I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis with a treatment plan.
This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.
A 45 year old female who is an agriculture labourer by occupation to OPD with chief complaints of:
- fever 15 days back
-bl loin pain-10 days back
- unable to pass urine since 10 days
- altered sensorium 1 week back
History of presenting illness:
Patient was apparently asymptomatic 15 days back,then she developed low grade intermittent fever with no chills and rigors for which she went to local hospital and the reports showed:
-Serum creatinine: 1.8
-Pus cells in urine
-USG abdomen: left hydronephrosis
Fever subsided on taking medication. It was associated with burning micturition.
B/L loin pain was colicky type with no aggravating and relieving factors
On admission, Foley's catheter was passed and pus was noticed.
Patient had slurred speech on the day of admission and couldn't recognise anyone.
Dialysis was done due to abnormal RFT results.
Swelling of upper and lower limbs started to appear since 1 week due to fluids infusion.
Her sensorium improved during course of treatment.
Past history:
History of renal calculi since 1 month.
Not a known case of Diabetes,Hypertension, Coronary Artery Disease,Asthma, Chronic Kidney Disease.
Surgical history:
Hysterectomy done 10 years ago.
Vitals on examination:
Temperature: afebrile
PR: 120 bpm
RR: 16cpm
BP: 110/80 mm Hg
GRBS: 106 mg/dl
CVS: S1,S2 present
RS: BAE +
CNS: Hypertonia of both lower limbs seen.
On examination:
Abdomen is soft and distended.
Midline scar is present.
No guarding or rigidity.
Investigations:
On 8th: On 9th:
Hb: 11.0 mg%. Hb: 10.8 mg%
TLC: 41,000. TLC: 41,600
Platelets: 2.0 lakh. Plt: 1.7 lakh
pH: 7.29
pCO2: 26.2
pO2: 69.6
SO2: 92.2
HCO3: 12.5
S.Creat: 4.2
S. Urea: 153
S. Uric acid: 10.4
S. Ca: 9.4
S.PO4: 3.8
S. Na: 140
S. K: 6.4
S. Cl: 103
LFT:
TB: 4.34
DB: 2.86
AST: 22
ALT: 16
ALP: 679
TP: 4.7
Albumin; 1.8
A/G: 0.62
On 9th:
S. Iron: 84
RBS: 64
HbA1C: 6.4 %
On 10/2/22:
pH: 7.31
pCO2: 31.4
pO2: 90.8
HCO3: 15.4
SO2: 94.3
Hb: 11.1
TLC: 48000
Plt: 1.35
S. Urea: 80
S. Creat: 2.9
S. Na: 141
S. K: 4.8
S. Cl: 101
LFT
TB: 5.28
DB: 4.25
AST: 36
ALT: 17
ALP: 657
TP: 5.1
Alb: 1.9
A/G: 0.5
ECG on 8/2/22:
Shows sinus tachycardia
X ray KUB on 8/2/22:
USG DONE ON 8/2/22:
B/L hydronephrosis
Right simple renal cortical cyst
Grade I fatty liver
NCCT KUB:
Pneumoperitoneum with ?left perinephric abscess.
Air foci in upper calyx of right kidney- ? Emphysematous pyelonephritis
Mild ascitis.
MDCT SCAN BRAIN- PLAIN:
No abnormality in brain.
Treatment given:
On 8/2/22:
Soft diet
IV FLUIDS 1. NS and 1. DNS at 75ml/hr
Inj. MEROPENEM 1g/IV/BD
INJ. PAN 40mg IV BD
INJ. PCM 1g IV BD
INJ TRAMADOL 2amp in 100ml NS IV BD
Monitor vitals
On 9/2/22:
INJ MEROPENEM 1gm IV BD
INJ METROGYL 100ml IV TID
INJ. PCM 1g IV BD
INJ. PAN 40mg IV BD
IV FLUIDS 2. NS AND 2. RL at 100ml/hr
Ryle’s tube feeds (100ml milk and 100ml water) 4th hourly
INJ. NORAD (2amp + 36ml NS)
GRBS 4th hourly monitoring
Strict I/p and O/p monitoring
On 10/2/22:
INJ MEROPENEM 1gm IV BD
INJ METROGYL 100ml IV TID
INJ. PCM 1g IV BD
INJ. PAN 40mg IV BD
IV FLUIDS 3. NS AND 2. RL at 100ml/hr
Ryle’s tube feeds (100ml milk and 100ml water) 4th hourly
INJ. NORAD (2amp + 36ml NS)
GRBS 4th hourly monitoring
Strict I/p and O/p monitoring
INJ HAI S/C TID after informing GRBS
Nephrostomy was done on 10/2/22 at 2:30 PM and 500 ml of pus was drained.
Nephrostomy procedure
On 19/2/22:
INJ MEROPENEM 500 mg IV BD
INJ METROGYL 500mg(100ml) IV TID
INJ PAN 40 mg IV OD
HAI s/c acc to GRBS
INJ TRAMADOL(1 amp 1ml) NS IV BD
INJ NEOMOL 1g IV
GRBS monitoring 6th hrly
BP,PR,SpO2 monitoring 4th hrly
On 20/2/22:
INJ MEROPENEM 500mg IV BD
INJ METROGYL 500mg(100ml) IV TID
INJ PAN 40mg IV OD
INJ HAI s/c after GRBS
INJ TRAMADOL (1 amp 1ml) NS IV BD
INJ NEOMOL 1g IV
GRBS monitoring 6th hrly
BP, SpO2,PR monitoring 4th hrly
PROVISIONAL DIAGNOSIS:
B/L emphysematous pyelonephritis with aki secondary to sepsis
With denovo diabetes mellitus
Discussion:
Emphysematous pyelonephritis refers to a morbid infection with particular gas formation within or around the kidneys. If not treated early, it may lead to fulminant sepsis and, therefore, carries a high mortality.
Clinical presentation
The patient usually presents with fevers and flank pain. In diabetics, who are the ones at risk for this condition, leukocytosis and hyperglycemia are prominent laboratory findings.
Pathology
Etiology
It tends to be more common in females, and approximately 90% of patients have uncontrolled diabetes mellitus 1. It may however also be seen in immunocompromised individuals or associated with urolithiasis, neoplasms, or sloughing of papilla.
Causative organisms include:
Escherichia coli: usually considered the commonest causative organism 3
Klebsiella pneumonia
Proteus mirabilis
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