70 years old unstable female presenting with sudden swelling in the face and fever for last 8 days with the history of T2DM, low back pain & HTN

Disclaimer:-

This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here February 2017 after collecting informed patient consent (form downloadable Click Here)  by BMJ Elective Student. 

According to patient's relative:

1. Patient was reasonably well 3 years back and 6 months prior to that patient was taken to the doctor and she was diagnosed with Diabetes Mellitus. Doctor advised her to make lifestyle modifications. After repeated follow up with doctor her Diabetes Mellitus was well-controlled and advised to continue the same. 

2. Years after the diagnosis of diabetes mellitus patient developed cataract in her left eye and in the meantime she also had difficulty in hearing with her ears & 40 years back she got meningitis malaria. 

3. Due to cataract, she was not able to walk properly and tried to walk forcing in her soles. Gradually she started developing pain in her low back. After taking consultation, doctor said there are lower vertebral displacement that needs conservative treatment with lumber belt and some calcium tablets & Aceclofenac and whenever she visits any doctor with the low back pain, she was priscribed with Aceclofenac and she took this NSAID for more than 1 year.   

4. Since 2006 her work activity got reduced. He was not so active and lying in the bed most of his time for last 1.5 years. 

 5. Suddenly on 06.02.2017 patient got fever (102 F), cough and lost her appetite. Patient was started on amoxicillin and the symptoms continued for 3 days. Previously about 4 months back she also had frequent loose motion and during that time medicines were given and symptoms went away. Patient has drug allergy to amoxicillin and despite of the allergy she was given the same antibiotic which relieved her fever & cough but her loose motion started and was not able to hold it voluntarily. 

6. Suddenly the night before admission to the hospital she was unable to speak properly and noticed that her face his significantly swollen. She was not able to sit properly. According to patient's relative, previously kidney function test & lipid profile were done which are suggestive of prior normal kidney function (Reports written below). And 8 month prior to the admission she was diagnosed with hypertension also. Next day after facial swelling she was taken to the hospital for admission.

  

Prior (Before the recent symptoms) Kidney function test & Lipid profile: (Done on 02/01/2017):

Fasting Plasma Glucose 87 mg/dl

S. Cholesterol    148 mg/dl

S. Triglycerides 124 mg/dl

S. Urea               21 mg/dl

S. Creatinine      0.9 mg/dl

S. Uric Acid         4.3 mg/dl

S. HDL-C (D)      32 mg/dl

S. LDL- C (D)     79 mg/dl    

How the Case presented in the Emergency department? 

Patient was presented with facial puffiness and inability to speak properly and had H/O urinary & fecal incontinence. 

According to Critical Care Daily Progress Notes:

Diagnosis: 

1. Sepsis

2. Hypoalbuminemia.

3. Acute Kidney Injury.

4. Anemia.

5. Left sided lower zone consolidation. 

6. On ABG, Metabolic Acidosis.

Till 14/02/2017 patient got 1 dialysis and started second dialysis the next day with under observation. 

Past Patient documents Including medicines & follow up status, progress notes, critical care assessment notes, USG W/A, ABG reports: 

Last report & medications (On 02/01/2017)

Last Prescription list that follows "Aceclofenac" throughout for more than 1 year:

Urine R/M/E Reports after admission: (14/02/2017)

ABG report after admission: (Showing Metabolic Acidosis)

 Critical Care Initial Assessment Sheet:

Critical Care Daily Progress Note:

Observation Chart: 

Medications list  that conitnued during admission:

USG Whole Abdomen report findings: