OSCE -60 year old female with complaints of vomitings,pain abdomen since 10 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

Chief complaints-

60 year old female patient came to casualty with complaints of vomitings since 10 days which is non bilious, non projectile, food particles as content. 

C/O pain abdomen since 10 days,insidious onset, intermittent type of pain at left loin associated with giddiness since morning. 

H/O increased urine output since 3 to 4 days ,increased frequency, increased urgency present. 

H/O fever present 

No H/O hematuria

No H/O pyuria

No H/O graveduria 

No H/O previous renal surgeries

H/O constipation present.

N/H/O cold,cough,allergies. 

N/H/O chest pain

Past History -

K/C/O DM type 2 since 5 months ,on irregular medication 

No h/o Hypertension, asthma, tuberculosis, epilepsy ,CVA,CAD

Personal history 

Appetite-Normal 

Diet-Mixed

Bowels-Regular

Micturition-Increased urination

Allergies-No

Addictions-Alcohol -occasional

Family history-Not significant 

General examination-

Patient is conscious, coherent and cooperative and well oriented to time place and person 

No signs of,icterus,cyanosis,clubbing, lymphadenopathy 

Pallor -present 

Vitals -

Temp-102.9F

PR-102/MIN

BP-110/70MM HG

GRBS-416MG/DL

SYSTEMIC EXAMINATION 

CVS-S1,S2 heard no murmurs 

RS-BLAE ,NVBS

Abdomen-soft,tenderness present at left iliac region

No organomegaly 

Bowel sounds-Present

CNS-NFD

Investigations 

urine for ketone bodies-negative 

serum osmolality-285m osm/kg

Troponin I -6.9pg/ml

Urinary chloride-196mmol/l

spot urinary potassium-4.6

Spot urinary sodium -42mmol/l

FBS-236mg/dl 

Hba1c-7.5%

Hemogram on 9/11

Serum electrolytes on 9/11

rft on 9/11

Serology -Negative 

hemogram on 11/11

rft on 11/11

Hemogram on 12/11

rft on 12/11

Hemogram on 13/11

rft on 13/11

CT

2d echoe 

urine for c/s -no growth seen 

Blood for c/s-no growth seen 

Chest x ray

USG- altered echotexture and increased AP diameter, increased vascularity of left kidney 

Impression-Left pyelonephritis 

Diagnosis-k/C/O DM 2 with left pyelonephritis with dyselectrolemia 

Inpu/output-2000/700ml on 9/11

Input/output -2150/750 ml on 10/11

GRBS 

9/11/23

8am -250mg/dl -12units HAI,8 units nph 

10am -248 mg /dl 

2pm-115 -6 units HAI 

8pm-177 no food taken 

10pm -139

2am -134

10/11/23

8am -163 -6units HAI ,4units nph 

10am-360mg/dl

4pm-133mg/dl

8pm-103mg/dl

2am-115mg/dl

11/11/23

8am-147-6units HAI,4units nph 

10am -175

12pm-113-6units HAI

4pm-216

8pm-344-12units HAI 8units nph 

12/11/23

2am-85

8am -107mg/dl -6units HAI,4 units nph 

10am -161 mg /dl 

2pm-225 -6units HAI 

4pm-310

8pm-296-6units hai,4units nph given 

10pm-183

13/11/23

12am-155

8am -146 6units HAI

   4units nph

Treatment 

1:Inj Neomol 1g IV sos if temp >101F

2:IV fluids NS at 100ml /hr

3:Inj Piptaz 4.5gm IV/TID

4:Inj HAI According to GRBS SC/TID(pre meal)

5:Inj -NPH according to GRBS SC/BD

6:Monitor vitals 

7:GRBS monitoring 

8:TAB dolo 650 mg PO/SOS 

9:Inj Kcl 20meq in 500ml NS over 4 to 6 hours ×2 infusions

OSCE

Q.What are the symptoms  and classic triad of pyelonephritis?

Ans-Pain at left loin region radiating to iliac fossa and suprapubic area

Tenderness and guarding in renal angle 

H/O Increased urination associated with increased frequency and increased urgency 

Burning micturition

Fever

Classic triad-loin pan,fever,tenderness over kidneys

Q.What are the investigations done to dignose pyelonephritis?

Ans-1.Hemogram-Show leucocytosis

2.Urine examination-

Microscopy shows pus cells and organisms

Urine C/S- shows growth of causative organism

3.Usg

4.CT

Q.Management of Acute pyelonephritis?

Ans-Intravenous antibiotics according to growth of organism 

Q.What are the complications of pyelonephritis?

Ans.common in patient of diabetes mellitus or with urinary tract obstruction 

Necrotising papillitis/papillary necrosis -More common in analgesic abuse nephropathy and in sickle cells disease 

Pyonephrosis- rarely the abscesses in kidney in Acute pyelonephritis are extensive this results in inability of abscesses to drain and transforms kidney intlo multilocular sac filled with pus

Perinephric abscess-The abscesses in kidney may extend through capsule of kidney into perinephric tissue and form abscess 

Q.What is the etiopathogenesis of Acute pyelonephritis?

Etiology- infection of lower uti

Mc organisms - E.coli ,Enterobacter,kliebsiella,Pseudmonas and proteus

Pathogenesis-

Ascending infection-Bacteria multiply in urinary bladder and produce asymptomatic bacteriuria and causes urethritis,cystitis ascend further up into ureter,extend into renal pelvis and then to renal cortex 

Hematogenous infection-MC in immunocompromised patients 

Q.What are the morphological features of pyelonephritis?

Gross- enlarged swollen kidney

C/S- small abscesses with heamorrhagic rim 

Microscopic -Acute Inflammation involving interstitium and tubeles.shows large number of neutrophils .

Q.What are the radiological findings of pyelonephritis?

Usg- Altered echotexture and increased vascularity ,increase in size of kidney

CT-perinephric stranding present.,dilated collecting system.

SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the patient's case:

Strength

She has good support from family 

She recovered very soon with the medication

Weaknesses:

1. Her financial status

2. She is depressed about her disease 

Opportunities:

1. Provision of free testing such as CECT