A 40yr old male patient with emphysematous pyelonephritis

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SHORT CASE : FINAL PRACTICAL

Name : Jatin Sharma

Hall ticket no : 1701006066

CASE PRESENTATION :

A 46 year old male came with chief complaints of:

Burning micturition present since 10 days

Vomiting since 2 days  ( 3 - 4 episode)

Giddiness and deviation of mouth since 1 day 

HISTORY OF PRESENTING ILLNESS:   

Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on OHAs, 3years back OHAs were converted to insulin.

2 days back, he developed vomiting , containing food particles and  non bilious. He also complained of deviation of mouth and giddiness 1 day

His  GRBS  was also recorded high , for which he was given NPH 10 IU and HAI 10 IU

No history  of fever/cough/cold

No history of previous UTIs

No history of  chest pains/palpitations/syncopal attacks

PAST HISTORY:    

    

10yrs back patient complained of polyuria and was diagnosed with Type 2 DM and started on OHA( oral hypoglycemic agents).

OHAs were converted to insulin 3 years back

3 years back , he underwent cataract surgery

1 year back, he had h/o small injury on leg which gradually progressed to non healing ulcer extending upto below knee eventually ended with below knee amputation  i/v/o development of wet gangrene

Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD

PERSONAL HISTORY:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol- 

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off  consumption pattern previously present

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Vitals @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 101F

SpO2: 98% on RA

GRBS: 124 mg/dL

Pallor present

No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema

No dehydration

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Patient is having altered sensorium

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

INVESTIGATIONS:

                                  

                                 

Culture report:  Klebsiella Pneumonia positive

Pus cells

Sodium- 130

Chloride- 97

Hb- 6.4

TLC- 13,700

Platelet count- 50000

Urea - 146 

Creatinine- 4.2

Uric acid- 9.1

X ray KUB 

PROVISIONAL DIAGNOSIS:

Right emphysematous pyelonephiritis and left acute pyelonephiritis and encephalopathy secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years

TREATMENT: 

INJ. MEROPENEM 500mg IV BD 

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS

50 year old male patient with abdominal distension

FINAL EXAMINATION CASE REPORT 

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. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

LONG CASE : FINAL PRACTICAL

Name : Jatin Sharma

Hall ticket no : 1701006066

HISTORY:

50 year old male, farmer by occupation, resident of Pochampally, came to Medicine OPD with complaints of : 

- Distended abdomen since 7 days 

- Pain abdomen since 7 days

- Pedal edema since 5 days 

- Breathlessness since 4 days.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 months ago when he developed jaundice and was treated at a private practitioner.

Later he developed abdominal distension about 7 days ago - insidious in onset, gradually progressive to the present size - associated with 

- Pain in epigastric and right hypochondrium - colicky type.

- Fever - high grade, not associated with chills and rigor, decreased on medication, No night sweats.

- Not associated with Nausea, vomiting, loose stools 

There was pedal edema 

- Gradually progressive  

- Pitting type

- Bilateral 

- Below knees

- Increases during the day - maximum at evening.

- No local rise of temperature and tenderness 

- Grade 2 

- Not relived on rest 

  

He also complained of shortness of breath since 4 days - MRC grade 4

- Insidious in onset

- Gradually progressive

- Aggregated on eating and lying down ; No relieving factor

- No PND

- No cough/sputum/hemoptysis

- No chest pain

- No wheezing

Patient is a known alcoholic since 20 years. Ascites increased after his last drink on 29th May, 2022.

Daily Routine : 

Wakes up at 5am and goes to field.

Comes home at 8am and has rice for breakfast. Returns to work at 9am.

1pm - lunch

2-6 pm - work

6pm - home

8pm - dinner

Alcohol- 2 times a week, 180 ml.

PAST HISTORY: 

No history of similar complaints in the past 

Medical history- not a known case of DM, HTN, TB, Epilepsy, Asthma, CAD

Surgical history - not significant 

PERSONAL HISTORY: 

- Diet - mixed

- Appetite- reduced since 7 days

- Sleep - disturbed

- Bowel - regular

- Bladder - oliguria since 2 days, no burning micturition, no feeling of incomplete voiding. 

- Allergies- none

- Addictions - Beedi - 8-10/day since 20 years ; 

                     - Alcohol - Toddy - 1 bottle, 2 times a week, since 20 years;

                                     - Whiskey-180 ml, 2 times a week, since 5 years.

                                     - Last alcohol intake - 29th May, 2022 , amount : more then usual.

FAMILY HISTORY:

Not significant 

GENERAL EXAMINATION: 

Patient is conscious, coherent and co-operative.

Examined in a well lit room.

Moderately built and nourished

Icterus - present (sclera)

Pedal edema - present - bilateral pitting type, grade 2

No pallor, cyanosis, clubbing, lymphadenopathy.

 

Vitals : 

Temperature- afebrile

Respiratory rate - 16 cpm

Pulse rate - 98 bpm

BP - 130/90 mm Hg.

SYSTEMIC EXAMINATION: 

CVS : S1 S2 heard, no murmurs

Respiratory system : normal vesicular breath sounds heard.

Abdominal examination: 

INSPECTION : 

Shape of abdomen- distended

Umblicus - everted

Movements of abdominal wall - moves with respiration 

Skin is smooth and shiny;

No scars, sinuses, distended veins, striae.

PALPATION : 

Local rise of temperature present.

Tenderness present - epigastrium.

Tense abdomen 

Guarding present

Rigidity absent 

Fluid thrill positive 

Liver not palpable 

Spleen not palpable 

Kidneys not palpable 

Lymph nodes not palpable 

PERCUSSION: 

Liver span : not detectable 

Fluid thrill: felt 

AUSCULTATION: 

Bowel sounds: heard in the right iliac region 

CNS EXAMINATION: 

Conscious 

Speech normal

No signs of meningeal irritation 

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes:      Right.           Left. 

Biceps.         ++.                 ++

Triceps.         ++.                 ++

Supinator      ++.                  ++

Knee.              ++.                 ++

Ankle              ++.                  ++

Gait: normal 

INVESTIGATIONS: 

 

- Hemogram :

Hemoglobin : 9.8 g/dl

TLC : 7,200

Neutrophils : 49%

Lymphocytes : 40%

Eosinophils : 1% 

Basophils : 0%

PCV : 27.4%

MCV : 92.3 fl

MCH : 33 pg

MCHC : 35.8%

RDW-CV : 17.6%

RDW-SD : 57.8 fl

RBC count : 2.97 millions/mm3

Platelet count : 1.5 lakhs/mm3

Smear : Normocytic normochromic anemia

- LFTs :

Total Bilirubin : 2.22 mg/dl

Direct Bilirubin : 1.13 mg/dl

AST : 147 IU/L

ALT : 48 IU/L

ALP : 204 IU/L

Total proteins : 6.3 g/dl

Serum albumin : 3 g/dl

A/G ratio : 0.9

- ESR :

15mm/1st hour

- Prothrombin time : 16 sec

- APTT : 32 sec

- Serum electrolytes :

Sodium : 133 mEq/L

Potassium : 3 mEq/L

Chloride : 94 mEq/L

- Blood Urea : 12 mg/dl

- Serum Creatinine : 0.8 mg/dl

- Ascitic fluid :

Protein : 0.6 g/dl

Albumin : 0.34 g/dl

Sugar : 95 mg/dl

LDH : 29.3 IU/L

SAAG : 2.66 g/dl

- Serology : 

HbsAg : Negative

HCV : Negative

HIV : Negative

chest xRay

 

ECG

 

USG Abdomen

Ascitic fluid cytology

Culture And Sensitivity Report

 

PROVISIONAL DIAGNOSIS: 

Acute decompensated liver failure with ascites.

TREATMENT: 

Fluid restriction less than 1L per day     

Salt restriction less than 2 gm per day   

Inj. Pantoprazole 40 mg IV OD

Inj. Lasix 40 my IV BD

Tab. Spironolactone 50 mg BB

Inj. Thiamine 1 Amp in 100 ml IV TID

Syrup Potchlor 10ml PO TID

Syp. Lactose 15ml TID 

Ascitic fluid tapping