43 yr/F with fever and pain abdomen.







13th sep 2022 

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input
This Elog also reflects my patient centered online learning portfolio.
Your valuable inputs on 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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan


A 43yr old female farmer by occupation resident of auravani came with chief complaints of fever associated with chills and rigors since 3 days, diffuse pain abdomen since yesterday and right loin pain since 1 day and burning micturition since 15 days.


History of presenting illness:—
Patient was apparantly assymptomatic 3 days back, then she developed high grade fever associated with chills and rigors. 2 episodes of vomiting which is non projectile, non bilious in nature 2 days back. Then she devoleped diffuse pain abdomen and right loin pain. 

Past History:—
K/C/O leprosy 10 years ago diagonsed by hypopigmented patches insensitive to touch.(used medication for 1year— dapsone 100mg and clofazimine50mg)

H/O UTI 6 months back.


No history of diabetes, hypertension,thyroid , asthma and epilepsy.

Surgical history:— underwent tubectomy 20yrs back.
      — underwent hysterectomy 5 yrs back.

Drug history:— used ALD for 1 yr.
            -used syrup citralka 6 months back.

Personal history:— diet - mixed
          Appetite- normal
          Sleep- adequate
          Bowel and bladder movements are regular 
    - mild burning micturition 
      Addictions:— none.

General examination:— patient is concious coherent and cooperative and well oriented to time place and person. Moderately built and nourished.

On examination— pallor is seen
         —No Icterus , cyanosis, clubbing, lymphadenopathy and pedal edema.









Vitals:— Temp:-
          BP:- 120/70
        Pulse rate:- 82bpm
       R.rate:- 18 cpm
        SpO2 :- 99%
      Grbs:— 109 mg%

Systemic examination:— 
CVS:— S1 and S2 are heard , no murmers.
RS :— BAE is normal.
CNS :— no foacl abnormal deficits.
Per Abdomen:— sofr and tender.

Investigations:— 

Fever chart:—


Hemogram:—


Renal function tests:- 


Liver function tests:—


USG:— 


Chest Xray:-


ECG:—


CRP:- 


ESR:—




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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