A 26 year old female with lower back pain and fever

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.

Hall ticket no. 1701006119

Final practical exam long case -

CHIEF COMPLAINTS:

 26 yr old female ,who is a housewife came to hospital with chief complaints of - 

Lower back ache since 10 days and 

Fever since 5days

HISTORY OF PRESENTING ILLNESS: 

▪Patient was apparently asymptomatic 10 days back then she developed severe lower back ache which is sudden in onset and continuous in nature and which was dragging type of pain and not a radiating to other areas. Then she used pain killers it relieved the pain but not completely.  

▪ After that she developed fever 5 days back and associated with chills and rigors through out the day but more during night times for which she was given injections by local rmp but it got subsided temporarily.

So she went to nearby hospital A , there she underwent some tests , they diagnosed it as kidney infection.

Afterwards she went to hospital B and got admitted on 2nd June 2022.

▪ 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 micturition, no urge to pass urine,Incomplete voiding,burning micturition .

▪ After admission she had vomitings on 2nd June ( 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 developed abdominal distension on 6th june and got subsided.

▪ There is no history of cough ,cold ,loose stools, constipation. 

PAST HISTORY-

▪ No similar complaints in the past .

▪At 10 yrs of age she underwent mitral valve replacement surgery for rheumatic heart disease. 

- she had undergone c- sec 7 months back and delivered female baby.

-No history of diabetes,Hypertension,Asthma , tuberculosis.

PERSONAL HISTORY :

Diet- mixed

Appetite - Normal

Sleep - adequate

Bowel and Bladder movements - regular

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:34/min

BP:120/70 mmHg 

Temp:afebrile

FEVER CHART

LOCAL EXAMINATION

PER ABDOMEN

Inspection:

Shape of the abdomen -scaphoid

Umbilicus - inverted and central in position

C section scar visible

No dilated veins

No abdominal swellings

No visible peristalsis

No abdominal distension

All quadrants are moving equally with respiration.

Stria gravidarum is visible.

PALPATION :

No local rise of temperature, soft and non tender .

Inspectory findings are confirmed

No palpable mass

No hepatomegaly 

No splenomegaly

Kidneys are not palpable

PERCUSSION:

 

Resonant 

AUSCULTATION

Bowel sounds heard

CVS EXAMINATION:

INSPECTION 

Midline scar is visible

Shape of the chest is normal

No precordial bulge

JVP not raised

No visible pulsations

PALPATION

apex beat felt at 5th intercostal space

1 cm medial to mid clavicular line.

AUSCULTATION

s1 s2 heard 

No murmurs 

RESPIRATORY SYSTEM 

Bilateral air entry - present

Normal vesicular breath sounds heard

CENTRAL NERVOUS SYSTEM 

All Higher mental functions and Sensory and motor examinations are intact.

No signs of meningeal irritation

Provisional diagnosis:-

Acute pyelonephritis

INVESTIGATION:-

On June 2:-

Hemoglobin- 9.8

Total leukocyte count- 21900

neutrophils- 83

lymphocyte- 07

basophils- 02

monocytes- 08

Platelets- 2.1 lakh

Normocytic mormochromic anemia

aptt- 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

on day 3

Hemoglobin- 10.1

Total leukocyte count- 13000

neutrophils- 70

lymphocyte- 19

eosinophils- 01

basophils- 00

monocytes- 10

Platelets- 2.8 lakh

Normocytic normochromic anemia

Urea- 23

Sodium-137

Pottasium- 3.6

Chloride- 105

on day 4

Hemoglobin- 10

Total leukocyte count- 13700

neutrophils- 67

lymphocyte- 20

eosinophils- 03

basophils- 00

monocytes- 10

Platelets- 3.14 lakh

Normocytic normochromic anemia

Serum creatinine- 0.8

Urea- 18

Sodium- 133

Pottasium- 3.9

Chloride- 97

Complete urine examination

Colour- reddish

Appearance- cloudy

Pus cells- 1-2

Epithelial cells- 3-4

RBC- plenty

on day 5

Hemoglobin- 10

Total leukocyte count- 13000

neutrophils- 70

lymphocyte- 19

eosinophils- 02

basophils- 00

monocytes- 10

Platelets- 3.18 lakh

Normocytic normochromic anemia

Serum creatinine- 0.7

Urea- 12

Sodium- 125

Pottasium- 3.4

Chloride- 92

Alkaline phosphate- 109

USG REPORT:-

Other investigations:-

FINAL 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