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