A 41 year female with pain abdomen

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This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs  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 diagnosis and treatment plan


CASE:

A 41 years female housewife came to opd with cheif complaints of:

Pain abdomen from 2 months


HOPI:

Patient was apparently asymptomatic 2 months ago then she developed 
Left lumbar pain which is continuous, dragging type of pain with no aggravating and reliving factors. since 5 days pain has increased in intensity 
she was having fever intermittently from 2 months which is relived on medications
Episodes of burning micturition +/-
Episodes of vomitings which has increased in frequency to 2-3 times a day, non bilious, non projectile, food particles as content, not blood stained

Past history:

she was diagnosed with DM type 2 four days back

Hysterectomy 2 months back for PV discharge 

N/k/c/o HTN, TB, Epilepsy, CVA, CVD, Thyroid disorders, asthma

Personal history:

Mixed diet
Decreased appetite
Normal bowel movements
Burning micturition
No allergies
Occasionally consumes toddy

Family history:

Not significant

General examination:

Patient is conscious, coherent, cooperative, well oriented to time and place

Vitals:

Temperature: 103 F
PR: 121
BP: 160/90
RR: 24/min
SPO2: 96%
GRBS: 114 mg%


Pallor present
No icterus, cyanosis, clubbing, lymphedema
B/L pitting oedema

Pallor 




 
Systemic examination:

CVS- S1 S2 heard no murmurs
CNS- No focal neurological deficit
RS- Normal vesicular sounds heard

Provisional diagnosis:

Acute pyelonephritis

Investigations:










X ray findings: Bilateral pleural effusion 



Treatment:

1.IVF NS, RL @ 75ml/hr

 2. INJ. PIPTAZ 4.5g IV/TID

 3. INJ. PAN 40MG IV/OD (BBF)

 4. INJ. BUSCOPAN 1AMP IM/SOS

 5. INJ. TRAMADOL 1AMP IN 100ML NS IV/SOS

 6. INJ. ZOFER 4MG IV/BD

 7. INJ. NEOMAL 1G IV/SOS (IF TEMP> 101F) 

 8. INJ. HAI S/C TID BEFORE MEALS ACC TO GRBS 

9. SYP. POTCHLOR 15ML PO/BD 

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