FINALS LONG CASE

 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"



Date of Admission-9/02/2022


A 45year old female who is farm worker by occupation presented to OPD with chief complaints of   pain in the loin region along with fever which was irregular type   since 1 week and decreased urine output from 1day.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic one week back then she developed fever which was irregular type and subsided on medication.

The lower back pain in the loin which was non radiating and no aggrevating or reliveing factors.

The patient complains of burning micturation and unable to pass urine from 1day.


HISTORY OF PAST ILLNESS :

The patient was identified with the presence of renal stones one month back.

She underwent hysterectomy 10 years back.

The patient is not a known case of DM/HTN/Asthma/CAD/CKD.


PERSONAL HISTORY:


APPETITE :normal.

DIET:mixed.

BOWEL AND BLADDER MOVEMENT :regular

MENSTRUAL HISTORY: hysterectomy 10 yrs ago.

 ADDICTIONS: occassionally alcoholic  (gudumba)

SLEEP : adequate.

FAMILY HISTORY:

 history of DM, CAD, Asthma and thyroid disorders in the family.


GENRAL EXAMINATION :

Patient is conscious, non co-operative.

There are no signs of icterus, clubbing, pallor, cyanosis, lymphadenopathy.

VITALS:

Temperature- afebrile

Pulse rate- 148 bpm

Respiratory rate - 22cpm

BP- 130/80mm Hg

Spo2- 100

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Cardiac sounds- S1, S2 heard.

RESPIRATORY SYSTEM:

Position of trachea- central

Breath sounds- vesicular

Adventitious sounds- No

ABDOMEN:

Mild tenderness

Palpable mass- none

Hernias orifices- 


Free fluid- mild ascites.

Liver- Not palpable

Spleen- Not palpable

Bowel sound- Yes

CENTRAL NERVOUS SYSTEM :

Patient is conscious 

Speech- normal

No sign of meningitis 

Motor and sensory system- Normal

Cranial nerves- intact

INVESTIGATION: 

9/2/2022

ECG:



Ultrasound:


DIAGNOSIS:UROSEPSIS


TREATMENT :

8/2/22

Monocef 1g/IV/BD.



Inj. PAN 40 mg.



Inj.TRAMADOL 2amp in 200ml N.S/IV/BD.



Inj. Diclofenac sodium.



IV normal saline.

9/2/22

Soft diet.

IV normal saline.

Inj.meropenem 1gm/IV/BD.



INJ.PAN 40mg IV/BD.

inj.paracetamol 1gm /IV/BD.



inj. TRAMADOL 2amp. In 200ml NS/IV/BD.

Monitor vitals









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