26 year old female with Lower Back pain and Fever

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Chenna Bhavana,

Roll No - 20,

Hall Ticket No - 1701006028.

Case Discussion :

I have been given this case to solve in an order to attempt to understand the topic of PATIENT CLINICAL DATA ANALYSIS to develop my competency in reading and comprehending clinical data including History, Clinical findings, Investigations and come up with a Diagnosis and Treatment plan.

A 26 year old female cam to the Hospital with :

Chief Complaints :

* Lower Back pain since 15 days 

* Fever since 10 days

History of Present Illness :

* Patient was apparently asymptomatic 15days back then she developed lower back pain which is : 

         ▪️  Insidious in onset 

       ▪️Gradually progressive 

       ▪️ Continuous, Non - Radiating and                               Dragging type of Pain

       ▪️ Diurnal Variation - More during night 

       ▪️ Relieving Factors - Relieved on                                                                     Medication.

* She also developed Fever 10 days Back which is :    

       ▪️  Insidious in onset  

     ▪️High grade 

       ▪️ Assosciated with chills and rigors 

 * Vomiting :

         ▪️Day 1 of admission : 1 episode of                                                                      vomiting 

         ▪️Day 2 : 6 Episodes of Vomiting

         ▪️Color - Yellow

         ▪️Content - Food

         ▪️Not projectile 

         ▪️Relieved on Medication 

* She also complaints of Red colored urine

( Blood in urine ) on the day before admission 

and the day one of admission which is :

      ▪️ Associated with Feeling of Sensation of                  Incomplete Voiding   

      ▪️ Not assosciated with pain or burning                      micturition or difficulty in passing urine

* She complained of Facial puffiness and 

abdominal distension on day 5 of admission 

and which subsided later on.

* No history of Chest Pain, Difficulty in Breathing, Cough, Indigestion or Heart burn .

History of Past Illness : 

* At the age of 10years,  She was diagnosed with Rheumatic heart disease and she underwent a surgery for it  ( Coronary Artery Bypass Graft  and Mitral valve replacement ) following which she took Medication for 2 years and she stopped using them thereafter, and again she started using the medication from the past 7months.

* Not a Known Case of Diabetes Mellitus, Tuberculosis, Hypertension, Epilepsy, Asthma.

Personal History : 

Diet -  Mixed

Appetite -  Normal

Sleep -  Disturbed due to Pain

Bowel and Bladder Movements -  Regular

Addictions - Absent

Family History :

Not Significant

Menstrual History :

* Age at Menarche - 13 Years

* Menstrual Cycle - 28/5, Regular, Moderate flow with Clots.

Physical Examination :

A. General Examination :

* Patient is conscious, coherent and co-operative and sitting comfortably on the bed.

* She is well oriented to time, place and person.

* She is moderately nourished.

Pallor -  Present

Icterus - Absent

Clubbing -  Absent

Cyanosis -  Absent

Lymphadenopathy -  Absent

Edema -  Absent

B. Vitals :

Temperature -  Afebrile

Pulse Rate -   70 BPM

Blood Pressure -   120/70 mmHg

Respiratory Rate -  34/Min

C. Systemic Examination

Per-abdomen examination 

Inspection:

* Shape of abdomen  -   normal

* Movements  -  all quadrants are moving equally with respiration 

* C-section scar is present 

* No engorged veins ,sinuses,swellings

* Striae gravidarum present 

* No visible gastric peristalsis

Palpation :

* No local rise of temperature ,no tenderness

* No palpable mass

* No hepatomegaly ,spleenomegaly

* Kidney ballotable 

Percussion :

* resonant note heard 

Auscultation : 

* bowel sounds heard

Cardiovascular system Examination :

Inspection:

* Midline scar is present 

* Shape of chest normal 

* No precordial bulge 

* JVP not raised 

* No visible pulsations

Palpation: 

* Apex beat felt at 5th ICS 2.5 cm lateral to mid clavicular line

Auscultation :

* S1S2 heard 

* no murmurs 

* Click sound is heard without stethoscope (replaced mitral valve )

Investigations :

On Day1:

Hb:9.8 %

TLC:21,900

N:83,L:7,B:2,M:8

Platelet:2.1 lakh 

Normocytic normochromic anemia

RFT:

APTT :51seconds

PT:25 sec 

INR:1.8

RBS:101 mg/dL

Urea:26

Sr.creatinine :1.4

Na+:141 mEq

K+:3.4

Cl_:106

On day 4

Hb:10.1

Urea :18 

USG :

(Done On the day of admission)

Impression:  Altered echo texture and increased size of right kidney

Provisional 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 (stopped)