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Medical Grandrounds

Medical Grandrounds. Kathleen B. Miranda, M.D. Medical Resident February 5, 2009. Objectives. To present a case of perinephric abscess To discuss the etiology, predisposing factors, complications, and management of perinephric abscess. Identifying Data. A.A. 52/female Single.

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Medical Grandrounds

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  1. Medical Grandrounds Kathleen B. Miranda, M.D. Medical Resident February 5, 2009

  2. Objectives • To present a case of perinephric abscess • To discuss the etiology, predisposing factors, complications, and management of perinephric abscess

  3. Identifying Data A.A. 52/female Single

  4. Chief Complaint Abdominal Enlargement

  5. History of Present Illness 3 days PTA enlarging abdomen with palpable mass over the right flank area vague abdominal pain no fever, dysuria,hematuria no trauma anorexia

  6. History of Present Illness Consult CT scan of the abdomen done revealing presence of right perinephric and pararenal abscess formation Admission

  7. Review of Systems • Skin: (-) pruritus, (-) rashes, (-) easy bruising, (-) telangestasia, (-) spiderangiomatas • HEENT: (-) headache, (-) dizziness, (-) BOV, (-) eye redness, (-) colds, (-) epistaxis, (-) deafness, (-) ear discharge, (-) bleeding gums, (-) oral sores, (-) hoarseness, (-) neck pain, (-) limitation of motion

  8. Review of Systems • Respiratory: (-) cough, (-) DOB, (-) hemoptysis • Cardiovascular: (-) chest pain, (-) palpitations, (-) orthopnea, (-) paroxysmal nocturnal dyspnea • Gastrointestinal: (-) dysphagia, (+) early satiety, (-) jaundice, (-) nausea, (-) vomiting, (-) hematemesis, (+) constipation, (-) diarrhea

  9. Review of Systems • Extremities: (-) joint pains, (-) swelling • Neurologic: (-) seizures, (-) tremors, (-) involuntary movement • Endocrinologic: (-) polyphagia, (-) polyuria, (-) polydipsia

  10. Past Medical History • Chronic schizophrenia, paranoid type since her college years and maintained on Clozapine (Leponex) and Fluoxetine (Prozac). • Diabetes mellitus type 2 since 2000 currently on Glimepiride 2mg (1/2-0-0) prior to admission. Home monitoring of blood sugar at 98-135mg% pre-breakfast.

  11. Family History (+) Hypertension- mother (+) Diabetes Mellitus- mother (-) Heart disease, psychiatric disorders, kidney disease, thyroid disease

  12. Social History • Non-smoker • Non alcoholic beverage drinker • College undergraduate • Unemployed

  13. Physical Examination • Drowsy, not in cardiorespiratory distress, wheelchair-borne • BP= 80/50-->90/60 HR=105 RR=21 T=36.7C Wt=59 kg Ht=160 cm BMI=23 • Pale palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy • Equal chest expansion, clear breath sounds, no crackles, no wheezes

  14. Physical Examination • Adynamic precordium, tachycardic, regular rhythm, distinct S1 and S2, no appreciated murmurs • Globularly distended abdomen, normoactive bowel sounds, ill-defined mass on deep palpation on the right lumbar region, (+) tenderness • No gross deformities of the extremities, grade II pedal edema, right,decreased pulse on right, no cyanosis, no tenderness,

  15. Salient Features • 52/F • Diabetic • Schizophrenic • Enlarged abdomen • Drowsy • Tachycardic • Pale palpebral conjuctivae • (+) tenderness on right lumbar region • Decreased pulse on right extremity • Grade II pedal edema, right

  16. Initial Impression • Urosepsis secondary to Acute Pyelonephritis, Perinephric Abscess 2. Peripheral vascular disease, right leg 3. Diabetes Mellitus Type 2 4. Chronic Schizophrenia

  17. Problem#1 UROSEPSIS

  18. At the ER • Drowsy • Hypotension: BP 80/50 • Tachycardic: 105bpm • Blood WBC: 17.73x103/L, segmenters 0.87 • Urinalysis: bacterial 44,208/hpf

  19. At the ER • Hypotension: BP 80/50, px noted drowsy • Tachycardic: 105bpm • Blood WBC: 17.73x103/L, segmenters 0.87 • Urinalysis: bacterial 44,208/hpf

  20. At the ER • IVF: PNSS 1L , 200ml fast drip then regulated 120ml/hr • Diagnostics: Na, K, crea, CBG, blood CS, urine CS • Therapeutics: Ertapenem 1g IV q24 Amikacin 500mg IV x 1 dose • Referred to Nephrology, Psychiatry

  21. 2nd HD • Still with febrile episodes • Urine CS: E.coli 100,000 cfu/ml and Grp B Streptococci (Enterococci) 100,000 cfu/ml • Tx: Clindamycin 300mg/tab, 1 tab q8 • Episodes of decreased urine output • Foley catheter inserted • Furosemide 40mg tablet, ½ tablet once daily

  22. 6th HD • Still moderate-grade fever • Abdomen still distended • Referred to Urology service for planned nephrectomy • Piperacillin tazobactam 4.5g IV infusion for 8 hours every 8 hours

  23. 7th HD • Right renal exploration, evacuation of perineprhic abscess, and right nephrectomy under GA

  24. 15th HD • Ertapenem (day 7) was discontinued and started on Cefixime 200mg capsule once a day and Clindamycin 300mg 3 times a day

  25. Problem# 2 Peripheral Vascular Disease

  26. 3rd HD • Right foot noted cyanotic and cold • Compression stockings and warm blanket • PT and PTT • Heparin drip 24,000 units in D5W 250ml at 1,000 units/hr

  27. 5th HD • Referral to Vascular Surgery

  28. 10th HD • 3rd post-nephrectomy day • No febrile episodes • Noted progression of the cyanosis of right foot from the initial 1st digit further to the plantar forefoot area • Heparin drip was increased to 1,100 units per hour

  29. 12th HD • 5th post-nephrectomy day • Referred to radiology service for right femoral angiography

  30. 12th HD • Suggested below the knee amputation, however relatives expressed to try less invasive procedure • Embolectomy of the right anterior tibial artery under local anesthesia was done immediately • Post-procedure heparin drip was resumed at 1,200 units per hour.

  31. 16th HD • 9th post-nephrectomy day • 4th post-embolectomy day • Warfarin 5mg tab OD started • Heparin drip adjusted at 1,000 units per hour

  32. 18th HD • 11th post-nephrectomy day • 6th post-embolectomy day • note of progression of hemorrhagic area above the level of the patient’s right ankle • Doppler evaluation, there is a faint signal heard beyond the popliteal area • Heparin drip increased to 700 units • Vascular Surgery service evaluated the progression at this time is irreversible and that below the knee amputation is already needed

  33. 19th HD • 12th post-nephrectomy day • 7th post-embolectomy day • Patient underwent below the knee amputation • Aspirin 80mg OD started

  34. 23rd HD • 16th post-nephrectomy day • 11th post-embolectomy day • 4th post-BKA day • patient discharged improved • Take home meds:Clindamycin 300mg TID for 7 days and Ciprofloxacin 500mg BID for 7 days.

  35. Problem#3 DIABETES MELLITUS

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