This is an E log book to discuss our patients de identified health data shared after guardians informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.
This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.
I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.
CHEIF COMPLAINTS
- burning micturition since 15 days
- fever associated with chills and rigors since 3 days
- diffuse pain abdomen since yesterday
- right loin pain since 1 day
History of presenting illness
Patient was apparantly assymptomatic 3 days back, then she developed high grade fever associated with chills and rigors, 2 episodes of vomiting which is non projectile, non bilious in nature 2 days back. Then she devoleped diffuse pain abdomen and right loin pain.
Past History:—
K/C/O leprosy 10 years ago diagonsed by hypopigmented patches insensitive to touch.(used medication for 1year— dapsone 100mg and clofazimine 50mg)
H/O UTI 6 months back
No history of diabetes, hypertension,thyroid , asthma and epilepsy.
Surgical history:
- underwent tubectomy 20yrs back
- underwent hysterectomy 5 yrs back.
Drug history:
- used ALD for 1 yr
- used syrup citralka 6 months back.
Personal history:
diet - mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements are regular - mild burning micturition
No Addictions
General examination:
The patient is conscious, coherent and cooperative and well oriented to time place and person. Moderately built and nourished.
On examination
Pallor is present
No Icterus , cyanosis, clubbing, lymphadenopathy and pedal edema.
Vitals:
Temp: afebrile
BP: 120/70
Pulse rate: 82bpm
RR: 18 cpm
SpO2 :99%
GRBS: 109 mg%
Systemic examination:
CVS: S1 and S2 are heard , no murmers.
RS : BAE is normal.
CNS: no focal abnormal deficits.
Per Abdomen: soft and tender.
Investigations:
Fever chart:
Hemogram:
Renal function tests:
Liver function tests:
USG:
Chest Xray:
ECG:
CRP:
ESR:
Diagnosis: pyrexia secondary to pyelonephritis.
Treatment:
1.Inj Magnex forte 1.5 mg/iv/BD
2.Inj PAN 40mg iv/OD
3.Inj.Optineuron 1 amp in 100 ml normal saline
4.T .Dolo 650 mgmg/po/TID
5.Temperature monitoring 4th hrly
6.vitals monitoring 4th hrly
7.Tab.Ultracet 1 tab/po/BD
Comments
Post a Comment