50 year female with loin pain

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PRESENTING COMPLAINTS:

C/O :-

 Left loin pain, Diffuse abdominal pain, Fever since 4 AM on 22/07/2022.

 Constipation since 3 days.

HOPI:  

A 55 year female presented to the casuality with c/o left loin pain radiating to the back and diffuse squeezing type of abdominal pain since 4 AM on 22/07/2022; Low grade intermittent fever associated with chills, relieved on taking medication. 2 episodes of vomiting, food as content, non bilious, non projectile at 6AM. History of Constipation since 3 days. Now admitted for further evaluation and management.

PAST ILLNESS:

In 2010 she had an episode of giddiness and sought for consultation and She was diagnosed as Type 2 Diabetis Mellitus. Since then she was on Insulin therapy.

 In July 2021 she sought for regular check and her HbA1c was 10.4%. 

In August she had complaints of multiple joint pains, sought for consultation and diagnosed to be having Diabetic Retinopathy with Uncontrolled Sugars; polyarthralgia and treated with Hydroxy chloroquine and Insulin. 

In September, she had complaints of polyarthralgia, Intermittent Fever associated with chills, lack of appetite associated with weight loss, Generalized weakness and Throat pain for which she sought for consultation and diagnosed as Enteric fever after confirming with widal test. 2d ECHO was done which showed No LV RWMA, Normal LV Systolic function, Trivial TR, No PAH/PE/LV Clot and EF 68%. 

In October she had complaints of burning micturition, abdominal pain she underwent priliminary investigations which showed negative for urine ketones, serum Amylase and lipase are normal; Urine for culture and sensitivity was positive for E.col for which she was started on Oral Nitrofurantoin.

  Urine C/S : 

On January 2022, she was admitted in hospital, Unconscious state and her blood sugars are low and her Insulin doses were corrected. In February, she had she sought for consultation for complaints of fever with chills, cough, SOB, burning micturition, polyarthralgia and was admitted in hospital, after Physician and Neurophysician evaluation, she was diagnosed as Uncontrolled T2DM with DKA, Dengue fever (IgG+), E.coli Urosepsis, L5- S1 PIVD with Radiculopathy.  

In March 2022, she was admitted in  with complaints of fever, nausea, malaise, decreased appetite and body pains; diagnosed as Uncontrolled T2DM, Acute Gastritis, AKI, Dyselectronemia with Septicemia, Right Pyelonephritis, Anemia. 

She has been discharged after resolving Right Pyelonephritis. 

In July 2022, She presented to casuality with complaints of Grade III SOB, referred from CHC i/v/o High blood sugars, she was treated and discharged on 20/07/2022.

SURGICAL HSITORY: 

S/P Hysterectomy with B/L salpingo-oophorectomy 13 years ago.

GENERAL EXAMINATION: 

Patient was conscious and coherent.

Afebrile.

Weight : 53kg.

pallor present

No Icterus/ cyanosis/ clubbing/ lymphadenopathy and edema of feet. 

VITALS:

Temp: 98.7F; PR: 124bpm; RR: 24cpm; BP: 160/80mmHg; SpO2: 98%@RA. GRBS : High.

SYSTEMIC EXAMINATION: 

CVS:- S1,S2+, No murmurs.

R/S:- BAE+, Clear.

P/A:- Soft, tenderness at Left loin region.

CNS:- 

HMF +

Normal speech; No signs of meningial irritation.

All Reflexes were present with B/L Plantar flexors.

Power and Tone in all limbs was normal.

ECG AT ADMISSION:

ECG ON 24/07/2022; Pulse was irregularly irregular.

Fever Chart:-

Investigations Chart:-

2D ECHO: 

COURSE IN THE HOSPITAL: 

A 55 year female presented with above mentioned complaints. Initial GRBS was High. 0.1U/kg of Human Actrapid Insulin was administered intravenously; grbs was checked after an hour, it was still high. She was started on Insulin infusion. Mean while necessary investigations were sent. Urine for ketone was positive, sugars 3+, 4-6 pus cells, albumin+. The patient beas on NBM on day 1. 2 D ECHO showed no RWMA; Mild LVH; Trivial TR/AR/MR; Sclerotic AV; No AS/MS; EF 62%, RVSP 35mmHg; Good LV Systolic function; Diastolic dysfunction; No PAH; Minimal pericardial effusion; IVC 1 cms non collapsing. 

CECT Adomen was done which showed B/L Acute Pyelonephritis 

TREATMENT:

1. NBM TILL FURTHER ORDERS

2. IVF NS @ 100 ML /HOUR

3. INJ. HUMAN ACTRAPID INSULIN 6U / IV / STAT.

4. INJ HUMAN ACTRAPID INSULIN 40 U + 49 ML NS INFUSION @ 6 ML/ HOUR

5. SYP. CREMAFFIN 30 ML / PO / STAT

6. GRBS MONITORING

7. FEVER AND VITAL CHARTING.