PROF.DR.NOORUL AMEENPANDICHELVAN

M4 UNIT

50 yrs old lady came withc/o Breathlessness – 2 days sudden onset not progressive not related with exertionh/o Fever – 2 days low grade fever not associated with chills and rigorh/o Cough with sputum production – 2 days

h/o Swelling of both legsh/o Decreased urine outputno h/o Vomitingno h/o loose stoolPast history K/C/O – SHT -18 yrs DM -18 yrs taking treatment pt recovered from DKA 1 wk ago

GENERAL EXAMINATION Concious Oriented Afebrile Dyspneic Mildly dehydrated Pallor BPPE Not icteric No cyanosis ; No clubbing; No LNE

VITALS PR 90/min BP 130/80 mmhg RR 28/min

CVS S1 S2 Heard

RS NVBS Heard B/L creps B/L wheeze

P/A Soft Tender No free fluid No Organomegaly BS Heard CNS NFND

PROVISIONAL DIAGNOSIS DM2

SHT

SEPSIS

UTI

? DKA

INVESTIGATIONUrine R/E Albumin-nil Sugar - + Deposit 4-6cells/hpfBlood Urea- 44 FBS – 202

mg/dl Cr -0.9 PPBS -306

mg/dl Sugar -286Urine Ketone – Negative

24 hr urine proetinuria – 150 mg

Complete Blood HaemogramHb -10.5TC-10500DC-P70;L28;E2ESR 10/20PLC-1.4 LACPCV-27%MCV-78MCH-31MCHC-30

MP PS /QBC- NegativeWIDAL –NegativeMSAT- Negative

Serum electrolytes NA- 123 K -3.9 CL -96 HCO3-20ECG - Normal

CXR - Normal

ECHO- No regional wall motion abnormality EF-73%

ABG- High anion gap metabolic acidosis

USG ABDOMEN- Increased echo texture in liver Cirrhosis Splenomegaly Lt renal cortical cyst Focal hypoechoic leison in upper

pole of left kidney LFTTB-0.8SGOT-36SGPT-31SAP-73TP-5.9ALP-3.2 PT-13.2APTT-30.4INR-1.2

Viral markers HBSAG - Negative ANTIHCV - Negative HIV ELISA - Non reactiveANA- Negative

MGE Opinion: DM2/UTI/CLD/NAFLD

Urine C/S on 16/8/11

Pseudomonas growth in culture Sensitive to Cephalosporin;

GM;Amikacin Sputum C/S -No growth

Blood C/S -No growth

TREATMENT

Inj. Cefatoxime Inj.Insulin IVF Syp Kcl Anti hypertensives

On 25/8/11 Urine C/S- No Growth

Two days later patient

c/o fever

c/o abdominal pain

temp 102 ^ f

COMPLETE BLOOD HAEMOGRAMHB-8.9TC-12100DC-P78;L22ESR-25/69PCV-28MCV-78MCH-31.8MCHC-30PLC-60000

Urine C/S 30/8/11 E.coli growth in culture Sensitive to Cefotaime and Amikacin

DIAGNOSIS

DM2

SHT EMPHYSEMATOUS

PYELONEPHRITIS CLASS 3B Pt transferred to Urology