Skip to main content

26yr female with lower back pain and fever

 26 year old female who is a resident of nalgonda and house wife by occupation came with a chief complaints of

  • Lower back pain since 10 days
  • Fever since 5 days
  • Abdominal pain since1day


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days ago then she developed lower back pain which was insidious in onset and persistent,aggregated during night,no radiation to lower limbs.

      Then she developed fever which was insidious in onset and gradually progressive,which is relieved on medication.It is associated with chills and rigors.
Then she developed abdominal pain in the epigastric region
Patient noticed reddish coloured urine which is not associated with any pain

No history of chest pain,palpitations,syncopal attacks ,burning micturition.

PAST HISTORY:
No similar complaints in the past
Patient had mitral valve replacement done at the age of 7 years
 c-section was done 7 months back.
No history of diabetes,hypertension,asthma,tuberculosis epilepsy.

PERSONAL HISTORY:
Diet: mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:regular
No addictions
No allergies 

FAMILY HISTORY:
No similar complaints in the past
No history of diabetes,hypertension,asthma,tuberculosis,
cad.

GENERAL EXAMINATION:
Patient was conscious coherent and cooperative,well built and we'll nourished.

VITALS:
Temperature:febrile


Respiratory rate:16c/m
Pulse rate:98bpm
Blood pressure:140/70mm/hg
Sp02:99%

Pallor: present
Icterus:absent
Clubbing:absent
Lymphadenopathy:absent
Edema:absent

SYSTEMIC EXAMINATION:
Abdominal examination:



Shape:scaphoid
Flanks:free
Umbilicus:central in position and inverted
Skin:normal
No dilated veins
Movements of abdominal wall is normal
No visible gastric peristalsis
Hernial orifices are normal
External genitalia: normal 
Renal angle:

PALPATION:
SUPERFICIAL PALPATION:
No local raise if temperature
Tenderness localised to right lumbar region(renal angle)
DEEP PALPATION:
Liver:palpable 2 cm below right costalmargin.
Spleen:not palpable
Kidney:not palpable
No other palpable swellings

PERCUSSION:
No fluid thrill

AUSCULTATION:
Bowel sounds heard
Bruits not heard
Venous hum not heard.

INVESTIGATIONS :



 X ray:


KUB:





Drugs
Inj. PIPTAZ
Inj.PANTOP
Inj.ZOFER
Inj.NEOMOL




Comments

Post a Comment

Popular posts from this blog

80Yr male with altered sensorium

 This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input This Blog also reflects my patient-centred online learning portfolio. Your valuable input 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 competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan CHEIF COMPLAINTS: Fever since 10 days  Burning micturition since 1 day Left loin pain since 1 day  Decreased urine output since 1day Blood in urine since 3 hrs HISTORY OF PRESENTING ILLNESS A 80Yr male, agriculture by occupation,c
Post a Comment
Read more

72 Female with Fever, Burning micturition, Abdominal pain

  Chief complaints:   Fever since 1month (sep15th) Burning micturition for 10days (sep15th -25th) Abdominal pain since 1month  Decreased appetite since 20 days HISTORY OF PRESENTING ILLNESS: A 72 year post menopausal female , came to casualty with complaints of fever since sep15th ( 36th day of illness). Fever was high grade with evening rise in temperature associated with chills and rigors, not associated with nausea and vomiting/headache/cold/cough . She was treated with oral medicines on day 2 of illness,But fever dint subside . Not associated with loose stools /blood in stools On 2nd October (17th day of illness ) she was given IV antibiotics for 2 days , and was on antipyretics From 9th October she had feverspike , she consulted a doctor, she was started on inj. Magnexforte and Tab. Farepeneum 200mg for a week.   “presented to outside hospital with fever , right hypochondriac pain and nausea , she was clinically as SEPSIS WITH MODS, surgical opinion was taken and adviced for lap c
Post a Comment
Read more

67yr male with fever and generalized weakness

This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input This Blog also reflects my patient-centred online learning portfolio. Your valuable input 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 competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan CHIEF COMPLAINTS  Fever since 10days Dry cough since 10days  Generalized weakness and bodypains since 10days  Decreased appetite since 5 days  Red colored urine since 5 days  Vomiting on Day 4 of illness Pain abdomen since 2 days H
Post a Comment
Read more