Case 42 Doa 6/1/24 Dod 10/1/24 46 male with fever and rt loin pain since 1 week

Diagnosis

PYREXIA UNDER EVALUATION

? UROSEPSIS WITH RIGHT PYELONEPHRITSWITH ANEMIA SECONDARY TO IDA WITH

DIABETES MELLITUS TYPE II

Case History and Clinical Findings

PATIENT CAME TO OP WITH COMPLAINTS OF FEVER SINCE 7 DAYS, RIGHT FLANK PAIN

SINCE 7 DAYS, BURNING MICTURITION SINCE 7 DAYS , PEDAL EDEMA SINCE 7 DAYS

HOPI:- PATIENT WAS APPARENTLY ASYMPTOMATIC 7 DAYS BACK THEN HE DEVELOPED

FEVER WHICH IS HIGH GRADE , INTERMITTENT , ASSOCIATED WITH CHILLS AND RIGORS

NOT RELIEVED BY MEDICATION ASSOCIATED WITH FLANK PAIN SINCE 7 DAYS DRAGGING

TYPE OF PAIN NO AGGRAVATING OR RELIEVING FACTORS

C/O BURNING MICTURITION SINCE 7 DAYS

C/O B/L SWELLING OF LOWER LIMBS PITITNG TYPE EXTENDING UPTO THE ANKLE NOT

RELIEVED ON LYING DOWN

C/O PASSING HARD STOOLS ONCE IN EVERY 2 DAYS

NO C/O COLD, COUGH , DECREASED URINE OUTPUT , NAUSEA , VOMITINGS CHEST PAIN.

PAST H/O :-

K/C/O DM2 SINCE 2 YEARS USING TAB. GLIMI M1 IRREGULAR MEDICATION.

NO HTN, TB, EPILEPSY, CVA,CAD, THYROID DISORDERS , BRONCHIAL ASTHMA.

C/O B/L HEARNING LOSS SINCE 4 - 5 YEARS FOLLOWING EAR INFECTION.

ADDICTIONS- REGULAR ALCOHOLIC AND SMOKER FOR 20 YRS AND THEN HE STOPPED 5

YRS BACK

GENERAL EXAMINATION-

TEMP- 99.8F

PR- 90BPM

RR-20CPM

BP- 60/40 MMHG

SPO2-99 % AT ROOM AIR

GRBS- 207 MG/DL

SYSTEMIC EXAMINATION-

CVS- S1 S2 HEARED , NO MURMURS.

RS- BAE +, NVBS

CNS- NFND

P/A - SOFT , PAIN IN RIGHT HYPOCHONDRIUM, LUMBAR AND UMBILICAL REGION.

Investigation

BLOOD UREA 06-01-2024 04:27:PM 33 mg/dl 42-12 mg/dl

SERUM CREATININE 06-01-2024 04:27:PM 1.8 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 06-01-2024 04:27:PM

SODIUM 130 mEq/L 145-136 mEq/L

POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L

CHLORIDE 98 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.26 mmol/L mmol/L

LIVER FUNCTION TEST (LFT) 06-01-2024 04:27:PM

Total Bilurubin 0.59 mg/dl 1-0 mg/dl

Direct Bilurubin 0.16 mg/dl 0.2-0.0 mg/dl

SGOT(AST) 11 IU/L 35-0 IU/L

SGPT(ALT) 8 IU/L 45-0 IU/L

ALKALINE PHOSPHATE 138 IU/L 128-53 IU/L

TOTAL PROTEINS 4.5 gm/dl 8.3-6.4 gm/dl

ALBUMIN 2.5 gm/dl 5.2-3.5 gm/dl

A/G RATIO 1.26

HBsAg-RAPID 06-01-2024 04:27:PM Negative

Anti HCV Antibodies - RAPID 06-01-2024 04:27:PM Non Reactive

COMPLETE URINE EXAMINATION (CUE) 06-01-2024 04:27:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Trace

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 3-4

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

PERIPHERAL SMEAR 06-01-2024 08:56:PM RBC : Normocytic normochromic WBC : Increased in

count with Neutrophilia PLATELET : Adequate

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-01-2024 05:49:AM

SODIUM 137 mEq/L 145-136 mEq/L

POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L

CHLORIDE 103 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.26 mmol/L mmol/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 07-01-2024 11:02:PM

SODIUM 138 mEq/L 145-136 mEq/L

POTASSIUM 3.1 mEq/L 5.1-3.5 mEq/L

CHLORIDE 105 mEq/L 98-107 mEq/L

CALCIUM IONIZED 1.27 mmol/L mmol/L

FBS 158 mg/dl

PLBS 186 mg/dl

Hba1c 6. 3%

T3, T4, TSH 07-01-2024 11:02:PM

T3 0.93 ng/ml 1.87-0.87 ng/ml

T4 11.51 micro g/dl 12.23-6.32 micro g/dl

TSH 3.84 micro Iu/ml 5.36-0.34 micro Iu/ml

STOOL FOR OCCULT BLOOD 08-01-2024 11:47:AM Negative (-ve)

SERUM AMYLASE 08-01-2024 04:46:PM 33.8 IU/L 140-25 IU/L

USG ABDOMEN AND PELVIS DONE ON 6/1/24

IMPRESSION :- TINY RENAL CORTICAL CYSTS.

REVIEW USG DONE ON 9/1/2024 I/V/O ? PYELONEPHRITIS AND ? LIVER ABSCESS

IMPRESSION- B/L RENAL CORTICAL CYSTS.

RAISED ECHOGENICITY OF LEFT RENAL CYST.

Treatment Given(Enter only Generic Name)

IVF - NS@75ML/HR

INJ. OPTINEURON 1AMP IN 100ML NS IV OD

INJ PIPTAZ 4.5 GM IV TID

INJ METROGYL 400MG IV TID

INJ NEOMOL 1GM IV SOS ( IF TEMP . 101 F)

INJ PAN 40MG IV OD

INJ HAI S/C TID BEFORE MEALS

INJ BUSCOPAN 1 AMP IM SOS

TAB PCM 650 MG TID

TAB DULCOLAX 2TAB HS

SYP POTKHLOR 10 ML IN 1GLASS OF WATER TID

SYP CREMAFFIN PLUS 15ML BD

Advice at Discharge

TAB METROGYL 400MG PO BDX 3 DAYS.

TAB AUGUMENTIN 625MG PO BDX 3 DAYS.

TAB PCM 650 MG PO BDX 3 DAYS

TAB MVT PO OD X 3 DAYS

TAB PAN 40MG PO OD BBF X 3 DAYS

SYP CREMAFIIN PLUS 10ML HS

Follow Up lost