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












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