This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.
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.
HISTORY OF PRESENTING ILLNESS:
▪Patient was apparently asymptomatic 15 days back then she developed severe lower back adhe which was insidious in onset and gradually progressive and continuous type which was squeezing in character and not a radiating type of pain which is relieved on medication
, there are no associated symptoms
▪ Then she developed fever 10 days back which was insidious in onset which started as chills then developed fever which was gradually pprogressive and associated with chills and rigors more during night times
▪ She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication given on 4th june
▪ She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine.
incomplete voiding
▪ she had puffiness of face and abdominal distension on 6th june and got subsided
▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints
PAST HISTORY
▪ no similar complaints in the past
▪At 10 yrs if age ,Patient had history of chest pain for which she was diagnosed with rhuematic heart disease and was on medication for it but not subsided so surgery was done( CABG & MITRAL VALVE REPLACEMENT) then she was on prophylaxis for 2 years then she discontinued then she had c section done 7 months back as baby is weak she consulted doctor from then she again started the prophylactic medication
• no history of diabetes , Hypertension,Asthma , tuberculosis
MENSTRUAL HISTORY : Age of menarche 13 yrs
5/28 regular , not associated with pain
but associated with clots
MARITAL HISTORY
married for 7 years
Had a female baby 7 months back
PERSONAL HISTORY : diet- mixed
appetite - Normal
sleep - disturbed due to pain
bowel and bladder movements - regular
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
measured on right hand
in a sitting position
Temp:afebrile
FEVER CHART
LOCAL EXAMINATION
PER ABDOMEN
INSPECTION
shape of the abdomen - normal
c section scar
no dilated viens
no abdominal swellings
no visible peristalsis
all quadrants are moving equally with respiration
stria gravidarum is visible
PALPATION
no local rise of temperature
no palpable mass
no hepatomegaly
no spleenomegaly
Kidneys ballotable
PERCUSSION
resonant sounds heard
AUSCULTATION
bowel sounds heard
CVS EXAMINATION
INSPECTION
midline scar is visible
shape of the chest is normal
no precordial bulge
JVP not raised
no visible pulsations
PALPATION
apex beat felt at 5th intercostal space
2.5 cm medial to mid clavicular line
AUSCULTATION
s1 s2 heard
No murmurs
click sound is heard without stethoscope (REPLACED MITRAL VALVE)
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
INVESTIGATIONS
on day 1
Hemoglobin- 9.8
Total leukocyte count- 21900
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia
LIVER FUNCTION TESTS
Appt- 51secs
Pt -25 secs
INR- 1.8
Random blood sugar- 101 mg/ dl
Urea- 26
Serum creatinine- 1.4
Sodium- 141meq
Pottasium- 3.4
chloride- 106
DAY 4TH
Hemoglobin- 10.1
Urea- 18
USG REPORT
DIAGNOSIS
right Acute pyelonephritis and is on anticoagulants
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
