doc_clotaire
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A 45-year-old woman is brought to the health center by her husband because of nausea, confusion, chills, fever, flank pain and cloudy
urine. She has a history of insulin-dependent diabetes mellitus, poorly controlled hypertension and recurrent urinary tract infections. Her
vital signs are:
Temperature 40.0°C (104.0°F)
Pulse 120/min
Respirations 24/min
Blood pressure 110/70 mm Hg
Funduscopic examination shows diabetic retinopathy, which is unchanged from the previous examination. Neck is supple. Lungs are clear
to auscultation and percussion. Examination of the abdomen is normal. Marked pain is present at the right costovertebral angle. Several hemorrhagic bullous lesions are noted on the extremities.
Without prompt and aggressive treatment, this patient is most likely to develop which of the following?
A) Diabetic ketoacidosis
(B) Hyperosmolar coma
(C) Meningitis
(D) Pneumonia
(E) Septic shock
If this patient were to develop anuria, which of the following would be the most likely cause?
(A) Acute papillary necrosis
(B) Bladder outlet obstruction
(C) Neurogenic bladder
(D) Renal lithiasis
(E) Tumor encroachment on the ureters
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| robin082006
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1. E, this is acute pyelonephritis.
2. C
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| Aashi
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E-----> Septic shock
A-----> Acute papillary necrosis
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| 92306
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(E) Septic shock
(A) Acute papillary necrosis
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| prasanthi
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1.e
2.a
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| Geroo
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1.E
2.A
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| zaidsuror
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1-e
2-a
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| dr.wad
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1- C
2_ A
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| doc_clotaire
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The correct answer is E
The patient is presenting with signs of septic shock from
pyelonephritis, including nausea, confusion, chills, fever, flank pain, and cloudy urine.
The hemorrhagic extremity lesions are most likely a sign of septicemia and toxemia.
Immediate treatment with intravenous antibiotics is necessary to prevent
cardiopulmonary collapse and death.
Diabetic ketoacidosis (choice A) is a possibility, but the cloudy urine, chills, fever, and
hypotension point to developing pyelonephritis and septic shock in this patient. Diabetic
ketoacidosis alone would be unlikely to give a fever and chills.
Hyperosmolar coma (choice B) typically presents with decreased consciousness in the
absence of signs of sepsis. The cloudy urine, chills, fever, and hypotension point to
developing pyelonephritis and septic shock in this patient.
Meningitis (choice C) is unlikely because the neck is supple. Meningitis cannot be
definitively excluded without a lumbar puncture, however. In this patient, the signs and
symptoms clearly point to pyelonephritis and sepsis, and another source of infection does
not need to be worked up at this time.
Pneumonia (choice D) is unlikely because the lungs are clear. This could be confirmed
by a chest x-ray. However, the patient in this case has signs and symptoms consistent
with pyelonephritis and sepsis.
The correct answer is A
This patient is young and quite ill. She has multiple medical
issues active at once and therefore, the question requires focus on the physical findings. A
history of insulin dependent diabetes, coupled with the presence of retinopathy on exam,
is an indication that this patient has poorly controlled diabetes. The physical findings of
fever and right CVA pain associated with a history of multiple recurrent urinary
infections makes clear that this patient has an active infection. The danger for her is that
of diabetic ketoacidosis or severe renal damage. In the case of anuria, the most common
cause in poorly controlled diabetics is papillary necrosis. Renal papillary necrosis occurs
in about 2 out of 10,000 people. It is most commonly associated with analgesic
nephropathy and it also occurs in patients with diabetic nephropathy. Diabetics with
retinal lesions have a 20-50% incidence of concomitant renal disease. Anuria is the
setting of severe diabetes is almost always associated with acute tubular necrosis (ATN)
from a cell death such as that with papillary necrosis.
Bladder outlet obstruction (choice B) or renal lithiasis (choice D) are unlikely is this
patient since she has no history of renal calculi.
Neurogenic bladder (choice C) commonly occurs with advanced diabetes as part of the
general autonomic neuropathy. However, it is not an acute occurrence and since the
patient had no history of generalized autonomic dysfunction or bladder dysfunction, this
is unlikely to be the cause of her anuria.
Tumor encroachment on the ureters (choice E) is highly unlikely given that there is no
component of this patient’s history or physical exam that suggests tumor.
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| oasis
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septic shock is a complication of diabetis mellitus
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| oasis
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diabetes mellites-->pyelonephritis. dm + pyelonephritis--->septic shock
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