26 year old female with lower back pain and fever

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 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 patients clinical problems with collective current based inputs.

CASE

26 year old female who is a resident of nalgonda and housewife came with the complaints of

▪ Lower back ache since 15 days

▪ Fever since 10 days

HISTORY OF PRESENTING ILLNESS

▪Patient was apparent asymptomatic 15 days back then she developed severe lower back adhe which was insidious in onset and gradually progressive and continuous type which was squeezing in character and not a radiating type of pain and it gets relieved by medication and the injection given by local doctor there are no associated symptoms

▪ Then she developed fever 10 days back which was insidious in onset which started as chills then developed fever which was gradually progressive and associated with chills and rigors  more during night times 

▪ She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication given on 4th june

▪ She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine, there is a feeling of incomplete voiding of urkne

▪ she had puffiness of face and abdominal distension on 6th june and got subsided 

▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints

PAST HISTORY

 ▪ no similar complaints in the past 

▪Patient had history of chest pain when she was 10 years old  diagnosed rheumatic heart disease for which she was on medication for it but no subsided so surgery was done( CABG , MITRAL VALVE REPLACEMENT)  then she was on prophylaxis for 2 years then she discounted then she had c section done 7 months back as baby is weak she consulted doctor from then she again started the penicillin prophylaxis 

▪ She has a history of  PCOS for which she is on medication 

▪ not a known case of diabetes, Hypertension, asthma, tuberculosis 

MARITAL HISTORY

3rd degree consangious marriage , 6 years back and had 7 months old baby 

FAMILY HISTORY 

 not significant 

PERSONAL HISTORY

 Diet - mixed 

Appetite- normal

Sleep - decreased because of pain

Bowel and bladder movements - regular

no addictions

no allergies 


 MENSTRUAL HISTORY

 menarche - 13 years

 regular periods 

5/ 28 - moderate flow 

not associated with pains

GENERAL EXAMINATION 

Patient is conscious coherent  cooperative well oriented  to time , place , person moderately built and moderately nourished 

Pallor- present 

Icterus- absent 

Cyanosis- absent 

Clubbing - absent 

Lymphadenopathy - absent

Edema- absent 








VITALS

 Pulse- 70 bpm

Respiratory rate- 34 per min

Blood pressure- 120/ 70 mm hg

Temperature - afebrile





 SYSTEMIC EXAMINATION


Per abdomen 

INSPECTION

 shape of abdomen- normal 

c section scar is seen and stria gravidarum

umbilicus central in position

 no abdominal swellings seen 

no dilated veins are seen

no visible peristalsis 

all quadrants are moving equally with respiration




PALPATION

No local rise of temperature and no tenderness

no palpable mass

no hepatomegaly and no spleenomegaly

Kidney - ballatoble 

PERCUSSION

resonant sound heard

ASCULTATION

 Bowel sounds heard

CVS

INSPECTION 

midline scar is seen

shape of chest - normal

no precordial bulge seen

JVP not raised

no visible pulsations

PALPATION-

Apex beat felt at left 5th intercoastal space 2.5 cm medial to mid clavicularl ine

 Ausculatation -

S1 , S2  heards 

no murmurs 

click sound heard ( without stethescope)

Respiratory system- normal

CNS- intact

INVESTIGATIONS

 on day 1

Hemoglobin- 9.8

Total leukocyte count- 21900

neutrophils- 83

lymphocyte- 07

basophils- 02

monocytes- 08

Platelets- 2.1 lakh

Normocytic mormochromic anemia

LIVER FUNCTION TEST

Appt- 51secs

Pt -25 secs

INR- 1.8

Random  blood sugar- 101 mg/ dl

Urea- 26 

Electrolytes

Serum creatinine- 1.4

Sodium- 141meq

Pottasium- 3.4

chloride- 106

day 4th

Hemoglobin- 10.1

Urea- 18


USG




NCCT


2d echo-

X ray-

ECG-

Intake and output chart
 
2nd day 


4/06/2022

5/06/2022

6/06/2022


DIAGNOSIS
 
Acute pyelonephritis 

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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