26yrs 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:1701006084

FINAL PRACTICAL : LONG CASE

 A 26 year old female who is a resident of suryapet and house wife by occupation came on 2.06.2022 with a chief complaints of

Lower back pain since 10days

Fever since 5 days

HISTORY OF PRESENT ILLNESS:(02.06.2022)

Patient was apparently asymptomatic 10 days back then she developed severe lower back pain which was sudden in onset, continuous, dragging type and not radiating to other region which was relieved on medication

And she also developed fever after 5 days which was insidious in onset with chills and rigor throughout the day and more during night times, for which she was given injections by a local rmp

but there is only temporary relief.

So, she went to near by hospital (A) where she underwent some tests and diagnosed with kidney infection.

Later after few days she was admitted in hospital (B) on 2.06.2022

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 urination, no urge to pass urine.

incomplete voiding

She had vomitings on 2nd( 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

There is no history of cough, cold,rash,loose stools

PAST HISTORY:

No similar complaints in the past

Patient had mitral valve replacement done at the age of 10 years due to rheumatic heart disease ( mitral regurgitation) and she is on tab acitrom medication

 c-section was done 7 months back.

No history of diabetes,hypertension,asthma,tuberculosis,

Cad.

PERSONAL HISTORY:

Diet: mixed

Appetite:normal

Sleep:adequate

Bowel and bladder:regular

No addictions

No allergies 

FAMILY HISTORY:

No relevant history

GENERAL EXAMINATION:

Patient is conscious, cohorent,cooperative and well oriented to time, place and person.

She is moderately built and nourished

Pallor- present

Icterus- absent

Clubbing-absent

Koilonychia- absent

Lymphadenopathy- absent

Cyanosis- absent

VITALS:(06.06.2022)

B.P:110/70 mmhg

P.R:80bpm

R.R: 14cpm

Temp: Afebrile

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Inspection

shape of the abdomen - scaphoid

c section scar present

no dilated veins

no abdominal swellings

no visible peristalsis

all quadrants are moving equally with respiration

stria gravidarum is visible

Umblicus - central and inverted

Palpation

no local rise of temperature

Soft and non tender

no palpable mass

no hepatomegaly 

no spleenomegaly

Kidneys not palpable

Renal angle tenderness - absent

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

No tracheal deviation 

Chest bilaterally symmetrical

Moving equally with respiration on both sides

Bilateral air entry present

Normal vesicular breath sounds are heard

CENTRAL NERVOUS SYSTEM

All higher mental functions, motor system, sensory system and cranial nerves- intact.

No signs of meningeal irritation

PROVISIONAL DIAGNOSIS: Acute pylonephritis (with mitral valve replacement surgery for rheumatic heart disease)

INVESTIGATIONS

on day 1

Hemoglobin- 9.8

Total leukocyte count- 21900

neutrophils- 83

lymphocyte- 07

eosinophils- 02

basophils- 02

monocytes- 08

Platelets- 2.1 lakh

Normocytic normochromic anemia

Appt- 51secs

Pt -25 secs

INR- 1.8

Random blood sugar- 101 mg/ dl

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

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