70 YEAR OLD MALE WITH FLANK PAIN AND FEVER

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CHEIF COMPLAINTS:

Patient came with c/o of flank pain and fever since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 month back then developed flank pain which is insidious in onset and gradually progressive which is of dragging type

Then developed fever  and burning micturition 7 days back

For   burning micturition he used citralka syrup and subsided and he stopped using medication and again started burning micturition

H/o increased frequency of urination +

(He urinates for every 20 min)

H/o urgency of urination +

No h/o Hematuria,

No h/o suprapubic pain

No h/o dribbling of urine

Fever which aggrevates at night and subsides automatically  and associated with chills and subsides in the morning automatically

H/o nausea since 5 days

No h/o chest pain,palpitation,sob,sweating

PAST HISTORY:

K/c/o HTN since 1 year used medication(unknown medication) for 2 months and stopped due to controlled blood pressure

K/c/o DM for 2 year used medication (unknown medication)for 3 months and stopped due to controlled blood sugars

Not a k/c/o TB,ASTHMA, EPILEPSY,THYROID DISORDERS,CVA,CAD

ALLERGIC HISTORY:

No history of any kind of allergies of food or drug

PERSONAL HISTORY:

Appetite: decreased

Sleep:adequate

Bowel and bladder regular

Addictions:He stopped taking alcohol 1 year back

Before 1 year he used to drink  for every 1 month (90ml at a time)

He used to be a smoker 20 years back

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

patient is conscious/coherent/cooperative

No pallor,icterus,cyanosis,clubbing,lypmaphadenopathy,edema

SYSTEMIC EXAMINATION:

cvs:s1 and s2 +

Rs:Bae+nvbs

P/A :

Inspection:

abdomen distended

No scars sinuses present

Umbilical inverted

Palpation:

soft and tenderness in right lumbar region

Right loin tenderness+

Fluid thrill +

Percussion:

Shifting dullness +

Auscultation:

Bowel sounds +

CNS:

no focal neurological deficits

Provisional diagnosis:

FEVER UNDER EVALUATION

K/C/O DM ,HTN

INVESTIGATIONS:- 

DATE :- 8/2/24

BT - 2min 00sec

CT - 4 min 30 sec

PT 1.20 sec

Malaria --ve

Dengue -ve

Widal test -ve

Urine for ketone bodies - +ve

CBP:- 

Hb:-  12.1   gm/dl

TLC :-  8,300  cells N-85/L-10/E-2/M-3/B-0

PLT -   1.20  lakhs 

CUE:- 

Alb- 3+

Sugars - 4+

Pus cells -    4-6cells

epi:-    2-4cells

RFT:- 

Serum creatinine:-   1.2 mg/dl

Serum Na :-135   mEq/L

Serum  K :- 3.5   mEq/L

Serum cl :-98

Serum ca -1.21

CHEST XRAY:

8/2/24

ECG:

USG ABDOMEN:

BULKY RIGHT KIDNEY WITH HYPERECHOGENICITY

E/O FEW CYSTS NOTED IN LEFT KIDNEY LARGEST MEASURING 11 X 9 MM IN UPPER POLE

Bulky right kidney

IMPRESSION:

ACUTE RIGHT PYELONEPHRITIS

GRADE 1 PROSTATOMEGALY

GRADE 1 FATTY LIVER 

LEFT RENAL CORTICAL CYSTS

MILD SPLENOMEGALY

2D ECHO :

SINUS ARRYTHMIA

CONCENTRIC LVH

MODERATE AR,MILD MR,MODERATE TR

MILD CALCIFIED AV,THICKENED AV

EF =63

GOOD LV SYSTOLIC FUNCTION

DIASTOLYIC DYSFUNCTION+

NO PAH

MILD MA +

IVC SIZE (1.18CMS) COLLAPSING

https://youtube.com/shorts/5TFi6jZ1sDk?si=FMBt4bUbYNcJ6tWt

DIAGNOSIS :- 

DIABETIC KETOSIS

ACUTE PYELONEPHRITIS

K/C/O HTN AND DM

9/2/24:

FBS -129

Serum NA:135

SERUM K :3.5

SERUM CL :98

SERUM CA : 1.23

SERUM OSMOLALITY: 275

URINE KETONE BODIES :+VE

DOA - 8/2/24

S :- 

Fever at 10:30am 

Stools not passed

O:

Pt is c/c/c

Bp - 110/80 mmhg

Pr- 81 bpm

RR :- 18 cpm

Grbs :- 174 mg/dl

Cvs - S1 S2 heard no murmurs

Rs - Bae+ Nvbs

P/A :

Soft and tenderness present in right lumbar region

CNS:- NFND 

       

A:

-DIABETIC KETOSIS

-ACUTE PYELONEPHEITIS

-K/C/O DM AND HTN

P :- 1 IVF 2 Ns @ 100 ml/ hr

2 INJ MONOCEF 1g IV / bd

3 INJ NEOMOL 1g IV /soa IF TEMP > 101F

 4 TAB AMLONG 5.mg po /OD

5 INJ HAT sc/TID ACC TO GRBS

6 GRBS MONITOR EVERY HOURLY

INJ KCL 1amp IN 500 ml NS OVER 5 HOURS

10/2/24

Hb:13.1

Tlc:9,400

N/L/E:88/6/0

Pcv:38.4

Mcv:81.5

Serum NA:134

SERUM K :3.5

SERUM CL :99

SERUM CA : 1.13

DOA - 8/2/24

S :- 

2 fever spikes at 11:30 pm and 6:00am

Stools not passed

O:

Pt is c/c/c

Temp: 97.6f

Bp - 140/80 mmhg

Pr- 102bpm

RR :- 22 cpm

Grbs :172mg/dl

Cvs - S1 S2 heard no murmurs

Rs - Bae+ , crepts at right axillary area and right mammary area

P/A-Inspection:

abdomen distended

No scars sinuses present

Umbilical inverted

Palpation:

soft and tenderness in right lumbar region

Right loin tenderness+

Fluid thrill +

Percussion:

Shifting dullness +

Auscultation:

Bowel sounds +

CNS:- NFND 

       

A:

-DIABETIC KETOSIS

-ACUTE PYELONEPHEITIS

-K/C/O DM AND HTN

P :- 1 IVF 2 Ns @ 100 ml/ hr

2 INJ MONOCEF 1g IV / bd

3 INJ NEOMOL 1g IV /sos

 4 TAB AMLONG 5.mg po /OD

5 INJ HAT sc/TID ACC TO GRBS

6 GRBS MONITOR EVERY HOURLY

7 SYRUP CREMAFFIN PLUS 15ml PO/HS

8 NEB WITH DUOLIN AND BUDECORT 6th HOURLY

11/2/24: