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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




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