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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
H.no. 1701006011
Name A pavan kumar
38 year old female came to casualty with chief complaints of pain abdomen flanks radiating to front since 4 days fever since four days lower backache since 4 days
History of presenting illness
Patient was asymptomatic 20 years back then she develop fever and weakness nearby hospital she was known to be as a diabetic at the age of 18 years she continued the medications of oral hypoglycemic agents 2 years later then she developed pain abdomen and fever they suspected pylo nephritis she has a similar episodes for 3 to 4 times and treated conservatively one year back there is a fever flank pain and abdominal pain on investigation they got to know that there is an uncontrol blood sugars when was given insulin after sometime this which to do oral hypoglycemic agents on discharge
Patient developed fever 4 days back high grade fever not associated with cough cold loose tools shortness of breath and vomiting
Pain(squeezing) in the flank radiating to the abdomen increases during micturation relieved after the urination
Lower back a radiating to the front not associated with burning micturation
She is a k/c/o DM and on medications tab metformin glimeperide volibox
N/k/c/o asthma TB Epilepsy htn cad
On Examination :pt is coherent cooperative and well oriented to time place and person
vitals are
Bp 130/70
PR 64
RR 22
Temperature
Grbs
CVS examination :
S1 S2 heard
Apex beat is medial to mid clavicular line
No palpable thrills and murmar no thrills bilateral
Respiratory system examination:
Bilateral airway entry is present
Wheeze and crepts are absent
P/A :
Tenderness present on left iliac and lumbar
Supra pubic and renal angle tenderness
Investigations :
3/10/22
S
B/l flank pain lt>rt radiating to front fever
O
Vitals 150/90
PR 68
Temp 97.7
RR 16
Grbs 238
spo2 98
A
Acute lt pyelonephritis
P
IVF ns rl @75ml / hr
Inj piptaz 4.25 MG IV tid
Inj diclo 1amp IV sos
Inj hai s/c ACC grbs
Grbs monitoring
4-10-22
S: pain in the left flank
1 episode of vomiting
O:
BP-130/90mmHg
PR-68bpm
RR- 22cpm
Spo2-98@ RA
Temp - 98.7
CVS-S1 S2 +
RS-BAE+
CNS-NFND
A:LT. ACUTE PYELONEPHRITIS
P:
IVF NS RL @75ML/HR
INJ. PIPTAZ 4.25 MG/IV/TID(DAY6)
INJ. TRAMADOL 1AMP IN 100 ML NS TID
TAB. ULTRACET PO/ 1/2 TAB /QID (DAY2 W/H)
(1/2-1/2-1/2-1/2)
INJ. HAI S/C ACC TO GRBS INFORM
GRBS CHARTING
MONITOR VITALS INFORM SOS
5/10/22
S
B/l flank pain lt>rt radiating to front fever
O
Vitals 130/90
PR 68
Temp 97.7
RR 16
Grbs 238
spo2 98
A
Acute lt pyelonephritis - emphysematous
P
IVF ns rl @75ml / hr
Inj piptaz 4.25 MG IV tid
Inj Tramadol 1amp in 100ml ns tid
Tab ultra cet po 1/2 tab qid
Inj hai s/c ACC grbs
Grbs monitoring
Cubical 2
38year old /female.
S:NO FEVER SPIKES
PAIN IN THE LEFT ILIAC , LUMBAR AND LOWER BACK
O:
Patient is c/c/c
Temp : 98.9°F.
PR: 60bpm;
BP: 150/100mmHg
RR: 22cpm;
SpO2: 95%@RA;
CVS: S1,S2+;
R/S: BAE+, Bilateral crepts at IAA;
P/A: Soft, Non tender, BS+;
CNS: NFND
A: ACUTE PYELONEPHRITIS - EMPHYSEMATOUS WITH DIABETES MELLITUS
P
. INJ KETOROLAC 30MG/IV/BD
. TAB. GLIMIPERIDE 1.5 MG PO/ OD
. TAB. MVT PO/OD
. TAB DOLO 650 PO/TID
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