertion , High grade Fever since 2 days associated with chills and rigor , burning micturition since 4 days ( 3rd admission)

And there was raised creatinine levels upto 10mg/dl

There is a history of fleshy mass like  and foamy passage in his urine 6 days back (as said by patient's attender)



He presented to the hospital on june 14th 2021 with complaints of High grade fever and pus in the Urine ( 4th Admission )





Past History

He is a known case of Diabetes since 5 years, previously took oral hypoglycemics and now he's taking insulin.

No history of HTN, Asthma, Tuberculosis, Epilepsy, CVDs

H/o Transurethral Resection of Prostrate


Personal history

Diet - mixed diet

Appetite - decreased

Sleep - adequate

Bowel - regular

Bladder - Increased frequency

Addictions - occasional Alcohol consumption

Allergies - No known allergies


Family History

 Not significant


General Examination

The patient was conscious,coherent and cooperative
He is well oriented to time place and person

He is moderately built and moderately nourished


Vitals

Temperature - Afebrile
Pulse - 88beats per min, regular, normal in volume and character, there is no radioradial and radiofemoral delay
BP - 100/70mmHg
Respiratory rate -14 cycles per minute
JVP - Normal

No pallor 
No icterus
No Clubbing
No Lymphadenopathy
No Edema

Systemic Examination

Abdominal Examination 

 Soft and obese
non tender
 

Respiratory system

Elliptical and bilaterally symmetrical chest
Both sides moving equal with respiration
B/L air entry present
Normal vesicular breath sounds

Cvs Examination

S1 and S2 heard
No murmurs

     

          INVESTIGATIONS 

14th June 2021

       RBS - 98
       Creatinine - 3.8 mg/dl
       Urea - 70mg/dl




















17June 2021







21June









25June









28 June





















  14 April to 27 April 2021












                   21 May 2021       


























Temperature charting



                            
  Urine bag with plenty of pus cells on 22nd may 2021









       Urine bag on 31 May 2021 ( After treatment)








Xray

 



                       NCCT KUB




 (Normal KUB for reference)


 

             HYDRONEPHROSIS


        








NCCT KUB

IMPRESSION   


* Bilateral Hydroureteronephrosis, severe on  right side and moderate on left


* Both dilated in entire course with  tortuosity of lower portion


* Urinary bladder shows diffuse circumferential wall thickening( 6 -7mm)


*  Tiny calcific focus in pelvis on right side - outside the urinary tract - phlebolith


*  No obvious obstructing lesion in urinary tract









Diagnosis 

Renal AKI secondary to urosepsis with b/L hydroureteronephrosis with K/c/of DM -2 since 5 yrs with diabetic nephropathy with Anemia secondary to CKD with grade 1 bed sore






TREATMENT 


  
Injection PANTOP 40mg IV/OD

Injection PIPTAZ  4.5 stat  and 2.25 gm  IV/ TID

Injection LASIX 40mg IV/BD

Injection optineuron 1AMP in 100ml NS slow IV/OD

Injection NEDMOL 100ml IV/SOS

Tab PCM 650mg TID

Insulin Human actrapid - 16 IU/TID







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