A 60 year old female came to OPD with complaints of severe left lower back pain, vomittings, fever.

july 13, 2023 

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim  to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of  “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical  findings,investigations and come up with diagnosis and treatment plan. 

This is the case of 60 year old fruit vendor by occupation resident of Bhuvanagiri. 

CHIEF COMPLAINTS:

Severe left lower back painpain associated with fever and vomittings. 

HISTORY OF PRESENTING ILLNESS: 

Patient was apprently asymptomatic 25 days ago. She then developed severe left lower back pain, fever, vomittingsvomittings,  burning Micturition and pain during defecation. 

pain was continous, stabbing type, no aggrevating and relieving factors. 

Fever was  relieving on medication. 

Pricking type of pain during Micturition. 

Vomittings we are relieved on medication. 

25 days ago patient had severe back pain followed by which she was taken to NIMS hospital. 

They had performed  several investigations and she was diagnosed with hyperglycemia 600 mg/dl, kidney stones and pus in kidney. 

She was first treated for hyperglycemia and NIMS hospital referred her to OSMANIA OR GANDHI medical hospitals for further treatment.

But the patient was brought to KIMS narketpally for treatment. 

Negative history:

No history of SOB. 

Past history:

No other complaints of SOB, orthopnea, PND, chest pain, palpitations. 

No complaints of giddiness. 

Known case of diabetes, hypertension since 25 years and anemia. 

N/K/C/O  of asthma, thyroid disorders, epilepsy. 

History of hysterectomy and surgery to right leg. 

Family history:

No family history

Personal history:

Mixed diet

Decreased appetite

Inadequate sleep

Irregular bowl and bladder movements 

Occasional consumption of alcohol

No history of smoking and tobacco addiction. 

GENERAL EXAMINATION:

Prior consent was taken and patient was examined in a well lit room.

Patient was conscious, coherent and cooperative.

No pallor ,icterus, clubbing ,cyanosis.

No generalised lymphadenopathy and bipedal edema. 

VITALS :

Temperature- 98°F

BP-170/90

PR-78 bpm

RR-28 per min

Spo2-95%

GRBS-148mg/dl

SYSTEMIC EXAMINATION:

RS: Bilateral chest airr entry, 

CVS: S1,S2 positive

PA: soft,  tenderness

CNS : NF NB

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS

Acute empysematous pyelonephritis