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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