A 43 year old female with fever and pain in abdomen
A 43 year old female , farmer by occupation and resident of narketpally came to hospital on 12/9/22 came with
Chief complaints of
Fever since 3 days associated with chills and rigors and episodes of vomitings since 2 days and pain in abdomen and right loin since yesterday. She complains of burning micturition since 15 to 20 days. No complaints of cough and cold.
HISTORY OF PRESENT ILLNESS
The patient was apparently assymptomatic 3 days back. Then she developed high grade fever associated with chills and rigor .Then she had 2 episodes of vomitings which were non projectile , foul smelling. Then she developed pain in abdomen and in right loin. The pain was continuous and aggeviated while walking.
PAST HISTORY
NO history of DM
No HTN
No CAD , Epilepsy , Asthma
She suffered with leprosy 12 years back .
She suffered with uterine infection 6 months back.
She has undergone hysterectomy 4years back.
PERSONAL HISTORY
Married
Farmer by occupation
Mixed diet
Loss of appetite
Adequate sleep
Burning micturition and normal bowel movement
Non alcoholic
Non smoker
No addictions to any
No known allergies
FAMILY HISTORY
No history of DM , HTN ,CAD , cancer and asthma.
GENERAL EXAMINATION
Conscious , coherent
Moderately built and moderately nourished
Pallor -present
Icterus - present
No cyanosis ,clubbing of fingers , lymphadenopathy, edema.
VITALS
Temperature - 99.2F
Pulse rate - 82 beats /min
Respiratory rate - 16 beats /min
BP- 120/70 mm Hg
SpO2 - 99%
GRBS - 109 mg%
SYSTEMIC EXAMINATION
CVS
No thrills
Cardiac sounds - S1,S2 +
No cardiac murmurs
RESPIRATORY SYSTEM
Centrally located trachea
Breath sounds - vesicular
No wheezing
No dyspnea
ABDOMEN
Shape of abdomen- scaphoid
No tenderness
No palpable mass
No spleen and liver enlargement
No free fluid
CNS
Conscious
Normal speech
INVESTIGATIONS
TREATMENT
Tab. Dolo 650mg
Inj PAN 40 mg IV/OD
Inj MAGN6 FORT6 1.5gm/IV/BD
Inj OPTINGURON IV/OD
Inj TRAMADOL IV
Tab. ULTRACET
PROVISIONAL DIAGNOSIS
Pyrexia secondary to pyleonephritis
