A 26 year old female presented with fever and abdominal pain since 10 days

  Hi , I am Saranya ,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolios


A 26 year old female daily wage worker by occupation resident of narketpally came to causality with complaints of fever and abdominal pain 6 days back on 2nd june.

HISTORY OF PRESENT ILLNESSES

Suffering from lower abdominal pain since 10 days and fever since 5 days relieving by medication

PAST HISTORY

Epigastric abdominal pain 
Normal mituration
No constipation
No chest palpitations

TREATMENT HISTORY

7 years ago mitral valve replacement surgery
No diabetes
No hypertension

PERSONAL HISTORY

Normal apitite
Regular bowels
Normal mituration
No drug use

FAMILY HISTORY

No hypertension
No diabetes
No heart disease
No cancers 
No asthma

GENERAL EXAMINATION
 
Pulse rate : 96 per minute 
Respiratory rate : 18/min
B.p : 140 / 80 
Spo :99%

SYSTEMIC EXAMINATION

 CVS
NO thrills
S1 ,S2 present

RESPIRATORY SYSTEM
NO dyspenoea
No wheezing
Central position of trachea

ABDOMEN
Scaphoid shape of abdomen
No palpable mass
No hernial orifices
No bruits
No free fluids
Bowel sounds heard
No palpable liver and spleen

CNS
Patient is Alert
Normal speech
No neck stiffness

 PROVISIONAL DIAGNOSIS
 Acute pylonephritis

CLINICAL DIAGNOSIS


























MEDICATIONS







































 ACUTE PYLONEPHRITIS
Where is anatomical location of this patient's problem? (related to Macroanatomy) 

It is a clinical syndrome characterized by chills and fever , flank pain,and constitutional symptoms caused by bacterial invasion of the kidney . Micro anatomical location is RENAL PELVIS in kidney

Why is the patient having this problem? (related to microanatomical pathogenesis as well as macro-social environmental events influencing it) 

Microantomical pathogenesis
Bacteria in the enteric flora periodically gain access to the genitourinary tract.close proximity of the anus to the genitourinary tract in women is a likely factor.subsequent bacterial colonization of uroepithelial cells sets the stage for persistent bacteriuria.
Following periurethral colonization,uropathogens gain access to the bladder via urethra and to the kidneys and finally the renal pelvis 
Macrosocial environmental factors also affects this due to unhygienic environment and poor sanitization causes especially in rural areas.

What are we doing about it? (pharmacological and non pharmacological interventions)

Pharmacological interventions
Inj-Piptaz 4.5gms /IV
Inj-PAN 40 mg/Iv
Inj-zoffer 4mg/Iv
Inj-Neomal/IV if temperature is more

Non pharmacological interventions
TPR graphic sheet 
Ultrasound scanning
NCCT-KUB(PLAIN)
2D Echo
ECG



Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE elog 1

Image
  Hi , I am Saranya ,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolios A 26 year old female daily wage worker by occupation resident of narketpally came to causality with complaints of fever and abdominal pain 6 days back on 2nd june. HISTORY OF PRESENT ILLNESSES Suffering from lower abdominal pain since 10 days and fever since 5 days relieving by medication PAST HISTORY Epigastric abdominal pain  Normal mituration No constipation No chest palpitations TREATMENT HISTORY 7 years ago mitral valve replacement surgery No diabetes No hypertension PERSONAL HISTORY Normal apitite Regular bowels Normal mituration No drug use FAMILY HISTORY No hypertension No diabetes No heart disease No cancers  No asthma GENERAL EXAMINATION   Pulse rate : 96 per minute  Respiratory rate : 18/min B.p : 140 / 80  Spo :99% SYSTEMIC EXAMINATION  CVS NO thrills S1 ,S2 present RESPIRATO
Read more

26 years old male presented with pain abdomen and vomitings

Image
Hi I'm Saranya, 3rd sem student .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-centered online learning portfolio and your valuable inputs on the comment box. CHEIF COMPLAINT  Pain abdomen after taking food since 1 day  Vomitings since 3 days Loss of appetite Burning mituration Cold and cough SOB HISTORY OF PRESENT ILLNESS- A 26 year old male , car driver by occupation came with abdominal pain and vomitings of 3 episodes which is bilious,non blood tinged,No fever and has cold and cough He is apparently asymptomatic 4 months back,then he took alcohol regularly for 1 week, then started developing pain
Read more