70 YEARS FEMALE A K/C/O DM, K/C/O HYPOTHYROIDISM, K/C/O CKD

 Case History and Clinical Findings :-

COURSE IN THE HOSPITAL:-

70 YEARS FEMALE A K/C/O DM SINCE 20 YEARS USING INJ HUMAN MIXTARD 30/70 15U(BBF) 10U(BD), K/C/O HTN SINCE 20 YEARS USING TAB METOPROLOL 50MG OD , K/C/O CAD WITH CABG DONE 8 YEARS BACK USING ANTIPLATELETS, 

K/C/O HYPOTHYROIDISM SINCE 8 MONTHS USING THYROXINE 50MCG OD, 

K/C/O CKD SINCE 2 MONTHS ON CONSERVATIVE MANAGEMENT WITH HISTORY OF LEFT MASTECTOMY 3O YEARS BACK CAME TO HOSPITAL WITH COMPLAINTS OF FEVER SINCE 2 DAYS AND ON FURTHER EVALUATION WAS PROVISONALLY DIAGNOSED TO HAVE UROSEPSIS WITH RENAL AKI ON CKD WITH HFpEF(EF : 53%) RELEVANT INVESTIGATIONS AND BLOOD AND URINE CULTURE SENT AND INITIATED ON APPROPRIATE ANTIBIOTICS(INJ PIPTAZ AND INJ LINEZOLID). NEPHROLOGY OPINION WAS TAKEN I/V/O AKI ON CKD AND SEPSIS AND ADVISED FOR DIALYSIS WITH PRBC TRANSFUSION . 5 SESSIONS OF HEMODIALYSIS WAS DONE WITH 2 UNITS OF PRBC TRANSFUSION URINE CULTURE SHOWED PSEUDOMONAS AUREUGINOSA GROWTH AND SENSITIVE FOR MEROPENEM AND OFLOXACIN AND HENCE INITIATED ON INJ MEROPENEM AND TAB OFLOXACIN. AND SUPPORTIVE TREATMENT WAS GIVEN WITH SOLUBLE INSULIN, ANTIPLATELETS, DIURETICS, ANTI HYPERTENSIVES, AND MULTIVITAMINS. PATIENT WAS ON OXYGEN SUPPORT AND SATURATION WAS MAINTAINED . PULMONOLOGY REFFERAL WAS TAKEN IN V/O XRAY CHANGES AND ADVISED FOR HRCT CHEST AND IT SHOWED MODERATE TO SEVERE BILATERAL PLEURAL EFFUSIONS AND SEGMENTAL ATELECTASIS IN LEFT LUNG LOWER LOBE AND ANVISED FOR NEBULISATIONS WITH IPRAVENT AND BUDECORT. SURGERY REFERAL DONE I/V/O NOT PASSING STOOLS SINCE 5 DAYS MICROLITHS IN GALL BLADDER AND ADVISED TO 

1.X RAY ABDOMEN SUPINE AND LATERAL DECUBITUS POSITION 

2. REPEAT USG ABDOMEN AND PELVIS UROLOGY REFERRAL DONE I/V/O RIGHT MODERATE HYDROURETERONEPHROSIS AND ADVISED TO

 1. NCCT KUB ( FINDINGS: RIGHT MODERATE TO SEVERE HYDRONEPHROSIS , DILATED RIGHT URETER UP TO MID PORTION WITH MILD THICKENING AND IRREGULARITY OF MID/DISTAL PORTION OF RIGHT URETER- TO RULE OUT STRUCTURE/ TRANSTIONAL CELL CARCINOMA. 

 40X36 MM SOFT TISSUE DENSITY IN URINARY BLADDER AROUND THE CENTRAL TUBE OF FOLEYS? SPECIALISED FOLLEYS BULB? MASS LESION. SUGGEST CYSTOSCOPY). SLUDGE/CALCULI IN GALL BLADDER. AND ADVISED FOR BIOPSY UNDER CYSTOSCOPY 

ON EXAMINATION :-

 Temp :AFEBRILE

 BP:110/70MMHG

 PR:88BPM

 RR:18CPM 

 GRBS:170

 CVS: S1 S2 +, NO MURMURS 

 CNS: NFND

 RS:BAE+ NVBS HEARD

 P/A: SOFT, NON TENDER

 Provisional Diagnosis:-

 1.UROSEPSIS , 

2.TYPE 2 DM,

3.RENAL AKI ON CKD STAGE 4,

4.HFPEF ( EF-53%) SECONDARY TO CAD (S/P-CABG) 5.K/C/O , HTN , HYPOTHYROIDISM 6.?TRANSITIONAL CELL CARCINOMA

 Investigation:-

 9/11/23: 10/11/23 11/11/23 12/11/23 14/1/23 

HB : 9.2 GM/DL 10.4 GM/DL 10.7 9.5 9.7 

TLC : 17,100 CELLS /CUMM 19,200CELLS /CUMM 15,500 12,600 10900

PLATELET COUNT : 3.41 LAKHS/ CUMM 3.63 LAKHS / CUMM 3.78 3.15 2.63

RFT : UREA : 53 MG/DL 70 MG/DL 81 84 60

CREATININE : 2.5 MG/DL 3.0 3.6 3.5 2.6 

URIC ACID: 2.3 MG/DL 4.8 5.2 6.0 4.7 

CALCIUM : 9.6 MG/DL 9.7 9.6 9.0 9.5

PHOSPHORUS : 4.6 MG /DL 5.6 6.1 6.3 4.0 

SODIUM : 134MEQ/L 137 132 132 133 

POTASSIUM : 3.5 MEQ/L 4.1 4.3 3.6 3.7 

CHLORIDE : 97MEQ/L 101 94 97 97 

ABG :-

 PH : 7.48

 PCO2 : 34.8 MMHG

 PO2 64.9 MMHG 

 HCO3 25.6 MMOL/L 

 O2 SAT : 93.5

Advice at Discharge

1. TAB ECOSPRIN AV 75/20 HS 0-0-1

2. TAB CLOPIDOGREL 75MG HS 0-0-1

3. TAB THYRONORM 50MCG OD BBF 1-0-0

4. INJ HUMAN ACTRAPID INSULIN S/C TID BEFORE MEALS 6U-6U-6U

5. TAB METOPROLOL 50MG OD 1-0-0

6. TAB NIFEDIPINE 20MG TID 1-1-1

7. TAB NODOSIS 1GM TID 1-1-1

8. TAB TORSEMIDE 100MG BD 1-0-1

9. TAB METAZOLONE 5MG OD 0-1-0

10. TAB NICORANDIL 5 MG 1-0-1

11. TAB SORBITRATE 5MG 1-0-1

12. TAB LORAZEPAM 5MG 0-0-1

13. TAB FAROPENEM 200 MG 1-0-1 FOR 7 DAYS

14. TAB OFLOXACIN 200 MG 1-0-1 FOR 10 DAYS