CBBLE UDHC similar cases


I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis with a treatment plan.

This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent. 

A 45 year old female came with complaints of 
  • Fever since 10 days
  • Pain in B/L loin since 5 days 
  • Unable to pass urine since 1 day 
  • Altered sensorium since 1 day 
History of presenting illness: 
Patient was apparently asymptomatic 10 days ago then she developed low grade, intermittent fever not associated with chills or rigors, and relieved on taking medication, she was taken to another hospital for the same and reports showed: 
  • Serum creatinine-1.8
  • CUE: pus cells loaded
  • USG abd: left hydronephrosis 
Fever is associated with burning micturition. 

Pain in B/L loin which was colicky type with no aggravating or relieving factors. 

Unable to pass urine since 1 day. 
On admission, foley’s was passed and frank pus noticed. 
Patient had slurring of speech from 2 pm and then started speaking incoherently and couldn’t recognise anyone. 

Dialysis was initiated due to deranged RFT, Hypercalcia, metabolic acidosis to remove toxic metabolites. 


Past history:
History of renal calculi since 1 month, present. 

Not a known case of Diabetes mellitus, Hypertension, Coronary Artery Disease, Chronic Kidney Disease, Asthma. 

Surgical history: 

Hysterectomy done 10years ago. 

Vitals on admission: 

Temperature: afebrile 
PR: 120 bpm
RR: 16 cpm
BP: 110/80 mm Hg 
SpO2: 98%
GRBS: 106 mg/dal
CVS: S1 S2 present 
RS: BAE +
CNS: Hypertonia of both lower limbs seen. 




On examination: 
  1. Abdomen is distended. 
  2. Midline scar present. 
  3. Bladder distended till umbilicus. 
  4. Abdomen soft. 
  5. No guarding or rigidity. 







Investigations: 

On 8th:                          On 9th:  
Hb: 11.0 mg%.              Hb: 10.8 mg%
TLC: 41,000.                TLC: 41,600
Platelets: 2.0 lakh.         Plt: 1.7 lakh       

pH: 7.29
pCO2: 26.2 
pO2: 69.6
SO2: 92.2 
HCO3: 12.5 

S.Creat: 4.2
S. Urea: 153
S. Uric acid: 10.4 
S. Ca: 9.4
S.PO4: 3.8
S. Na: 140
S. K: 6.4
S. Cl: 103 

LFT: 

TB: 4.34
DB: 2.86
AST: 22
ALT: 16
ALP: 679
TP: 4.7
Albumin; 1.8
A/G: 0.62

On 9th: 

S. Iron: 84
RBS: 64
HbA1C: 6.4 %

On 10/2/22: 

pH: 7.31
pCO2: 31.4
pO2: 90.8
HCO3: 15.4 
SO2: 94.3 

Hb: 11.1 
TLC: 48000
Plt: 1.35

S. Urea: 80
S. Creat: 2.9
S. Na: 141
S. K: 4.8
S. Cl: 101

LFT
TB: 5.28
DB: 4.25
AST: 36
ALT: 17
ALP: 657
TP: 5.1
Alb: 1.9
A/G: 0.5


ECG on 8/2/22: 
Shows sinus tachycardia 




X Ray KUB on 8/2/22: 





USG DONE ON 8/2/22:
  1. B/L hydronephrosis 
  2. Right simple renal cortical cyst
  3. Grade I fatty liver

NCCT KUB: 





  1. Pneumoperitoneum with ?left perinephric abscess. 
  2. Air foci in upper calyx of right kidney- ? Emphysematous pyelonephritis 
  3. Mild ascitis.
MDCT SCAN BRAIN- PLAIN: 
No abnormality in brain. 

Treatment given: 

On 8/2/22:
  1. Soft diet 
  2. IV FLUIDS 1. NS and 1. DNS at 75ml/hr
  3. Inj. MEROPENEM 1g/IV/BD
  4. INJ. PAN 40mg IV BD 
  5. INJ. PCM 1g IV BD
  6. INJ TRAMADOL 2amp in 100ml NS IV BD 
  7. Monitor vitals

On 9/2/22:
  1. INJ MEROPENEM 1gm IV BD 
  2. INJ METROGYL 100ml IV TID 
  3. INJ. PCM 1g IV BD
  4. INJ. PAN 40mg IV BD 
  5. IV FLUIDS 2. NS AND 2. RL at 100ml/hr 
  6. Rule’s tube feeds (100ml milk and 100ml water) 4th hourly 
  7. INJ. NORAD (2amp + 36ml NS)
  8. GRBS 4th hourly monitoring 
  9. Strict I/p and O/p monitoring
On 10/2/22: 
  1. INJ MEROPENEM 1gm IV BD 
  2. INJ METROGYL 100ml IV TID 
  3. INJ. PCM 1g IV BD
  4. INJ. PAN 40mg IV BD 
  5. IV FLUIDS 3. NS AND 2. RL at 100ml/hr 
  6. Rule’s tube feeds (100ml milk and 100ml water) 4th hourly 
  7. INJ. NORAD (2amp + 36ml NS)
  8. GRBS 4th hourly monitoring 
  9. Strict I/p and O/p monitoring
  10. INJ HAI S/C TID after informing GRBS 


S: 

Disturbed sleep, patient irritable 


O: 

Temp: afebrile 

BP: 120/80 on Norad 6ml/hour 

PR: 112 bpm

RR: 20 cpm

SpO2: 95% on 6L O2

Input: 3000ml

Output: 350ml 

CVS: S1 S2 +

RS:  BAE + 

Crepts heard in Left mammary and infra axillary 


NC-CT KUB:  

  1. B/L emphysematous pyelonephritis
  2. Free air in retroperitoneum and peritoneum. 
  3. Mild free fluid in pelvis


A: 

B/L emphysematous pyelonephritis with AKI secondary to sepsis with metabolic acidosis 


P: 

One session of Hemodialysis done yesterday. Postdialysis Reports awaited

Inj. Meropenem 1g IV BD 

Inj. Metrogyl 500mg IV TID 

Inj. PAN 40mg 

RT feeds 4th hourly 

IVF NS and RL @100ml/hr

Temp, BP, PR, SpO2- monitoring hourly 

GRBS charting 6th hourly 

Input output charting 


Nephrostomy was done on 10/2/22 at 2:30 PM and 500 ml of pus was drained.  


11/2/22: 




S: 

Disturbed sleep, patient irritable 


O: 

Temp: 102°F 

BP: 120/70 on Norad 4ml/hour 

PR: 133 bpm

RR: 22 cpm

SpO2: 95% on 6L O2

Input: 4400ml

Output: 1200ml 

CVS: S1 S2 +

RS:  BAE + 

CNS: E3V2M4

Pupils: B/L NSRL

Hypertonia of both lower limbs 

P/A: Distended 




A: 

B/L emphysematous pyelonephritis with AKI secondary to sepsis with metabolic acidosis 


P: 

Inj. Meropenem 1g IV BD  (Day 3)

Inj. Metrogyl 500mg IV TID  (Day2)

Inj. PAN 40mg 

IV fluids 3  . NS and 2. RL

RT feeds 4th hourly 

IVF NS and RL @100ml/hr

Inj. NORAD 

Inj. HAI s/C TID

Temp, BP, PR, SpO2- monitoring hourly 

GRBS charting 6th hourly 

Input output charting 


X Ray KUB




12/2/22

Hemogram: 
RBCs: Normochromic Normocytic anemia
WBCs: increase in count with neutrophilic predominance. 
Platelets: adequate 

ABG: 
pH: 7.25
pCO2: 29.3
pO2: 123
HCO3: 12.5

LFT: 
TB: 3.12
DB: 2.14
SGOT: 39
SGPT: 15
ALP: 525
TP: 4.7
Albumin: 1.8
A/G: 0.58

RFT: 
Urea: 105
Creat: 3.3
UA: 7.7
Phosphate: 6.2
Sodium: 145
Potassium: 4.5
Cl: 106

13/2/22





45 y old female With pain b/l loin and unable to pass urine

S- Pt is irritable
    No h/o fever spikes

O - temp:99 f
      Bp  120/70 mm/hg
      Pr: 101bpm 
      Rr:24cpm
      SPO2: 99%on 4 litres of o2
      Grbs :183 mg/dl
      Input : 3400ml
      Output:1950ml
      Drian output : Nil

A- b/l pyelonephritis with aki secondary to sepsis
     With denovo diabetes mellitus

S/p : left percutaneous nephrostomy

P : 1 session of hemodialysis done yesterday
     Post dialysis reports awaited
     Inj meropenem 1gm iv bd
     Inj metrogyl 500 mg iv TID
     Inj pantop 40mg iv od
     IVF -ns @100ml/hr
     IVF -rl @100ml/hr
     Inj Tramadol 1amp in 100ml ns iv tid
     Inj neomol 1gm iv sos
     Monitor vitals hourly
     Grbs 6th hrly
     Inj HAI S/C according to sliding scale
     I/o charting

Drain output: 10ml



Hb: 8.7
TLC: 31,600
PCV: 25.3
Imp: normochromic normocytic anemia with neutrophilic leuckocytosis
 

ABG: 
pH: 7.29
pCO2: 39.2
pO2: 55.6
HCO3: 18.6


RFT: 
Urea: 78
Creat: 2.2
UA: 5.8
Phosphate: 5.4
Sodium: 143
Potassium: 4
Cl: 103

14/2/22







45 y old female With pain b/l loin and unable to pass urine 

S- Pt is irritable
    No h/o fever spikes
    Stools passed
     Swelling of both upper limbs present 
     Facial Swelling present 

O - temp:100.1 f
      Bp  100/70 mm/hg
      Pr: 101bpm 
      Rr:24cpm
      SPO2: 99%on 4 litres of o2
      Grbs :170 mg/dl
      Input : 3900ml
      Output:1700ml
      Drian output : Nil 

A-septic shock with septic encephalopathy with MODS ( secondary to uremic sepsis) with AKI with denovo diabetes mellitus type 2 

S/p : left percutaneous nephrostomy 

P : 2 sessions of hemodialysis done 
     Inj meropenem 1gm iv bd
     Inj metrogyl 500 mg iv TID
     Inj pantop 40mg iv od
     IVF -ns @100ml/hr
     IVF -rl @100ml/hr
     Inj Tramadol 1amp in 100ml ns iv tid
     Inj neomol 1gm iv sos
     Monitor vitals hourly
     Grbs 6th hrly
     Inj HAI S/C according to sliding scale
     I/o charting







15/2/22 

ICU 
BED 1
45 y old female With pain b/l loin and unable to pass urine 

S- Sensorium improved 
    Obeying commands 
    No h/o fever spikes
    Stools passed
     

O - temp: 99.8
      Bp  90/60 mm/hg
      Pr: 82 bpm 
      Rr:22cpm
      SPO2: 98% on 4 litres of o2
      Grbs :127 mg/dl
      Input : 4000ml
      Output:1750ml
      Drain output : 100 




A-septic shock with septic encephalopathy with MODS ( secondary to uremic sepsis) with AKI with denovo diabetes mellitus type 2 

S/p : left percutaneous nephrostomy 

P : 2 sessions of hemodialysis done 
     Inj meropenem 1gm iv bd
     Inj metrogyl 500 mg iv TID
     Inj pantop 40mg iv od
     IVF -ns @100ml/hr
     IVF -rl @100ml/hr
     Inj Tramadol 1amp in 100ml ns iv tid
     Inj neomol 1gm iv sos
     Monitor vitals hourly
     Grbs 6th hrly
     Inj HAI S/C according to sliding scale
     I/o charting

16/2/22

45 y old female With pain b/l loin and unable to pass urine 

S- Sensorium improved 
    Obeying commands 
    No h/o fever spikes
    Stools passed
     

O - temp: 97.2F
      Bp  100/60 mm/hg
      Pr: 96 bpm 
      Rr: 14cpm
      SPO2: 99% in RA
      Grbs : 95 mg/dl
      Input : 3250ml
      Output:1400 ml
      Drian output : 100 

A-septic shock with septic encephalopathy with MODS ( secondary to uremic sepsis) with AKI with denovo diabetes mellitus type 2 

S/p : left percutaneous nephrostomy 

P : 2 sessions of hemodialysis done 
     Inj meropenem 1gm iv bd
     Inj metrogyl 500 mg iv TID
     Inj pantop 40mg iv od
     IVF -ns @100ml/hr
     IVF -rl @100ml/hr
     Inj Tramadol 1amp in 100ml ns iv tid
     Inj neomol 1gm iv sos
     Monitor vitals hourly
     Grbs 6th hrly
     Inj HAI S/C according to sliding scale
     I/o charting



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