SHORT CASE - PRACTICAL


SHORT CASE- PYELONEPHRITIS WITH RHD 
7/06/22

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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 in reading and  clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.


CASE:

CHIEF COMPLAINTS: 

26 yr old female, resident of Nalgonda, who is a housewife came to OPD with chief complaints of :

• lower back ache since 10 days and
• fever since 5 days

HISTORY OF PRESENTING ILLNESS: 

▪ Patient was apparently asymptomatic 10 days back then she developed severe LOWER BACK PAIN which was insidious in onset and gradually progressive, continuous type, dull aching type, no radiation to lower limbs, aggrevated towards the end of the day.

▪ Then she developed FEVER 5 days back which was insidious in onset, gradually pprogressive, relieved on medication. It is associated with chills and rigors. 

▪ She had noticed RED coloured urine, which is not associated with pain, difficulty in passing urine, oliguria, increased frequency of urination, urge to pass urine, incomplete voiding.

▪ she had puffiness of face and abdominal distension
 
▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints

PAST HISTORY: 

• no similar complaints in the past 

• At 10 yrs of age ,Patient had history of chest pain for which she was diagnosed with RHD and was on medication for it And eventually surgery was done (CABG & MITRAL VALVE REPLACEMENT). She was on prophylactic medications for 2 years. 

• Undergone c section 7 months ago
• No H/O DM/HTN/TB/Epilepsy/Asthama

MENSTRUAL HISTORY : 
Age of menarche 13 yrs 
5/28 regular , not associated with pain 
but associated with clots 

MARITAL HISTORY:
married for 7 years 
Had a female baby 7 months back 

PERSONAL HISTORY : 
diet - mixed
appetite - Normal
sleep - disturbed due to pain
bowel and bladder habits - regular
No addictions or allergies.

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, pedal edema 




Vitals:
PR :70/min
RR : 34/min
BP : 120/70 mmHg
Temp : Febrile

FEVER CHART:


SYSTEMIC EXAMINATION:
PER ABDOMEN:

INSPECTION: 
shape of the abdomen - scaphoid
Skin : normal
Flanks : free 
Umbilicus : central and inverted 
No visible gastric peristalsis  
no dilated viens
no abdominal swellings
stria gravidarum is visible
C section scar visible
All quadrants are moving equally with respiration






PALPATION:  
SUPERFICIAL PALPATION:
No local rise of temperature
Tenderness localised to right lumbar region (at renal angle)

DEEP PALPATION:
Liver : palpable 2 cm below right costalmargin.
Spleen : not palpable
Kidney : not palpable
No other palpable swellings

PERCUSSION:  
Resonant sounds heard
No fluid thrill

AUSCULTATION: bowel sounds heard


CVS EXAMINATION:
INSPECTION:
midline scar is visible
shape of the chest is normal
no precordial bulge
JVP not seen
no visible pulsations

Midline Scar: 


PALPATION:
apex beat felt at 5th intercostal space
2.5 cm medial to mid clavicular line

AUSCULTATION:
S1 S2 heard 
No murmurs
click sound is heard (REPLACED MITRAL VALVE)  

RESPIRATORY SYSTEM: 
bilateral air entry - positive 
Normal vesicular breath sounds heard

CNS: 
Higher mental functions are normal 
Sensory and motor examinations are normal
No signs of meningeal irritation


INVESTIGATIONS: 

Hemoglobin- 9.8gm%
TLC - 21900
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia

Appt- 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
DAY 4TH
Hemoglobin- 10.1
Urea- 18 


USG REPORT


KUB: 


DOPPLER:


X-RAY:


ECG: 


PROVISIONAL DIAGNOSIS:  
Acute pyelonephritis.

TREATMENT:
IV fluids - 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




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