70 years old female with recurrent complicated UTIs
A 70 years old female patient residing in Nalgonda, is a homemaker, presented to OPD with
complaints of- loss of appetite since one week,
- generalised weakness since one week
- fever since 5 days
-burning micturation since 5days
History of present illness-
patient was apparently asymptomatic one week back then she gradually developed loss of appetite since one week which was not associated with nausea, vomiting, associated with generalised weakness
fever since 5 days which was high grade associated with chills and rigors, no diurnal variation, relived on taking medication, not associated with headache, cold , cough
she also started experiencing burning micturation since 5 days associated with low backache , no history of dark coloured urine or blood in urine
no h/o cold, cough, chest pain, palpitations, shortness of breath, pedal edema , reduction in urine output, diarrhoea, constipation, vomiting, nausea, pain abdomen
Past history:
she has been having similar episodes since 2016
she had 1st episode in 2016 it started with fever which was high grade associated with chills and rigors, associated with loss of appetite which were followed by loss of consciousness. she was immideatly rusged to a local hospital where the attenders were told that she had high blood pressure and had high blood sugars. she was diagnosed with UTI and was treated with parenteral antibiotics for 5 days and was discharged on oral antibiotics which she took for one week. since then she had been having recurrent episodes of UTI 2-3times every year. after the 2nd or 3rd episode she started having urinary incontinence for which she consulted a urologist and was said to have weakness of pelvic floor muscles and was advisced pelvic floor muscle strengthning exercises.
28 years back she underwent hystrectomy
25 years back she had complaints of generalised weakness
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went to a diagnostic center and got few investigations done
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consulted a physician and was diagnosed with type 2 diabetes mellitus and was started on OHAs
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she did not take OHAs regularly
during that time she was residing in Saudi Arabia and her husband took her to regular check ups almost every weekend during that period he sugars were under control with OHAs
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in 2007 they moved back to India in 2010 she had uncontrolled blood sugars for which she was started on insulin , she started using insulin pen
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in 2013 she consulted an endocrinologist and was started on injections Humalog (insulin Lispro) 28 units in the morning and Basalog ( insulin Glargine) 20 units at night
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started having tremors, weakness ,excessive sweating , and excessive hunger ( had recurrent hypoglycemic attacks) during which he son Dental surgeon adviced her to reducethe dose of Insulin lispro to 20 units
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reviewed with the same endocrinologist and was advisced to stop Insulin glargine and was told to take insulin lispro in the evening also
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had recurrent episodes of UTI and got hospitalised for the same
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10 years back she had chest pain for which she was taken to a cardiologist and was diagnosed with angina and was started on antiplatelets, statins and isisorbide dinitrate ( SOS) , tab febuxostat 40mg ( for joint pains), vitamin D3 supplementation, and was also advisced tab nitrofurantoin for 20 days since then she was on a regular follow up with the cardiologist every 3 months
she also started having complaints of tingling and numbness in her lower lower limbs and was diagnosed with peripheral neuropathy secondary to diabetes mellitus and was startedon tab. neuroprime plus ( alpha lipoic acid, thiamine, mecobalamine, elemental chromium)
was also diagnosed with CKD and anemia
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Diagnosed with Hypothyroidism 5 years back and was started on tab. levothyroxine 50 mcg daily before breakfast
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blood sugars were not undercontrol in 2020 consulted an endocrinologist was started on sitagliptin 50mg and metformin 1000mg everyday morning before breakfast along with insulin
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in 2020 she was treated at home by her son for the similar episodes
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in 2021 march she had complaints of fever , cough and was diagnosed with COVID 19 infection and was hospitalized
there she was treated with Injection remedesivir for 5 days along with parenteral steroids and was later discharged on oral prednisolone and was gradually tapered over 10 days and then stopped
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in july she again had another episode of UTI and was again hospitalized
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was brought to our center
Personal history: married with 8 children - 4 sons and 4 daughters all are well at present,
no addictions - non smoker non alcoholic
sedentary habit
adequate sleep
no bowel abnormalities
family history- not significant
treatment history:
used insulin lispro (50%) + insulin lispro protamine 25 units in the morning and evening subcutaneously
used - Tab Ecospirin AV 75/10 mg H/S
tab Met -XL initially 25 mg for few years then 5o mg once daily
tab. feburic acid 40mg
tab tenegliptin 20mg then changed to tab sitaglipten 50mg + metformin 1000mg once daily
vitamin D3supplementation
used multiple antibiotics for recurrent UTI- nitrofurantoin, clarithromycin, piptaz, meropenem, levofloxacin
tab isosorbide dinitrate SOS
PROVISIONAL DIAGNOSIS:
A 70 years old lady with Recurrent complicated UTIs with peripheral neuropathy, secondary to diabetes mellitus (type 2) with hypertension with hypothyroidism known case of ischaemic heart disease.
GENERAL EXAMINATION:
patient is conscious, coherent, cooperative and oriented to time, place and person
patient is lying comfortably in supine position
patient is obese and well nourished
Height- 151 cms
Weight - 57 kgs
BMI - 25.0 kg/m2
face- wrinkled
eye- no abnormalities, baggy lower eyelids, pallor present, no xanthelasma or xanthomas
no cyanosis
oral cavity- lost all teeth, mucosa appears normal
nails- normal, no clubbing
no thyroid enlargement
no lymphadenopathy
neck veins- not distended
skin- normal, No pigmentation ,No scars, No atrophic changes
pulse- 110 beats per minute in supine position in right radial artery, regular rhythm, high volume, vessel is thickened, all other peripheral pulses are felt and are normal
BP: 110/80 mmHg in Right arm in supine position
100/80 mmHg in standing position
Respiration-- 20 breaths per min, thoraco-abdominal type
temperature- normal at the time of examination
feet-no pedal edema, no ulcers or calluses
GENITOURINARY SYSTEM EXAMINATION:
perabdomen- no abnormalities, no visible scars and sinuses
foleys catheter is insitu and is connected to urobag
no renal lump felt
renal angle- no tenderness
urinary bladder- empty
local examination - pubic hair-sparse distribution
labia majora, minora- atrophied
external uretheral meatus- no discharge, healthy
per vaginal examination bimanual examination
bilateral fornices free , non tender
anterior fossa normal
posterior fossa normal
Vault intact - no palpable masses felt, no tenderness
NERVOUS SYSTEM EXAMINATION
patient is conscious, cooperative, alert and oriented to time place and person
cranium and spine -normal, no abnormalities
speech- normal
Recent and remote memory intact
1. CRANIAL NERVES
CRANIAL NERVE | TEST | RIGHT | LEFT |
I | Sense of smell i) Coffee ii) Asafoetida |
+ + |
+ + |
II | i) Visual acuity – Snellens Chart ii) Field of vision – Confrontation test iii) Colour vision – Ishihara chart iv) Fundus | 6/6 Normal Normal Normal | 6/6 Normal Normal Normal |
III, IV, VI | i) Extra-ocular movements ii) Pupil – Size iii) Direct Light Reflex iv) Consensual Light Reflex v) Accommodation Reflex vi) Ptosis vii) Nystagmus viii) Horners syndrome | full 4mm Present Present Present Absent Absent No | full 4mm Present Present Present Absent Absent No |
V | i) Sensory -over face and buccal mucosa ii) Motor – masseter, temporalis, pterygoids iii) Reflex a. Corneal Reflex b. Conjunctival Reflex c. Jaw jerk | Normal Normal
Present Present Present | Normal Normal
Present Present Present |
VII | i) Motor – nasolabial fold hyeracusis occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma ii) Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus iii) Reflex – Corneal Conjunctival iv) Secretomotor – Moistness of the eyes/tongue and buccal mucosa |
Present Absent Good Good Good Good Good
Normal
Normal
Present Present
Normal |
Present Absent Good Good Good Good Good
Normal
Normal
Present Present
Normal |
VIII | i) Rinnes Test ii) Webers Test
iii) Nystagmus | Positive Not lateralised
Absent | Positive
Absent |
IX, X | i) Uvula, Palatal arches, and movements
ii) Gag reflex iii) Palatal reflex | Centrally placed and symmetrical
Present present |
|
X1 | i) trapezius ii) sternocleidomastoid | Good Good | Good Good |
XII | i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side | Normal No No Normal | Normal No No Normal |
Right. Left
Bulk: inspection UL normal normal
LL normal normal
palpation. UL Normal normal
LL normal normal
LL: 5/5 5/5
LL lost in distal parts on both sides
Investigations
FINAL DIAGNOSIS:
- Recurrent complicated urinary tract infections
- Complicated Fungal UTI
- Asymmetric Peripheral neuropathy secondary to Diabetes mellitus type 2
- Diabetic nephropathy
- known case of Ischaemic heart disease, Hypertension, Hypothyroidism
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