72 year female with Uncontrolled T2DM

August 21, 2022

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PRESENTING COMPLAINTS:

C/O Vomiting since 3 days.

C/O Decreased appetite since 3 days.

C/O Uncontrolled Sugars since 3 days.

C/O SOB since yesterday night ( 14/08/2022)

HOPI:

A 72 year female presented to the casuality with complaints of low grade intermittent fever since 6 days which was relieved on taking medication. History of vomiting 2 episodes for 3 days which were non bilious and non projectile, food as content; associated with decreased appetite. History of SOB Grade III NYHA since yesterday night. No history of fever, cough, cold, chest pain, palpitations and burning micturition. Now admitted for further evaluation and management.

PAST MEDICAL ILLNESS:

In 1996, she sought for consultation for generalized weakness and was diagnosed with T2DM and started on OHA's; and started on Insulin therapy from 2010.

In 2011, she had complaints of chest pain and sought for consultation and diagnosed with IHD; she was started on Antiplatelet, Statins, Febuxostat and Nitrofurantoin ( for 20 days) and adviced for regular cardiology follow up.

In 2013, she had recurrent episodes of hypoglycemic attacks, sought for consultation for the same and her Insulin dosage was reduced.

In 2016, She sought for consultation for fever, loss of appetite and LOC; admitted in hospital and diagnosed to be having UTI for which she was treated with IV Antibiotics and got discharged.

Since then she was having Recurrent episodes of UTI 2-3 times a year.

She then had symptoms of urinary incontinence, for which she sought for Urology consultation; diagnosed to be having Pelvic floor muscle weakness and adviced for pelvic floor strengthening exercises.

In 2020, there is a slight pain in the knee joint and sought to a doctor and treated with a intra articular injection and there is increase in pain since then.

In 2021, she had complaints of decreased urine output and burning micturation, swelling of both limbs and decreased appetite and vomiting and admitted in the hospital and given medication. August 2021 candida

September 2021 klebsiella,

March E. Coli sensitive to carbapenems, June sensitive to Fosfomycin.

History not constipation since 3 years; since 2 years she was on regular medications for the same.

SURGICAL HISTORY:

S/P - Hysterectomy in 1993 under GA.

COURSE IN YHE HOSPITAL:

A 72 year female presented to the casuality with above mentioned complaints. Necessary investigations were done. Chest xray showed cardiomegaly and 2D ECHO was done on 16/08/2022 which showed findings of:-

Moderate MR/TR with PAH; Trivial AR; Mild Global Hypokinesia; No AS/MS; Sclerotic AV; Fair LV Systolic function; Eccentric TR; Diastolic dysfunction; No LV Clot; Dialated RA/LA and Concentric LVH; Minimal Pericardial effusion; IVC Size 1.93cms Dialated and non collapsing; EF 52%; RVSP 60mmHg.

USG ABDOMEN was done which showed findings:

1. Rt kidney 8.9×4.2cms; Lt kidney 9.8×5.5cms with normal size and echotexture; CMD maintained and Left PCS was dilated.

E/O : Raised echogenecity of B/L kidneys with left hydroureteronephrosis.

Her blood culture and sensitivity was negative and Urine c/s showed E coli growth, which was sensitive to fosfomycin.

Surgical cross consultation was done i/v/o constipation and distended abdomen and orders followed.

Urology cross consultation was done i/v/o left hydroureteronephrosis and adviced to get NCCT KUB to r/o ureteric stone.

Nephrology cross consultation was done i/v/o raised creatinine and they priscribed to add supportive medications.

Urine for ketones were negative; serum osmolality was 302; Serum Iron 46; serum LDH 180 IU/L; 24 hour urine creatinine 0.6g/day, protein 510mg/day, volume 1800ml; spot urine k+ 10.6, Na+ 180; Ncct kub was done on 19/08/2022 which showed:

1. Soft tissue density at the left pelvi ureteric junction.

2. Focal short segment thickening of distal part of left upper ureter.

3. Left moderate hydroureteronephrosis.

Urology review cross consultation was done after NCCT KUB, they advised to get CECT KUB, Cystoureteroscopy and Retrograde studies to rule out Transitional cell carcinoma. She was gradually improved and hemodynamically stable.

ECG at presentation: