48 YEAR FEMALE WITH SEPTIC SHOCK AND MODS 2° TO EMPHYSEMATOUS PYELONEPHRITIS

A 48 year female presented to opd with cheif complaints of fever since 10days
•burning micturition since 3 days
•Pain in B/l loin since 5days
•Unable to pass urine Since 1 day
•Altered sensorium since 1day
HOPI: 
Patient was apparently asymptomatic since 19 days then she developed fever which was low grade, intermittent not associated with chills and rigors, relieves on taking medication.She was taken to another hospital for the same and the report shows
  • Serum creatinine-1.8
  • CUE: pus cells loaded
  • USG abd: left hydronephrosis
•Burning micturition and B/L loin pain (colicky type) with no aggravating and relieving factors since 12 days
•Decreased urine output and altered sensorium since 10days
On admission, foley’s was passed and frank pus noticed. 
Patient had slurring of speech from 2 pm and then started speaking incoherently and couldn’t recognise anyone. 

Dialysis was initiated due to deranged RFT, Hypercalcia, metabolic acidosis to remove toxic metabolites. 

Past history:
H/o renal stones -1mnth 
H/o hysterectomy- 10yrs
No h/o DM,HTN,asthma,epilepsy
Personal history:
Diet:mixed
Sleep: disturbed
Appetite:normal
Normal bowel movements
Decreased urine output
Addictions:Chronic alcoholic since 9 yrs 
                   Daily dose: 90ml/ day, weekly 2 to 3 times, last drink - 3weeks ago
•No smoking
Family history:not relevant

GENERAL PHYSICAL EXAMINATION:

PALLOR - absent
Icterus - Absent
Cyanosis - Absent
Clubbing - Absent
Lymphadenopathy - Absent
Pedal oedema - PRESENT ( PITTING TYPE)

Vitals:
Temperature- afebrile
Pulse rate- 90 beats per minute
Respiratory rate- 22 breaths per minute
B.P- 110/80 mm hg
SpO2- 99% at room air
GRBS:106mg/dal
Pt is irritable
SYSTEMIC EXAMINATION

Cardiovascular system- s1 and S2 are heard no murmurs are heard

Respiratory system:
BAE- positive

Central nervous system- Patient was conscious coherent and cooperative.
• slurred speech
•hypertonia of both lower limbs
 
On examination: 
•Abdomen is distended. 
•Midline scar present. 
•Bladder distended till umbilicus. •Abdomen soft. 
•No guarding or rigidity

Investigations
•10/2/22                                •12/2/22
Total bilirubin:5.28               |3.12
Direct bilirubin:4.25             |2.14
SGOT:36                                 |39
Alkaline phosphatase:657   |525
Total proteins:5.1                  |4.7
Albumin:1.9                           |1.8
•11/2/22
Hb:9.4
TLC:32000
RBC:2.94
UREA:103                                |105
CREATININE:3.2                     |3.3
URIC ACID:7                            |7.7
FBS:201

ECG on 8/2/22: 
Shows sinus tachycardia 

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: 


•Pneumoperitoneum with ?left perinephric abscess. 
•Air foci in upper calyx of right kidney- ? Emphysematous pyelonephritis 
•Mild ascitis.
MDCT SCAN BRAIN- PLAIN: 
No abnormality in brain. 
  
•2 sessions of hemodialysis was done 
1 on 9/2/22 and 1 on 12/2/22

•Lt percutaneous Nephrostomy was done on 10/2/22 at 2:30 PM and 500 ml of pus was drained.  


16/2/22
   Sensorium improved 
    Obeying commands 
    No h/o fever spikes
    Stools passed
Treatment
Inj meropenem 1gm iv bd
     Inj metrogyl 500 mg iv TID
     Inj pantop 40mg iv od
     IVF -ns @100ml/hr
     IVF -rl @100ml/hr
     Inj Tramadol 1amp in 100ml ns iv tid
     Inj neomol 1gm iv sos
     Monitor vitals hourly
     Grbs 6th hrly
     Inj HAI S/C according to sliding scale
     I/o charting

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