A 45 year old female with altered sensorium , bilateral loin pain and fever.

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I’ve 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 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 1 month back when she developed pain the bilateral  loin region.  The pain was insidious in onset and of moderate severity. It was continuous in nature. For which she went to the hospital was diagnosed with a kidney stone. 10 days ago then she developed low grade, intermittent fever which was  not associated with chills or rigors. It was 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 was associated with burning micturition. 

She was not able to pass urine since 1 day. 

On admission, foley’s catherter was inserted  and frank pus  was noticed. 

Patient had slurring of speech from 2 pm and then started speaking incoherently and couldn’t recognise anyone. 

Dialysis was initiated due to metabolic acidosis (pH: 7.29) on the day of admission and another session was done on the next day. 

Left percutaneous  Nephrostomy was done on day 3 of hospitalisation and 500 ml of pus was drained.  

On day 6 of admission she was diagnosed with diabetes mellitus type 2. 

Past history

She is not a known case of HTN, CAD, Epilepsy, Asthma. 

Examination 16/02/22: 

The patient was conscious, coherent and cooperative. 

She is well built but poorly nourished. 

Pallor was present.

  Mild pedal edema was present.

No signs of iceterus, cyanosis, clubbing, generalised lymphadenopathy was seen 

Vitals :

      temp: 97.2F

      Bp  100/60 mm/hg

      Pr: 96 bpm 

      Rr: 14cpm

     

Respiratory system examination

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 

CVS: 

S1 and S2 are heard. 

No abnormal heart sounds were heard. 

Abdominal examination :

1. Abdomen is distended. 
2. Midline scar present. 
3. Bladder distended till umbilicus. 
4. Abdomen soft. 
5. No guarding 

INVESTIGATION:

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 ascites.

MDCT SCAN BRAIN- PLAIN: 

No abnormality in brain. 

PROVISIONAL DIAGNOSIS: 

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