28year old female with pyelonephritis

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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