26yr old female with fever and lower back pain

Final practical_long case

Name: M.Tejaswini
Halltkt no.: 170106107





This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.


26 year old female who is a resident of nalgonda and house wife by occupation came with a chief complaints of:

-Lower back pain since 10 days
-Fever since 5 days


HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 days ago (i.e 24/5/22) then she developed lower back pain which was sudden in onset and persistent,aggrevated during night,no radiation to lower limbs it relieved with medication.
      Then she developed fever 5 days back (i.e on 29/5/22). It was continous in nature. It was associated with chills and rigors.It was not associated with loose stools,rash,cough,cold.Fever relieved with medication.

Patient noticed reddish coloured urine on 1/6/22 which was not associated with pain, burning micturition, increased frequency of micturition. Which subsided on its own.

Patient also had multiple episodes of  vomitings on 2/6/22 which were non projectile, non bilious,content was food, which relieved with medication.



PAST HISTORY:
-No similar complaints in the past
-Patient had mitral valve replacement  at the age of 10.
-LSCS was done 7 months back (indication no labour pains)
-Not a known case of diabetes,hypertension,asthma,tuberculosis
CAD,epilepsy

PERSONAL HISTORY:
-Diet: mixed
-Appetite:normal
-Sleep:adequate
-Bowel and bladder:regular
-No addictions
-No known drug and food allergies 

FAMILY HISTORY:
Not significant

GENERAL EXAMINATION:
Patient was examined after taking informed consent in a well light room.
Patient was conscious,coherent and cooperative,well oriented to time place and person.
Moderately built and nourished

VITALS:
Temperature:afebrile
Respiratory rate:16cpm,thoracoabdominal
Pulse rate:80bpm,regular
Blood pressure:120/80mm/hg
Sp02:99%

Pallor: present
Icterus:absent
Clubbing:absent
Cyanosis:absent
Generalised Lymphadenopathy:absent
Generalised Edema:absent
                    pallor present

SYSTEMIC EXAMINATION:

1.Per Abdominal examination:
-INSPECTION:
Shape:scaphoid 
Scars:pfannestial incision LSCS scar is seen in lower part of abdomen
Flanks:free
Umbilicus:central in position and inverted
Skin: striae gravidarum is present
No engorged veins 
Movements of abdominal with respiration is equal in all quadrants.
No visible pulsations
Hernial orifices are normal
External genitalia: normal 

-PALPATION:
SUPERFICIAL PALPATION:
No local raise of temperature
No renal angle tenderness
DEEP PALPATION:
Liver:not palpable
Spleen:not palpable
Kidney:not palpable
No other palpable swellings

-PERCUSSION:
Resonant

-AUSCULTATION:
Bowel sounds heard.


           LSCS scar and striae gravidarum

2.Respiratory system:

Shape of chest: normal
Movement of chest is symmetrical on both sides
Trachea is not deviated
A linear scar is seen on anterior part of chest which was done for mitral valve replacement.
Normal vesicular breath sounds are heard
Bilateral air entry is present

   Surgical scar on anterior aspect of chest

3.Cardiovascular system:
JVP not raised
No precordial bulge
No visible pulsations
Apex beat Felt at 5th ICS 1cm medial to mid clavicular line.
S1,S2 heard.
No murmurs

4.Central nervous system:
Higher mental functions intact
Sensory and motor examination is normal
No signs of meningeal irritation.

Fever chart



PROVISIONAL DIAGNOSIS:
Acute pyelonephritis with mitral valve replacement


INVESTIGATIONS:
on day 1
Hemoglobin- 9.8
Total leukocyte count- 21,900cell/mm3
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia
LIVER FUNCTION TESTS

Appt- 51secs
Pt -25 secs
INR- 1.8

Random  blood sugar- 101 mg/ dl
Urea- 26 
Serum creatinine- 1.4
Sodium- 141meq
Pottasium- 3.4
chloride- 106



USG
2D ECHO
chest xray
ECG

TREATMENT

IV fluid -NS,RL :75mL/hr

Inj.piptaz 2.25 gm IV TID

Inj.pan 4mg IV OD

Inj. Zofer 4mg IV SOS

Inj.neomol 1gm IV SOS (if temp >101F)

Tab.PCM 500mg /PO/QID

Tab .niftaz 100mg /PO / BD












Comments

Post a Comment

Popular posts from this blog

NEUROLOGY(D)

Image
  A1. Occurrence of seizure due to brain stroke: ·          Cells in the brain send electrical signals to one another ·          The electrical signals pass along your nerves to all parts of the body ·          A sudden abnormal burst of electrical activity in the brain can lead to the signals to the nerves being disrupted, causing a seizure ·          This electrical disturbance can happen because of stroke damage in the brain. ·          A seizure can affect vision, smell and taste, loss of consciousness and jerking movements. Mechanism of seizure activity: ·          You’re more likely to have a seizure if you had a haemorrhagic stroke (bleed on the brain). ·          Seizures can also be more likely if you had a severe stroke, or a stroke in the cerebral cortex, the large outer layer of the brain where vital functions like movement, thinking, vision and emotion take place. ·          Some people will have repeated seizures, and be diagnosed with epilepsy. ·          The
Read more

55yr old female with fever and headache

Image
Final exam Short case Name: M.Tejaswini Halltkt:1701006107 A 55yr old female came with chief complaints of: -fever since 4 days -headache since 4 days History of present illness Patient was apparently asymptomatic 4 days back then she developed fever which was insidious in onset, continous type relieved with medication and not associated with chills and rigors. Fever was associated with diffuse headache which was throbbing type present throughout the day and relieved with medication. There was 1 episode of vomiting which non projectile, non bilious, content was food. She also had neck stiffness. There's no history of photophobia, giddiness,seizures. Past history No similar complaints in past Not a known case of DM, HTN, TB, asthma, epilepsy Personal history Diet:mixed Appetite:normal Sleep:adequate Bowel and bladder: regular No addictions No known drug and food allergies Family history Not significant General examination Patient is conscious, coherent, coperative. Moderately built
Read more

INFECTIOUS DISEASE HEPATOLOGY(B)

 A1. Most likely cause is Amoebic liver abscess because of the following findings:             - Age of the patient             - Single abscess             - Right lobe involvement A2.  - right hypochondriac and epigastric pain , fever ➡ can be liver, biliary or right lower lobe pneumonia -Invesigations:          -CBP : Leucocytosis          -LFT : Elevated Alkaline phosphatase          -RFT           -Urine analysis           -USG : Single hyperechoic   oval shaped mass in right lobe                                            Response to treatment                      Hypoechoic due to liquefaction of mass - Based on right hypochondriac and epigastric pain , fever * USG finding of hyperechoic mass in right lobe of liver along with other supportive investigations like leucocytosis ( suggestive of infection/inflammation) and ALP ( Alkaline phosphatase ) rise in LFT is a suggestive diagnosis of  LIVER ABCESS. Considering the following factors:  1) Age of the patient
Read more