A 27 year old female came with complaints of fever since 10-15 days and right sided lower abdominal pain radiating to lower back since 10-15days
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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .
History of present illness:
Patient was apparently asymptomatic 10-15 days ago then she developed fever high grade with chills and rigors(initial 3 days) not associated with cough, shortness of breath ,cold ,sore throat . Then she developed abdominal pain after 4 days of onset of fever, pricking type of pain. C/o Vomitings 1 episode for 1 day, contained food particles, non projectile, bilious.
Decreased urine output with burning micturition, dysuria aggrevated since 3 days. No complaints of hematuria, graveluria,pyuria.
Past history:
Not a K/C/O DM HTN CAD CVA ASTHMA EPILEPSY THYROID DISORDERS.
Family history: Not significant
Personal history :
Appetite : decreased since 10days
Diet : mixed
Sleep: adequate
Bowel : regular
Bladder: urine output decreased since 10 days
Addictions: none
Daily routine:
She wakes up at 5 am in the morning does her household chores, prepares breakfast and packs lunch boxes for her children. She has her breakfast by 8am and goes to the school. She is a teacher in preprimary school and teaches the students for 2 hours then does her work till 4pm. After 4pm she comes back to home and prepares dinner, spends time with her children, makes them do their homework and have dinner by 9pm and she sleeps around 10pm in the night.
General examination:
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Edema: absent
Vitals
Temperature-102F
PR-120bpm
BP-130/70mmhg
SpO2-98%
GRBS-105
Systemic examination
Cardiovascular system : S1 S2 + ,no murmurs heard.
Central nervous system:
Patient is conscious
Speech: normal
Cranial nerves: normal
Motor and sensory system: normal
Glassgow coma scale: E4 V5 M6
Respiratorysystem:
Bilateral air entry present
Normal vesicular breath sounds heard
Per abdomen :
Inspection-
Abdomen - Flat
No abdominal distension
Umbilicus is central
No engorged veins seen
No visible pulsations
Palpation-
Abdomen is soft , Tenderness present in Right Iliac region, no Hepatosplemomegaly.
Auscultation-
Bowel sounds heard.
Provisional diagnosis:
? Sepsis with Right mild Hydroureteronephrosis
Investigations:
Blood urea -37 mg/dl (N=12 to 42 mg/dl)
Serum creatinine-1.4mg/dl(N 0.6 to 1.1)
Serum electrolytes-
Na :133mEq/L(N-136 to 145)
K:4.0mEq/L(N:3.5 to 5.1)
Cl:99mEq/L(N=98 to 107)
Ionized Ca+2 :1.10mmol/L.
HEMOGRAM:
Hb : 8.3gm/dl.
Total count:14700 cell /cumm
Neutrophils:83 %
Lymphocytes:10%
Pcv:26.2 volume %
Platelets : 3.09 L / cumm.
Impression : Microcytic hypochromic anemia.
LFT:
TB: 0.80
DB:0.20
ALT: 14
AST: 16
ALP: 142
TP : 7.6
ALB: 3.1
A/G ratio : 0.70
CUE:
Albumin: ++
Sugars:nil
Pus cells:4-8/HPF
Epithelial cells:3-6 /HPF
Serum iron: 62
CXR :
USG ABDOMEN AND PELVIS:
FINDINGS:
E/o 8-9mm calculus noted in distal ureter
E/o 24x23mm cyst mited in Right ovary
Impression:
*Right distal ureteric calculus causing moderate hydroureteronephrosis
* Right simple ovarian cyst.
CT- KUB (PLAIN)
Kidney:
RIGHT KIDNEY: Pelvicalyceal system is dilated.
Ureter:
Right ureter dilated up to right midureteric calculus measuring 7mm with HU(1100-1400)
Impression: mid ureteric calculus causing mild hydroureteronephrosis.
TREATMENT:
1. IV fluids 3.NS @75ml/hr
2. INJ MONOCEF 1GM IV/BD
3. INJ PAN 40MG IV/OD
4. T.DOLO 650MG PO/TID
5.INJ NEOMOL IV/SOS ( If temp is > 101F)
6. VITALS CHARTING
7. I/O CHARTING
Comments
Post a Comment