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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.
38 year old female came to casualty with chief complaints of pain abdomen flanks radiating to front since 4 days fever since four days lower backache since 4 days
History of presenting illness:
Patient was asymptomatic 20 years back when she develop fever and weakness. She went to a nearby hospital. She was known to be a diabetic at the age of 18 years. She continued the medications of oral hypoglycemic agents. 2 years back she developed pain in abdomen and fever. They suspected pylonephritis. She had a similar episodes for 3 to 4 times and treated conservatively. One year back she again had flank pain and abdominal pain. On investigation they got to know that there is uncontrolled blood sugar for which they gave insulin. After sometime they switched to oral hypoglycemic agents on discharge. She stopped working at the dairy she used to, since a year.
Patient had sudden weight loss one year ago.
Patient developed fever 4 days back with high grade fever not associated with cough cold, loose tools, shortness of breath and vomiting
Pain (squeezing) in the flank radiating to the abdomen increases during micturition relieved after the urination
Lower back pain radiating to the front not associated with burning micturition
Patient has been vomiting once daily since 2 days
History of past illness:
She is a k/c/o DM and on medications tab metformin, glimeperide, volibox
N/k/c/o asthma, TB, Epilepsy, HTN, CAD
Personal history:
mixed diet
loss of appetite since a week
bowel and bladder movements are normal
inadequate sleep due to lower back pain. wakes up at midnight to urinate.
Family history:
mother is diabetic.
On Examination :Patient is conscious, coherent, cooperative and well oriented to time, place and person
Vitals:
BP- 130/70 mm of Hg
PR- 64 beats per minute
RR- 22 per minute
Temperature- afebrile
Grbs
CVS examination :
S1 S2 heard
Apex beat is medial to mid clavicular line
No palpable thrills and murmar no thrills bilateral
Respiratory system examination:
Bilateral airway entry is present
Wheeze and crepts are absent
P/A :
Tenderness present on left iliac and lumbar region
Supra pubic and renal angle tenderness
INVESTIGATIONS
3/10/22
S
B/l flank pain lt>rt radiating to front, fever
O
Vitals 150/90
PR 68
Temp 97.7
RR 16
Grbs 238
spo2 98
A
Acute lt pyelonephritis
P
IVF ns rl @75ml / hr
Inj piptaz 4.25 MG IV tid
Inj diclo 1amp IV sos
Inj hai s/c ACC grbs
Grbs monitoring
4-10-22
S: pain in the left flank
1 episode of vomiting
O:
BP-130/90mmHg
PR-68bpm
RR- 22cpm
Spo2-98@ RA
Temp - 98.7
CVS-S1 S2 +
RS-BAE+
CNS-NFND
A:LT. ACUTE PYELONEPHRITIS
P:
IVF NS RL @75ML/HR
INJ. PIPTAZ 4.25 MG/IV/TID(DAY6)
INJ. TRAMADOL 1AMP IN 100 ML NS TID
TAB. ULTRACET PO/ 1/2 TAB /QID (DAY2 W/H)
(1/2-1/2-1/2-1/2)
INJ. HAI S/C ACC TO GRBS INFORM
GRBS CHARTING
MONITOR VITALS INFORM SOS
5/10/22
S
B/l flank pain lt>rt radiating to front fever
O
Vitals 130/90
PR 68
Temp 97.7
RR 16
Grbs 238
spo2 98
A
Acute lt pyelonephritis - emphysematous
P
IVF ns rl @75ml / hr
Inj piptaz 4.25 MG IV tid
Inj Tramadol 1amp in 100ml ns tid
Tab ultra cet po 1/2 tab qid
Inj hai s/c ACC grbs
Grbs monitoring