General medicine final practical long case

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Vignatha 9th semester

roll no: 45

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.

Following is the view of my case:

A 26 year old female from nalgonda who is a homemaker came to the hospital with the chief complaints of : 

• Lower back pain since 15 days

• Fever since 10 days 

History of presenting illness:

• The patient was apparently asymptomatic 15 days back, then she developed lower back pain which was insidious in onset and gradually progressive, and continuous dragging type which finally became severe pain. Pain is more during night time. The severity of pain is decreased after medication. The pain is not radiating .

• Then she developed fever 10 days back which was insidious in onset gradually progressive which was high grade and associated with chills and rigors.

• She also had history of vomitings. On day 1 of admission - 1 episode and on  day 2 of admission - 6 episodes. They are yellow in colour,  food as contents, not projectile. Relieved on medication. 

• The patient had noticed red coloured urine before the day of admission and on the day of admission,  which is not associated with pain or burning or difficulty in passing urine, no oliguria or increased frequency of micurition .

•She had facial puffiness and abdominal distension on day 5 of admission which later subsided.

• There is no history of chest pain, breathlessness,  cough, indigestion and heart burn.

Past history:

At the age of 10years she was diagnosed with Rheumatic heart disease and she underwent a surgery (CABG and mitral valve replacement)following which she took medication for 2 years and she stopped using them thereafter ,and again she’s using the medication from past 7months.

No DM,TB,HTN,Epilepsy

Personal history :

Diet:mixed

Appetite:normal

Bowel and bladder movements:regular 

Sleep disturbed due to pain

No addictions 

No allergies 

Family history :not significant 

Menstrual history :

Age of menarche:13 years

5/28 cycle ,regular,moderate flow , with clots ,no dysmenorrhea 

Marital history : married for 7 years 7months back gave birth to a girl baby.

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,edema 

Vitals:

Pulse rate:70/min

RR:20/min

BP:120/70 mmHg

Temp:afebrile.

Fever chart:

Fluid intake and output chart:

Systemic examination:

Per-abdomen examination 

Inspection:

Shape of abdomen:normal

Movements:all quadrants are moving equally with respiration 

C-section scar is present 

No engorged veins ,sinuses,swellings

Striae gravidarum present 

No visible gastric peristalsis

Palpation :

No local rise of temperature ,no tenderness

No palpable mass

No hepatomegaly ,spleenomegaly

Kidney not ballotable.

Percussion :resonant note heard 

Auscultation : bowel sounds heard.

RESPIRATORY SYSTEM :

bilateral air entry - positive 

Normal vesicular breath sounds heard

CENTRAL NERVOUS SYSTEM :

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

Clinical images:

CVS :

Inspection:

Midline scar is present 

Shape of chest normal 

No precordial bulge 

JVP not  raised 

No visible pulsations

Palpation: Apex beat felt at 5th ICS 2.5 cm medial to mid clavicular line

Auscultation :

S1S2 heard no murmurs 

Click sound is heard without stethoscope (replaced mitral valve ).

Investigations:

On Day1:

Hb:9.8 %

TLC:21,900

N:83,L:7,B:2,M:8

Platelet:2.1 lakh 

Normocytic normochromic anemia

LFT:

APTT :51seconds

PT:25 sec 

INR:1.8

RBS:101 mg/dL

Urea:26

Sr.creatinine :1.4

Na+:141 mEq

K+:3.4

Cl_:106

On day 4

Hb:10.1

Urea :18

USG :

(Done On the day of admission)

Impression:altered echo texture and increased size of right kidney

2decho:

ECG:

X-ray:

Diagnosis:

Acute pyelonephritis 

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 (stopped)