28year old female with pyelonephritis

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 box 





Chief complaints 


Fever since 2 days with body pains 
Chills since 2 days
Right lumbar region pain since 1 day

HOPI 

Patient Was apparently asymptotic 2days back then she developed chills on Saturday on Saturday night 3.30 am
Followed with fever associated with body pains and headache then relieved on medication ( high grade fever) and then Saturday afternoon she had similar complaints with chills and fever then had pain in right lumbar region Pain and fever and relieved on medication 
Then she had similar complaints  Of right lumbar region  pain and fever and associated with chills on Sunday night and relieved on medication which is associated with headache and body pains and headache is throbbing type and in occipital region.

Past history 

on premol for 5 days to delay menstruation and had periods on Saturday and dysmenorrhea for 2 days

Patient had ectopic pregnancy 4 months back and had laproscopy was done and removed the pregnancy with Rt salpingotomy and 
not a k/c/o htn , dm , epilepsy, tb ,CAD and thyroid 

General examination 
Patient Is conscious coherent and co operative and well oriented to time place and person
Pallor present
No ictreus , clubbing, cyanosis, lymphadenopa And Edema
Afebrile
PR - 92
BP-120/80
CVS- s1s2 + 
R/s - BAE+
P/A- soft and tender in right lumbar region
 
INVESTIGATIONS 
15/11/22











16/11/22
   













Diagnosis:

Acute pyelonephritis with dysmenorrhea with right salpingectomy 

Treatment:

Oral fluids
Inj. Pan 40IV/OD
Inj. Zostum 1.5 gm IV/BD
IVF. Ns+DNS @100ml/hr
Inj. Zofer 4mg IV/SOS


SOAP NOTES:

16/11/22

S- fever spikes+
     Headache+,vomitings-2episodes

O-
Patient is conscious , coherent and coperative
BP -120/70mmHg
PR - 88BPM
CVS - S1,S2 +
R/s-BAE+
P/A - SOFT TENDERNESS IN THE RIGHT LUMBAR REGION 
NO ORGANOMEGALY
CNS-NFND
TEMP -99.7 (104.6 @4am)
 GRBS-116mg/dl 

A
ACUTE PYELONEPHRITIS
DYSMENORRHOEA
RIGHT SALPINGECTOMY 4 MONTHS BACK DUE TO ECTOPIC PREGNANCY

P
ESCALATING ANTIBIOTIC FROM CEFEPERAZONE+SALBACTUM TO INJ.PIPTAZ 4.5gm I//V TID

17/11/22

S:-
Pain in the right lumbar region decreased,
Vomitings subsided ,headache decreased ,Fever with chills subsided 

O:-
patient is conscious,coherent ,cooperative 
BP-120/80mmHg
PR:84bpm
CVS-S1S2+
RS-BAE+
P/A-soft and tenderness in the right lumbar region
No organomegaly
CNS-NAD
Temp-98.7(101@7am)
GRBS-104mg/dl
Urine culture : polymicrobial growth seen
Blood culture: No culture seen 

A:-
Right Acute pyelonephritis with evolving renal abscess
H/o ectopic pregnancy(S/p Lap Rt salpingectomy 4 months ago )
Anemia (Nutritional ?IDA)

P:-
Piptaz 4.5gm TID @Day 2




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