Final practical examination- Long case

 This is 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 patients 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 comment box is welcome.


E.Laharika 

Hall ticket no: 1701006040


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.

   20 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

Delayed Wound healing present- wound healing took 2 months time to heal


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

Not on any other medication

No h/o blood transfusion


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

Vitals @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 101F
SpO2: 98% on RA
GRBS: 124 mg/dL


GENERAL EXAMINATION:

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:


On 19/5/22:









X ray KUB


CT scan 



USG 










20.05.22
LDH- 192
24hr Urinary protein- 434
24hrs Urinary creatinine- 0.5






Pus cells





21.5.22
Hemoglobin- 6.8g%
TLC- 22,500cells/cumm
Platelets- 1.4lakhs/cu.mm

Urea- 155mg/dl
Creatinine- 4.7
Uric acid- 7.1
Phosphorus- 2.0
Sodium- 126
Potassium- 2.6
Chloride- 87

22.5.22
Hemoglobin- 7.2
TLC- 17,409
Platelet count- 1.5

Urea- 162
Uric acid- 5.0
Sodium- 125
Chloride- 88

23.5.22

Hemoglobin- 6.7
TLC- 21,000
Platelet count- 1.5

Urea- 160
Uric acid- 7.5
Sodium- 130
Chloride- 97


24.5.22

Hemoglobin- 6.8
TLC- 24000
Platelet count- 1.6


Sodium- 134
Chloride- 98




27.5.22
Hb- 7
TLC- 22,000
Platelet count- 26,000
Urea- 144
Creatinine - 4.8
Uric acid-9.1
Phosphorus- 4.8
Sodium- 135
Potassium- 4.3
Chloride- 98
Fasting blood sugar- 149

29.5.22
Hb- 6.4
TLC- 14,700
Platelet count- 6000
Urea - 149
Creatinine- 4.4
Uric acid- 9.2

30.5.22

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 
Encephalopathy secondary to sepsis 

TREATMENT: 




Day 1 to Day 3:
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. PAN 40mg IV OD
IV Fluids- NS,RL @ 100 mL/hr
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water

Day 4
INJ. MEROPENEM 500mg IV BD
INJ. ZOFER 4mg IV TID
INJ. RANTAC 50mg IV OD
INJ. KCl 2 Amp in 500 mL NS over 4.5 hrs infusion
IV Fluids- NS,RL @ 100 mL/hr
SYP. POTCHLOR 10 mL in 1 glass of water TID
SYP. MUCAINE GEL 10 mL PO TID
7 point profile
BP/HR/RR/SpO2 charting
Temp charting 4th hrly
RT feeds- 2nd hrly 100 mL water

Day 5 to Day 10:
INJ. MEROPENEM 500mg IV BD (Day 6)
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
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS
BP/HR/RR/SpO2 charting
Temp charting 4th hrly

Day 11:
INJ. COLISTIN 2.25 MU IV OD(Day 4)
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
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS

Day 12:
SDP Transfusion done I/v/o low platelet count 
Pre transfusion counts:
Hb:6.2 g/dL
TLC:14700
PLt:6000

Post transfusion counts:
Hb:6.4
TLC:13700
PLt:50000

INJ. COLISTIN 2.25 MU IV OD(Day 5)
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
GRBS 7 point profile
INJ.HAI SC TID ACC to GRBS
TAB.DOLO 650 mg SOS





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