45 year old female with fever and 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 came with complaints of 
Fever since 10 days
Pain in B/L loin since 5 days 
Unable to pass urine since 1 day 
Altered sensorium since 1 day 
History of presenting illness: 
Patient was apparently asymptomatic 10 days ago then she developed low grade, intermittent fever not associated with chills or rigors, and relieved on taking medication, she was taken to another hospital for the same and reports showed: 
Serum creatinine-1.8
CUE: pus cells loaded
USG abd: left hydronephrosis 
Fever is associated with burning micturition. 

Pain in B/L loin which was colicky type with no aggravating or relieving factors. 
Unable to pass urine since 1 day. 

Patient had slurring of speech from 2 pm and then started speaking incoherently and couldn’t recognise anyone. 
Dialysis was initiated due to deranged RFT, Hypercalcemia, metabolic acidosis to remove toxic metabolites. 


Past history:
History of renal calculi since 1 month, present. 
Not a known case of Diabetes mellitus, Hypertension, Coronary Artery Disease, Chronic Kidney Disease, Asthma. 

Surgical history: 
Hysterectomy done 10years ago. 
General examination:
?

Vitals on admission: 
Temperature: afebrile 
PR: 120 bpm
RR: 16 cpm
BP: 110/80 mm Hg 
SpO2: 98%
GRBS: 106 mg/dal
CVS: S1 S2 present 
RS: BAE +
CNS: Hypertonia of both lower limbs seen. 
On examination: 
Abdomen is distended. 
Midline scar present. 
Bladder distended till umbilicus. 
Abdomen soft. 
No guarding or rigidity. 
Investigations: 

On 8th:.                           
Hb: 11.0 mg%.                  
TLC: 41,000.                   
Platelets: 2.0 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: 
Hb: 10.8 mg%
TLC: 41,600
Plt: 1.7 lakh 
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 
Rule’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 
Rule’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.  
On 13/2/2022
Drain output: 10ml
Fever chart
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
Reference: https://caseopinionsbyrollno156.blogspot.com/2022/02/45-yo-female-with-pain-bl-loin-and.html?m=1


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