27/F Fever,right sided abdominal pain since 2 weeks

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A 27 year old female teacher by occupation, resident of suryapet presented to causalty with Chief complaints of fever since 10-15 days. Right sided abdominal pain radiating to lower back since 10-15 days.

History of present illness:

Patient was apparently asymptomatic 10-15 days ago then she developed fever high grade with chills and rigors(initial 3 days) not associated with cough, shortness of breath ,cold,sore throat . Then she developed abdominal pain after 4 days of onset of fever, pricking type of pain. C/o Vomitings 1 episode for 1 day, contained food particles, non projectile, bilious. 

Decreased urine output with burning micturition, dysuria aggrevated since 3 days. No complaints of hematuria, graveluria,pyuria. 

Past history:

Not a K/C/O DM HTN CAD CVA ASTHMA EPILEPSY THYROID DISORDERS. 

Personal history :

Appetite : decreased since 10days 

Diet : mixed (consumes both veg and non veg)

Sleep: adequate 

Bowel : regular

Bladder: urine output decreased since 10 days 

Addictions: none 

Routine History:

 

She wakes up at 5 am in the morning does her household chores, prepares breakfast and packs lunch boxes for her children. She has her breakfast by 8am and goes to the school. She is a teacher in preprimary school and teaches the students for 2 hours and then does her work till 4pm. After 4pm she comes back to home and prepares dinner, spends time with her children, makes them do their homework and have dinner by 9pm and she sleeps around 10pm in the night. 

General examination: 

Pallor: absent 

Icterus: absent 

Cyanosis: absent 

Clubbing: absent 

Lymphadenopathy: absent 

Edema: absent 

Vitals:

Temperature-102F

PR-120bpm 

BP-130/70mmhg

SpO2-98%

GRBS-105

Systemic examination:

Cardiovascular system : S1 S2 +  ,no murmurs heard.

Central nervous system: 

Patient is conscious,coherent.co-operative

Speech: normal 

Cranial nerves: normal

Motor and sensory system: normal 

Glassgow coma scale: E4 V5 M6

Respiratorysystem: 

Bilateral air entry present 

Normal vesicular breath sounds heard

Per abdomen : 

Inspection-

Abdomen - Flat

No abdominal distension

Umbilicus is central

No engorged veins seen

No visible pulsations

Palpation-

Abdomen is soft , Tenderness present in Right Iliac region, no Hepatosplemomegaly.

Auscultation-

Bowel sounds heard.

 

Provisional diagnosis: 

? Sepsis with Right mild Hydroureteronephrosis 

Investigations: 

Blood urea -37 mg/dl (N=12 to 42 mg/dl)

Serum creatinine-1.4mg/dl(N 0.6 to 1.1)

Serum electrolytes-

Na :133mEq/L(N-136 to 145)

K:4.0mEq/L(N:3.5 to 5.1)

Cl:99mEq/L(N=98 to 107)

Ionized Ca+2 :1.10mmol/L.

HEMOGRAM:

Hb : 8.3gm/dl.

Total count:14700 cell /cumm

Neutrophils:83 %

Lymphocytes:10%

Pcv:26.2 volume %

Platelets : 3.09 L / cumm.

Impression : Microcytic hypochromic anemia.

LFT: 

TB: 0.80

DB:0.20

ALT: 14

AST:  16

ALP: 142

TP : 7.6 

ALB: 3.1

A/G ratio : 0.70 

CUE: 

Albumin: ++

Sugars:nil

Pus cells:4-8/HPF

Epithelial cells:3-6 /HPF

Serum iron: 62

Chest X-ray:

USG ABDOMEN AND PELVIS: 

FINDINGS:  

E/o 8-9mm calculus noted in distal ureter 

E/o 24x23mm cyst mited in Right ovary 

Impression: 

*Right distal ureteric calculus causing moderate hydroureteronephrosis 

* Right simple ovarian cyst.

CT- KUB (PLAIN)

Kidney: 

RIGHT KIDNEY: Pelvicalyceal system  is dilated.

Ureter: 

Right ureter  dilated up to right midureteric calculus measuring 7mm with HU(1100-1400) 

Impression: mid ureteric calculus causing mild hydroureteronephrosis. 

TREATMENT: 

1. IV fluids 3.NS @75ml/hr 

2. INJ MONOCEF 1GM IV/BD 

3. INJ PAN 40MG IV/OD 

4. T.DOLO 650MG PO/TID 

5.INJ NEOMOL IV/SOS ( If temp is > 101F)

6. VITALS CHARTING 

7. I/O CHARTING