A 26 year old female with low backache and fever

Hall ticket number:1701006050.

G.Sai Vidya

MBBS-IV

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-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an 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. 

 Chief complaints :

Lower back pain since 15days

Fever since 10days

History of presenting illness:

Pt was apparently asymptomatic 15days back

 then she developed lower backache 

Description of complaints:

Pain:

which was insidious in onset ,gradually progressive,dragging type and continuous,and it became severe later on ,pain is more during night ,pain is decreased on medication ,pain is not radiating 

Fever:

She developed fever 10days back which was insidious in onset ,high grade and assosciated with chills and rigors 

Vomitings:

Day 1 of admission : 1 episode of vomiting 

Day 2 :6 episodes 

Color-yellow,

Content-food

Not projectile 

Relieved on medication 

Blood in urine:

She complaints of red colored urine (blood in urine ) 

On the day before admission and the day one of admission 

Not assosciated with pain or burning micturition 

Or difficulty in passing urine

Feeling of sensation of incomplete voiding .

Facial puffiness and abdominal distension :

On day 5 of admission and subsided 

Negative history:

No history of chest pain,difficulty in breathing,cough ,indigestion or heart burn .

Timeline:

Past history:

At the age of 10years she was diagnosed with Rheumatic heart disease and she underwent a surgery (CABG and mitral valve replacement)following which she took medication for 2 years and she stopped using them thereafter ,and again she’s using the medication from past 7months.

No DM,TB,HTN,Epilepsy 

Personal history :

Diet:mixed

Appetite:normal

Bowel and bladder movements:regular 

Sleep disturbed due to pain

No addictions 

No allergies 

Family history :not significant 

Menstrual history :

Age of menarche:13 years

5/28 cycle ,regular,moderate flow , with clots ,no dysmenorrhea 

Marital history : married for 7 years ,7months back gave birth to a girl baby 

General examination:

Patient is conscious,coherent and cooperative 

Well oriented to time place and person 

Moderately built and nourished 

Pallor -present 

No icterus ,cyanosis,clubbing ,generalised lymphadenopathy,edema 

Vitals:

Pulse rate:70/min

RR:20/min

BP:120/70 mmHg

Temp:afebrile 

Vital chart:

Fever chart:

Fluid intake and output chart:

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 not ballotable

Percussion :resonant note heard 

Auscultation : bowel sounds heard

CVS :

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 medial to mid clavicular line

Auscultation :

S1S2 heard no murmurs 

Click sound is heard without stethoscope (replaced mitral valve )

RESPIRATORY SYSTEM:

bilateral air entry - positive 

Normal vesicular breath sounds heard

CNS:

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

Clinical images :

Investigations:

On Day1:

Hb:9.8 %

TLC:21,900

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

Platelet:2.1 lakh 

Normocytic normochromic anemia

LFT:

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

2decho:

ECG:

X-ray:

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)