Sunday 21 August 2022

A 45 year old female with fever and bl loin pain

       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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70 F with fever and pain abdomen since 6 days and left lower limbs cellulitis

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed c...