Acute pyleonephritis on DKA







 E-LOGS GENERAL MEDICINE



 
Roll no 36
Hi, i am tejaswi5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 50 yr old female a resident of choutuppal came with cheif complaints of lower back pain on the left side since that day 4 am , vomitings since morning and constipation since 3 days


History of present illness 

Patient was apparently asymptomatic 13 yrs back . Later she had generalsed weakness , polyuria ,blurring of vision and unconscious for which she was taken to hospital and was diagnosed with diabetes for which she was given insulin injection . One and half yr back she absorbed polyuria ,  eye closings , weakness for which she went to  hospital and doctor prescribed medication tablets along with injection . 15 days back she hit her head to the fridge and developed one side headache . Later because of her polyuria and loss of consious for brought to our hospital and was treated for diabetic keto acidosis .  After one day stay at home the next day at morning 4 am she developed loin pain on the left side which radiated to the back . Its was a dragging type of pain back  she was admitted in our hospital on 22 july . She also had low grade fever associated  with chills  which relieved on medication 
She had two episodes of vomiting which was non projectile and non bilious type contents of vomiting inculded food and milk . She also had constipation since three days 
She had irregular bowel movements since 3 months now  hard stools with blood was seen sometimes . 


Past history 

K/c/o diabetes since 13 yrs 
K/c/a DKA 2 days back 
No history of hypertension , asthma , seizures , TB , CAD 
Hysterectomy done 18 yrs agoo

Personal history 

Her daily routine she is a housewife wakes up at 5 o vlock in the morning does her morning routine and household chores has her breakfast at 10 rests than lunch at 2 relaxes and evening snacks and night dinner at 9 o clock she sleeps by 10 o clock . 
Appetite reduced 
Sleep - insomniac since 3 months 
Vegetarian 
Micurition  incresased frequency polyuria 
Bowels movements irregular 
Has allergy of changapapu  ( chana dal ) a kind of dal 
No habits or addictions 

Treatment history 
Diabetes treatment 
Tab and injection 

Family history 
Father is a known case of diabetes 

Menstrual history 
Hysterectomy done 18 yrs back 

Obstetric history 
3 children 
3 gravida 3 para 3 live 
One boy and two girls  

Allergic history 

Allergic to Chana dall 

General examination 

Physical examination 

Pallor - Present 
Icterus - absent 
Cyanosis- absent 
Clubbing- absent 
Lymphadenopathy- absent  
Edema - absent  

VITALS : 

Temperature – febrile
Pulse rate –124 per min 
BP –160/80 mm of hg 
Respiration rate –24
GRBS –  327
SPO - 98 percent

SYSTEMIC EXAMINATION 
    CVS 
No Thrills 
Cardiac sounds S1,S2
No murmurs 

RESPIRATORY SYSTEM 

Dyspnoea - absent 
Wheeze - absent 
Position of trachea - central 
Breath sounds are vesicular

ABDOMINAL EXAMINATION 

Abdomen  scaphoid shape 
Tenderness  present left loin 
No palpable mass 
Hernial orifices normal 
free fluid absent 
No bruits 
Liver is not palpable 
Spleen is not palpable 
Bowel sounds heard 

CNS 
 Conscious
Speech is normal 
Signs of meningeal irritation- no neck stiffness
                                           No kernigs Investigations ordered 
 2 d echo                                         












 Blood culture 
14
15 
16 


Usg 




Ecg 





monitoring 








Provisional diagnosis 


Diabetic keto acidosis secondary to sepsis caused by bilateral pyelonephritis 
 

Treatment 

1) normal diabetic diet 
2)inj HAI 
3) inj NPH
4) inj meropenam 1gm/ ml / BD
5) TAB nitrofurontion 
6) IVF NS and RL 75 ml / hr 
7) inj meomol 100ml 
8) Tab  naxdom250 mg 
9) Tab orofer
10) TAb b - complex 
11) vital monitoring 






Comments

Post a Comment

Popular posts from this blog

CASE ON DENGUE

Image
GENERAL MEDICINE        Hello all. This is Tejaswi, a third-semester medical student. This e log depicts the patient-centered approach to learning.  This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent. Note: This is an ongoing case and will be updated as and when we find new information.            Th is e log is made under the guidance of Dr.Bavya    CASE SHEET  Date of admission:20/8/21 CHIEF COMPLAINT : Fever high grade associated with chills and rigor  Generalized weakness and giddiness  Decreasing trends of platelet counts (60,000 to 45,000 to 17000) HISTORY OF PRESENT ILLNESS: The patient presented with fever and chills   The onset of fever was from the past 3 days  The patient feels rotational  while walking, gid There is generalized weakness  No hematuria ,Malena ,petiche HISTORY OF PAST ILLNESS: 1 year back  He has a history of blood in stools 
Read more

58 yr old with stroke

Image
58 year old male construction worker by occupational came with chief complaints of Burning sensation at right upper half of the body since 2years History of present illness Patient was apparently asymptomatic 2years than one night he suddenly  complained  of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of left eye ball. After which patient went into coma for 3 months . He was taken to rk hospital Hyderabad treated there for 15 days than was brought back home . He was later taken to Khammam for treatment 3 times in a gap interval of 10 days still patient dint recover . Later they used some herbal medication and he regained consiousness slowly . He also was take
Read more

48M with Diabetes keto acidosis

Image
 48 M with diabetes keto acidosis  Hello all , I E. Tejaswi of eighth semester student.This E Log depicts the patient centered approach to learning This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 come up with diagnosis and treatment plan. A 48 year old male Patient lorry driver by occupation came to gener
Read more