43 year old female with cc of fever since 3 days and pain abdomen since 1 day
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13-09-22
A 43 year old female who is a farmer by occupation resident of auravani came with
cc of -fever associated with chill and rigors since 3 days
- diffuse pain abdomen since 1 day
- Right loin pain since 1 day
-Burning micturition since 15 days
Hopi-
Patient was apparently asymptomatic 3 days ago then she developed high grade fever associated with chills and rigors , 2 episodes of vomitings are present which is non projectile and non bilious in nature 2 days back.Then she developed diffuse pain abdomen and right sided loin pain
Past history -
not a k/c/o diabetes , hypertension,asthma, epilepsy,thyroid disorder
-she is a k/c/o leprosy (diagnosed 10 years back by presence of hypopigmented patches and it is insensitive to touch,biopsy done )
She used dapsone 100mg and clofazimine 50mg for 1 year
- H/o UTI 6 months back -used syp citralka
-Family history - not significant
-Surgical history -underwent tubectomy 20 years back and hysterectomy 5 years back.
-Drug history : dapsone and clofazimine for 1 year.
-Personal history:
•Diet-mixed
•Appetite- normal
•Bowel and bladder movements-regular and mild burning micturition is present
•Sleep- adequate
•Addictions -none
General examination -
patient is conscious, coherent,coperative,well oriented to time, place, person and moderately built and nourished .
On examination -
pallor - present
Icterus,cyanosis, lymphadenopathy,clubbing ,edema-absent
Vitals:
Temperature-
Bp - 120/80 mm hg
Respiratory rate-18 cpm
Pulse rate-82bpm
Grbs-109mg%
Systemic examination:
Cvs-s1,S2 heard,no murmers
Respiratory system - normal vesicular breath sounds,BAE+
Cns- no focal neurological deficits
Per abdomen - soft and tender
Investigations:
Hemogram:
Renal function test:
Liver function test:
Fever chart:
Diagnosis- pyrexia secondary to pyelonephritis
Treatment:
1.Inj Magnex forte 1.5 mg/iv/BD
2.Inj PAN 40mg iv/OD
3.Inj.Optineuron 1 amp in 100 ml normal saline
4.T .Dolo 650 mgmg/po/TID
5.Temperature monitoring 4th hrly
6.vitals monitoring 4th hrly
7.Tab.Ultracet 1 tab/po/BD
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